• Maybe self-insurers can lead the way — my concerns

    I agree with Aaron that self-insured companies will be health insurance (and wellness program) laboratories. (His two posts here and here.) They have been already. That’s good, provided some other conditions are met. I raise two of them below, in the form of concerns.

    Concern 1: Will employers offer data so their experiences can be analyzed by researchers? It’s wonderful if a company can save money and help its workers be healthier. It’s even better if they can share what they’ve learned to benefit others. The problem is, doing so may help the company’s competitors. That alone is reason for the firm not to share. There may be other costs and factors too.

    So, here’s my challenge: Any company making a claim about how well their innovations are reducing health care spending or improving health should offer their data to researchers for scruitiny (appropriately de-identified and with all due precautions, of course).

    There is a history of employers making big claims about health care savings that turned out to be overstated. (Safeway is a chief example.) That’s dangerous because it can lead to policy that may not, in fact, be broadly beneficial. In any event, I am among those who prefer to reason based on well-vetted facts, not grand, unverifiable claims. So, show me the data, please. If you believe in your program, there should be no problem demonstrating it works with some independent analysis.

    Concern 2: Will employer innovations address the highest cost patients? Many (though not all) of the costliest, sickest patients are not workers. In some sense, large employers have the easiest risk pool to work with. They can cut lots of stuff, and it won’t matter because workers and their families are relatively healthy and young compared to nonworkers and retirees.

    What are the long-term consequences of changes to insurance for workers? What happens to workers who become sick and leave the company? Did the health plan work for them or not? Could private cost cutting lead to increased public spending?

    I’m not saying companies should not experiment or that their experiments will be necessarily problematic. I just think we need to push hard on some areas so that their innovations can help improve the system for everyone. Experiments are good, but not if you don’t fully observe them. Cost cutting is good, but not when it is cost shifting. Saving health spending is good, but isn’t all that helpful if it is in ways that only address healthy populations.
    • Universities should lead the way in these data share/eval efforts

    • As a former health care consultant that consulted exclusively with large self-insured companies, I would suggest that the vast majority of the innovative claims are along the lines of Safeway. While there are some who do in fact move the needle, the overwhelming majority do very little other than traditional cost shifting. The things you do see…case management, disease management, health risk questionaires are of questionable effectiveness, despite sounding good in a seminar. Most large employers costs tend to move in line with market trend.

    • I would think that large hospitals, which often self insure, should be a good source of data. Probably a bit contaminated as they usually try to draw in non-employees from the community.


    • 1. Seems like that will depend on the extent to which the ACA allows or constrains innovation in self insured plans.

      2. Has anyone at TIE evaluated the cost-savings claims made on behalf of the plan offered by Whole Foods?

    • An employee is a captive audience in a way that a person buying insurance on the individual market is not. You have a motivation to please your employer that does not have a close analogue for your insurer or your government. You are in an environment with colleagues sharing an office culture that can be manipulated. Communication is easier; a message coming from the boss will be read rather than treated as spam, etc.

      Bottom line: don’t expect a wellness-related benefit design that works in a large group employer setting to have the same impact as an identical benefit design in an individual market setting, or the sort of small group setting you are likely to get on the exchanges.