Here's a case where the payers were willing to talk, but the hospitals weren't
As you know, Massachusetts has an individual mandate, which has successfully pushed coverage above 90%, but the state continues to struggle with increased demand and associated additional costs. The state has a concentration of academic medical centers and some of the highest costs in the nation, dating back even before the mandate took effect.
As part of the state's investigation, hospitals and health plans were invited to a series of public hearings to discuss rising costs at the system level. While the invitations weren't summonses, they weren't exactly friend requests either.
LONG LIST OF QUESTIONS
I called up Lora Pellegrini, acting president and CEO of the Massachusetts Association of Health Plans, to find out what was going on. She says invitations were sent by the division of insurance in late December, and sample questions were provided in advance. Health plans received 60 questions to discuss at the hearings, such as how they arrive at prices for specific products.
"Our member health plans spent thousands of hours preparing for the hearings," Pellegrini says.
The fact that the hospitals didn't attend could be viewed as a refusal to cooperate or as a suspicious action among organizations that have something to hide-which is ironic since health plans are often accused, rightly or wrongly, of doing just that.
Here's a situation where the health insurers were at the table, willing to be reasonably open with policymakers, and the providers were not. Criticizing hospitals and physicians who work passionately to save lives and reduce pain might be seen as distasteful, but they probably deserved it in this case. In their defense, many hospital executives claimed scheduling conflicts were the problem.
For high-level discussions-such as public hearings that the division of insurance and the governor invite you to-it would seem to be in the best interest of all the stakeholders to participate, even if their only motive is to show their faces. Perhaps the scrutiny often directed toward "greedy" insurers will start shifting onto providers.
PROVIDE POSSIBLE SOLUTIONS
Pellegrini says her association's member plans operate on 2% margins, and 90% of their premium dollars are spent on medical services. Many are not-for-profit companies and all are as transparent as contracts will allow, she says.
She seemed a little frustrated by the hospitals' lack of cooperation, and recommends that health plans in other states take the high road if faced with a similar situation.
"Try to provide solutions," she says. "Operate your business in a way that you don't have anything to hide."
Julie Miller is editor-in-chief of MANAGED HEALTHCARE EXECUTIVE. She can be reached at firstname.lastname@example.org