Some saw this coming with waivers HSS has granted under the medical loss ratio provision of the law. HHS gave waivers to states such as Maine, where, pre-ACA, there was a 70% threshold for MLR.
The health insurance industry, despite focus on quarterly earnings at the big national companies, has always looked at a very complex set of variables around the risk they're taking on not just for the immediate future, but for years to come. The insurance model is based on years from now. By definition, insurance is betting against risk. It's not just year-t- year risk, but multi-year risk, and if there is no mandate, all bets are off, says Keckley.
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"It's popular to beat up on the industry, but you have to imagine: What if we didn't have it?" he says.
And insurers do have other opportunities.
"They're looking globally, monetizing their data, expanding wellness and healthy living, and looking at other countries where they truly are managing population health," he says. "At least the seven big national insurers are leveraging their bets against a variety of scenarios and they won't operate in markets where they can't at least break even."
Another risk of a period of uncertainty?given that Congress may be unable to act very quickly?is that commercial health plans will more aggressively negotiate with hospitals and will push much more risk on them than they've seen so far.
"I'm not talking about accountable care and medical homes," Keckley says. "Those are interesting, but in the near term, they don't impact hospital revenues that much. Bundled payments and value-based purchasing do, and I think you'll see insurance companies walk in the door with some very aggressive, risk-based bundled payment proposals for hospitals."
Keckley says he can envision insurance companies quickly expanding the four approaches to bundled payments outlined in the ACA. He sees as many as 15 bundles as possible. Conflict with medical staff has always been over money and clinical autonomy, but if all of this uncertainty results in accelerated bundled payments, then physicians and hospitals will fight over standards of care, how to divide the money, and who's responsible for various outcomes.