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Mechanism Design and the Repairing the Healthcare System

May 15, 2019

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Stanley Feld M.D., FACP, MACE.

On November 11, 2007, I published the following blog: “Incentives and Mechanism Design.” The authors Leoid Hurwicz, Roger Meyerson and Eric Maskin were awarded the Nobel Prize in Economics for the concept in 2007.

http://stanfeld.com/?s=mechanism+design

I suspect few politicians know about Mechanism Design in 2019. I am certain Bernie Sanders and the “Medicare for All” crowd do not know anything about Mechanical Design.

In my last blog, I described how politicians and the mainstream media use Confirmation Bias to try to put the government in control of healthcare against the will and welfare of the public.

https://en.wikipedia.org/wiki/Confirmation_bias

I think Donald Trump either studied the use of Mechanism Design and its mechanics or he intuitively uses its principles in his thinking.

Mechanism Design is a concept that tries to put science into social science. It mathematically evaluates vested interests of stakeholders in order to eliminate confirmation bias and line up all the stakeholders’ vested interests for the greatest good. It assumes all the stakeholders have expressed their vested interests truthfully.

Please Read Between the Lines

The Democrats want to hold onto (fix) Obamacare. However, the Democrats understand Obamacare is not viable in its present form. I believe “Medicare for All” with central government control of healthcare will be a disaster as it has been in most single party payer systems.

I do not believe Obamacare is fixable. I believe President Obama and the Democrats believed that Obamacare would fail. Then the nation would beg either his public option or Medicare for All.

I think President Obama believes “Medicare for All” and the total government control of healthcare is the ideological solution to the problems in our healthcare system.

His confirmation bias overrules all of the examples of “Medicare for All” failed examples at home (Vermont California and Colorado), as well as Denmark, Sweden, England, and France.

In 2017, the Republicans with a slim majority in the Senate refused to repeal Obamacare. Whether the Republican failure to repeal Obamacare was because of intramural revenge or ideology is best to question is which system is best for the common good.

If our politicians understood the principles of Mechanism Design and were diligently working for the people who elected them benefit, America would be on the way to “Repairing the Healthcare System.”

Against this backdrop of a hostile Democratic Party, in control of the House of Representatives, Donald Trump and his administration is slowing working its way to “Repairing the Healthcare System” using the principals of Mechanism Design.

In November 2007, pre the Obama administration, I wrote:

Last month the Nobel Prize in economics was awarded to Leoid Hurwicz, Roger Meyerson and Eric Maskin. They were awarded the Nobel Prize for developing the economic theory of “Mechanism Design.” My first reaction was “what is that?”

https://en.wikipedia.org/wiki/Mechanism_design

After some research, I discovered the power of Mechanism Design. It is a brilliant economic theory that could solve many economic problems. Mechanism Design applied to our healthcare system could solve the healthcare systems problems.

What is it? “In economics, mechanism design is the art and science of designing rules of a game to achieve a specific outcome, even though each participant may be self-interested. This is done by setting up a structure in which each player has an incentive to behave as the designer intends. The game is then said to implement the desired outcome. The strength of such a result depends on the solution concept used in the game. It is related to metagame theory, which is the theory of games the play of which consists of developing the rules of another game.

Mechanism designers commonly try to achieve the following basic outcomes: truthfulness, individual rationality, budget balance, and social welfare. However, it is impossible to guarantee optimal results for all four outcomes simultaneously in many situations, particularly in markets where buyers can also be sellers [1], thus significant research in mechanism design involves making trade-offs between these qualities. Other desirable criteria that may be achieved include fairness (minimizing variance between participants’ utilities), maximizing the auction holder’s revenue, and Pareto efficiency. More advanced mechanisms sometimes attempt to resist harmful coalitions of players.”

Lodi Hurwitz contributed to the idea of incentive compatibility. His point is the way to get as close to the most efficient economic outcomes is to design a mechanism in which everyone does best for themselves. He says this can be achieved by sharing information truthfully (Price Transparency). It is easy to understand that some people can do better than others by not sharing information or lying.

If everyone’s incentives are aligned, you have a much more efficient economic system. An example is defense contracting. If you agree to pay on a cost-plus basis you have created an incentive for the contractor to be inefficient. If you agree to pay a fixed price you can come close to an efficient price if you have all the truthful information. If you do not you have incentives aligned and truthful information you create the incentive to be overcharged. Most people can do better by not sharing truthful information. If the rules of the game require truthful information you can get close to an efficient market-driven solution.

The concept of Pareto efficiency means no one can be made better off without someone becoming worse off. Therefore, the incentive is to maintain your dominance by not being truthful at the expense of others. Hurwicz observed as others had that the dispersion of information was at the heart of the failure of a planned economy. He observed that there was a lack of incentive for people to share their information with the government truthfully. The free market mechanism was far less afflicted than central planning bureaucracy by such incentive problems. The free market economy was by no means immune to this defect. He observed that the free market economy can get us closer than central planning to incentive compatibility because the end consumer can drive the discovery of truthful information.

The customer creating rules of engagement in a market-driven economy can get you closer to the ideal of Mechanism Design. Since the customer determines success of an enterprise by creating demand in a transparent environment, they can get closer to incentive efficiency. They create the rules of the game for compatible incentive.

Roger Meyerson contributed the revelation principle, a mathematical model that simplifies the calculation to create the most efficient rules of the game. The mathematical model gets people to reveal their truthful private information leading to aligned incentives.

Eric Maskin’s breakthrough was in perfecting Mechanism Design with his “implementation theory.” His theory clarifies how to design mechanisms that heighten incentive alignment and efficiency.

How does Mechanism Design relate to the Repair of The Healthcare System? We have to set the rules of the games so that we align all the stakeholders’ incentives without one stakeholder takes advantage of another. The insurance industry is taking advantage of the patients, doctors and hospital systems. The hospital systems are taking advantage of the patients, doctors and insurance companies. Doctors are taking advantage of the insurance companies, hospital systems, patients and the government. The government is taking advantage of the hospital systems, the doctors and the patients. Employers who pay the insurance bills for their employees are taken advantage of by the insurance companies. The drug companies are taking advantage of patients and unduly influencing physicians.

In our healthcare system, everyone is pursuing his vested interest in a game that has rules that do not lead to “incentive compatibility.”

Some politicians think central planning will straighten out the rules. Historically, central planning has not worked. The winners of this year’s Nobel Prize in economics have proven this fact.

I believe consumers can fix the rules of the game so that all the incentives are compatible. Consumers have to have incentives to force politicians to fix the rules of the healthcare game. Consumer-driven healthcare system will achieve the alignment (incentive compatibility) using the ideal medical saving account.

Twelve years have passed since 2007. America has not gotten closer to the solution to Repair the Healthcare System even though the solution is staring us in our eyes.

www. stanfeld.com

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.  

Copywrite 2006-2019

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Incentives and Mechanism Design

October 22, 2014

inMedicine: Healthcare System, Politicians,Healthcare and Vested Interests, Stakeholder Mistrust

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Stanley Feld M.D.,FACP,MACE

Why are Obamacare’s initiatives failing? There are several reasons.

1. Government is inefficient. It outsources all of its administrative services.

The contractors, in turn, subcontract out most of the work. The overhead for each function increases non-transparent costs. The execution of tasks decreases.

2. President Obama’s healthcare policy advisors are academics. They have little clinical experience. It is clear they have little experience in the trenches.

The healthcare policy advisors have no idea how to create incentives for physicians and hospitals.

They have no idea how destructive to clinical practice the lack of tort reform is.

3. Without clinical experience the policy advisors do not know how to create effective incentives for patients.

I have emphasized that patients must be responsible for themselves and their diseases. They must become professors of their diseases. They have to be provided with adequate incentives to become professors of their diseases.

Physicians must be provided with incentives to teach patients to be professors of their diseases.

4. The government outsources the administrative services to adjudicated Medicare and Obamacare billings. The government has little idea of the actual profits built into the fees the insurance companies charge the government. At intervals insurance companies are required to enter another bidding process. The government probably picks the lowest bidder.

It is not an efficient way to pick an insurance company. This is especially true when the government guarantees the insurance company‘s profit. The government does not know what the insurance company’s profit actually is. The profit is about 40% of the healthcare dollars.

President Obama’s ideological goal leads to these errors. His only concern is for the government to control the healthcare system.

Government control of a healthcare system has not been successful. The V.A. healthcare system is on example. Medicaid and Medicare’s increasing deficits has been another example.

None of the countries in the developed world have a financially viable universal healthcare system except Switzerland.

A few years ago I learned about “Mechanism Design.” My first reaction was “what is that?”

Leoid Hurwicz, Roger Meyerson and Eric Maskin received a Nobel Prize was for this economic theory in 2007.

Mechanism Design is a brilliant economic theory. If the theory was applied to the healthcare system it could solve much the system’s dysfunction.

When I wrote about Mechanism Design I felt that few people understood it.

What is it? Mechanism Design is the art and science of designing rules of a game to achieve a specific outcome, even though each participant may have a separate vested self-interest.

The design of the game is to align all the stakeholders’ vested self-interests.

Each stakeholder has an incentive to behave as the game designer intends. The game can then implement the desired outcome.

The strength of such a result depends on the solution concept used in the game.

None of the stakeholders’ vested interests are aligned in Obamacare except the vested self-interest of President Obama and his ideology.

The healthcare insurance industry thinks it has President Obama over a barrel.

Some of the hospital systems have figured out that they will be at the mercy of Obamacare.

Physicians already feel they are at the mercy of President Obama’s ideology.

Medical device companies and pharmaceutical companies have figured out they are dead already. It is only a matter of time until they cannot move. They are working around the system to come back from the dead.

None of the stakeholder’s vested interests are are aligned. This non-alignment will lead to destruction of the healthcare system.

Mechanism designers commonly try to achieve the following basic outcomes for stakeholders: truthfulness, individual rationality, budget balance, and social welfare.

With those four outcomes for stakeholders in the healthcare system one could get close to aligning stakeholders incentives.

Lodi Hurwicz’ point is the way to get as close to the most efficient economic outcomes is to design mechanisms in which everyone does best for themselves.

He says this can be achieved by sharing information truthfully (Price Transparency). It is easy to understand that some people can do better than others by not sharing information or lying in the short term. It will not serve all the stakeholders’ vested self-interest in the long term.

If everyone’s incentives are aligned you have a much more efficient economic system.

The example given in the military is defense contracting. If you agree to pay on a cost plus basis you have created incentives for the contractor to be inefficient.

If you do not you have incentives aligned and truthful information you create the incentive to be overcharged. Most people can do better by not sharing truthful information.

Many have observed that Obamacare has not been transparent or truthful.

If the rules of the game require truthful information you can get close to an efficient market driven solution.

The concept of Pareto efficiency means no one can be made better off without someone becoming worse off.

Hurwicz observed, as had others, that the dispersion of information was at the heart of the failure of a planned economy.

He observed that the free market economy can get us closer than central planning to incentive compatibility because in the end the consumer can drive the discovery of truthful information

A free market economy is by no means immune to the Pareto efficiency concept.

However, the free market mechanism was far less afflicted than central planning bureaucracy. A consumer driven system serves to force truthfulness.

Empowering consumers is the key to an efficient system. Customers determine success of an enterprise by creating demand. In a transparent environment they can get closer to incentive efficiency. They create the rules of the game for compatible incentive.

How does Mechanism Design relate to the Repairing The Healthcare System?

The rules of the games can align all the stakeholders’ incentives without one stakeholder taking advantage of another.

In our healthcare system everyone is pursuing his vested interest in a game that has rules that do not lead to “incentive compatibility.”

Some politicians think central planning will straighten out the rules. Historically, central planning has not worked. These Nobel Prize winners in economics have proven this fact.

A consumer driven healthcare system using the ideal medical saving account. Will be a good start in achieving alignment of all the stakeholders.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone

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A Comment On Mechanism Design

November 15, 2007

inMedicine: Healthcare System

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Stanley Feld M.D.,FACE,MACE

Dick Swersey is a Columbia College C’59 classmate. He is extremely intelligent. He has commented on my blog Repairing the Healthcare System in the past. He is a strong free market advocate. In response to my blog post Mechanism Design and Repair of the Healthcare System he wrote the following:

“Stanley:

History has proven over and over again that only the market mechanism of willing sellers and willing buyers is the optimal way to allocate economic resources. This presumes an informed buyer, and a willingness of sellers to compete for buyers. Adam Smith was clear on this in the Wealth of Nations.

But he expressed an additional concern. I am paraphrasing here but he said it was dangerous for craftsmen of the same trade (i.e. doctors and/or hospitals) to get together, even for merriment, that the event turns into a conspiracy against consumers. This thinking was 115 years before the Sherman Anti-Trust Law was enacted.

So, here’s the dilemma: we have long passed the point of sellers of medical services colluding (in the broadest sense). How do we get market power back into the hands of consumers?

I wouldn’t necessarily dismiss a role of government in this arena. Fully 20% of the Wealth of Nations is a section called “The Role of the Sovereign”. You might want to look at that section to see if there are any relevant principles. I’ll do the same.”

Dick is absolutely correct. The government is there to make the rules of the game. These rules need to be constructed so that they are fair to all. The rules have to align everyone’s incentive for the basic goal of the endeavor.

In medicine the basic goal should be the welfare of the patient. The goal should be the delivery of quality medical care at the most affordable price. The patients and not the insurance company should decide on what their needs are. The rules can not interfere with free choice. If a seller is unwilling to sell according to the rules they should not be forced to sell. However, they can not play the game. They need to play in another game. If there is an unwilling buyer to buy he should have the option to buy elsewhere. Both the buyer and the seller should be entitled to pursue their self interest within the rules of the game. All transactions should be transparent so the buyer knows exactly the quality of care he is buying and the price he is paying for it. The rules for defining quality of care and price have to be clearly stated. If the rules of the game are broken the party who breaks the rules should be penalized.

The distortion in the Healthcare System is the opacity of pricing and payment by the healthcare insurance industry, the hospital systems, and sometimes the physicians. Additionally, the consumer does not have the option to choose the products he feels he needs. (Access to care)

The healthcare system needs revision of the rules of the game. Consumers must own their healthcare dollar and drive the healthcare system. They should be able to buy high deductible insurance and deposit the initial at risk dollars in a tax free trust so they can pay for their initial care. If they do not spend the money in their trust account they should not be required to use it for healthcare expenses in the future. The trust account can be set up by their employer, themselves, or the government for them. Money not spent in the trust account should accumulate tax free and be used for retirement.

The self employed would be able to set up the trust with pre tax dollars just as the employer can. This would encourage young people who are well to buy insurance so that they have another source of forced savings for retirement. It is foolish for the young well person to be uninsured because illness can strike at anytime. It would also nullify the healthcare insurance industry’s complaint that the healthy young choose to be uninsured because they are paying for a higher risk pool.

Another required rule change would be the way premiums are calculated. The calculation should be based on community rating and not the archaic actuary calculations now used.

The “sovereign” should make the appropriate rules and then get out of the way and let the marketplace do the work.

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Mechanism Design and the Healthcare System

November 11, 2007

inMedicine: Healthcare System

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Stanley Feld M.D.,FACP,MACE

Last month the Nobel Prize in economics was awarded to Leoid Hurwicz, Roger Meyerson and Eric Maskin . They were awarded the Nobel Prize for developing the economic theory of “Mechanism Design.” My first reaction was “what is that?”

After some research I discovered the power of Mechanism Design. It is a brilliant economic theory that could solve many economic problems. Mechanism Design applied to our healthcare system could solve many of the problems.

What is it? “ In economics, mechanism design is the art and science of designing rules of a game to achieve a specific outcome, even though each participant may be self-interested. This is done by setting up a structure in which each player has an incentive to behave as the designer intends. The game is then said to implement the desired outcome. The strength of such a result depends on the solution concept used in the game. It is related to metagame theory, which is the theory of games the play of which consists of developing the rules of another game.

Mechanism designers commonly try to achieve the following basic outcomes: truthfulness, individual rationality, budget balance, and social welfare. However, it is impossible to guarantee optimal results for all four outcomes simultaneously in many situations, particularly in markets where buyers can also be sellers[1], thus significant research in mechanism design involves making trade-offs between these qualities. Other desirable criteria that may be achieved include fairness (minimizing variance between participants’ utilities), maximizing the auction holder’s revenue, and Pareto efficiency. More advanced mechanisms sometimes attempt to resist harmful coalitions of players.”

Lodi Hurwicz contributed the idea of incentive compatibility. His point is the way to get as close to the most efficient economic outcomes is to design mechanism in which everyone does best for themselves. He says this can be achieved by sharing information truthfully (Price Transparency). It is easy to understand that some people can do better than others by not sharing information or lying.

If everyone’s incentives are aligned you have a much more efficient economic system. An example is defense contracting. If you agree to pay on a cost plus basis you have created incentive for the contractor to be inefficient. I you agree to pay a fixed price you can come close to an efficient price if you have all the truthful information. If you do not you have incentives aligned and truthful information you create the incentive to be overcharged. Most people can do better by not sharing truthful information. If the rules of the game require truthful information you can get close to an efficient market driven solution.

The concept of Pareto efficiency means no one can be made better off without someone becoming worse off. Therefore the incentive is to maintain your dominance by not being truthful at the expense of others. Hurwicz observed as others had that the dispersion of information was at the heart of the failure of a planned economy. He observed that there was a lack of incentive for people to share their information with the government truthfully. The free market mechanism was far less afflicted than central planning bureaucracy by such incentive problems. The free market economy was by no mean immune to this defect. He observed that the free market economy can get us closer than central planning to incentive compatibility because the end consumer can drive the discovery of truthful information.

The customer creating rules of engagement in a market driven economy can get you closer to the ideal of Mechanism Design. Since the customer determines success of an enterprise by creating demand in a transparent environment they can get closer to incentive efficiency. They create the rules of the game for compatible incentive.

Roger Meyerson contributed the revelation principle, a mathematical model that simplifies the calculation to create the most efficient rules of the game. The mathematical model gets people to reveal their truthful private information leading to aligned incentives.

Eric Maskin’s breakthrough was in perfecting Mechanism Design with his “implementation theory.” His theory clarifies how to design mechanisms that heighten incentive alignment and efficiency.

How does Mechanism Design relate to the Repair Of The Healthcare System? We have to set the rules of the games so that we align all the stakeholders’ incentives without one stakeholder takes advantage of another. The insurance industry is taking advantage of the patients, doctors and hospital systems. The hospital systems are taking advantage of the patients, doctors and insurance companies. Doctors are taking advantage of the insurance companies, hospital systems, patients and the government. The government is taking advantage of the hospital systems, the doctors and the patients. Employers who pay the insurance bills for their employees are taken advantage of by the insurance companies. The drug companies are taking advantage of patients and unduly influencing physicians.

In our healthcare system everyone is pursuing his vested interest in a game that has rules that does not lead to “incentive compatibility.”

Some politicians think central planning will straighten out the rules. Historically, central planning has not worked. The winners of this year’s Nobel Prize in economics have proven this fact.

I believe the consumers can fix the rules of the game so that all the incentives are compatible. Consumers have to have incentives to force politicians to fix the rules of the healthcare game. Consumer driven healthcare system will achieve the alignment (incentive compatibility) using the ideal medical saving account.

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President Trump’s Drug Plan

November 26, 2018

inMedicine: Healthcare System, Patients Problems, Politicians,Healthcare and Vested Interests, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust

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President Trump’s Drug Plan

Stanley Feld M.D.,FACP,MACE

It is very difficult to know the truth in our post truth era. Intellectuals, elites and the well-educated are criticizing every idea the Trump administration brings forward.

He was hampered in moving forward in Repairing the Healthcare System when his own Republican Party did not pass the house of representatives’ bill to repeal Obamacare. The repeal would have enabled his administration to move the repair of the healthcare system forward quickly.

Most of President Trump’s ideas when it has related to repairing the healthcare system have been common sense. They are steps in the right direction.

Common sense solutions sometimes threaten to undermine extremely profitable private and public enterprises. The pharmaceutical industry and all related middlemen are an industry that is threatened by President Trump’s common sense solutions.

The industry will do everything in its power to spin the story so that the Trump administration’s plans sound sinister to the American public.

The American public can only make decisions on the information presented. In the post-true era the public does not know what to believe. The media has been anti-Trump and is not interested in presenting the details of President Trump’s blueprint for lowering drug prices utilizing free market principles.

“The problem of high prescription drug costs is something that’s been talked about in Washington for a long time. But that’s all it’s been: talk, talk, talk.

We are privileged to have a president finally acting, by laying out a blueprint for solving these problems using private-sector competition and private sector negotiation.

We’re not going to propose cheap political gimmicks. The President’s blueprint is a sophisticated approach to reforming and improving our system.

Everyone at HHS is rolling up their sleeves to get to work on this.”

On October 28,2018 the WSJ editorial board wrote a negative view of the Trump administration’s plan to lower drug prices. It is almost as if the editorial board did not read President Trump’s proposal as it appears on the White House web site.

I believe it is worth discussing President Trump’s blueprint for lower drug prices.

I will then present the main points in the Wall Street Journal editorial.

The blueprint starts by stating:

These are the main problems with drug prices in the U.S.

Drug costs consume 30% of the healthcare dollar. Drug costs are unaffordable to both consumers and the government. Over 40% of elderly patients consume greater than nine drugs daily. Fifty percent of those 40% experience adverse drug reactions due to drug interaction. Many end up being hospitalized thereby increasing the cost of medical care.

If a patient cannot afford to buy a drug because of its cost it will not help control their disease. A hospitalization will occur increasing the cost of healthcare.

“One of my greatest priorities is to reduce the price of prescription drugs. Prices will come down.”

President Donald J. Trump”

The public should take this comment at face value.

These are some of the facts;

According to the Organization for Economic Co-operation and Development (OECD), the United States had the highest per-capita pharmaceutical spending in 2015.
Senior citizens pay more in Medicare Part B and Part D because government rules prevent health plans and vendors from negotiating the better deals seen in other markets.

Isn’t that crazy? The government negotiates drug prices for the VA and Military but not for seniors. The government pays less than half for drugs in the VA healthcare system than seniors do for Medicare Part B and Part D.

Some hospitals that receive drug discounts under the 340B program, ultimately pushing up drug prices for patients with private health insurance.

The 340B program was enacted in 1992 by congress. Section 340B requires pharmaceutical manufacturers to enter into an agreement, called a pharmaceutical pricing agreement (PPA), with the HHS Secretary.

Under the PPA, the manufacturer agrees to provide front-end discounts on covered outpatient drugs purchased by specified providers, called “covered entities,” that serve the nation’s most vulnerable patient populations. Medicaid patients get drugs free. The government pays the pharmaceutical companies the money through a series of middlemen.

Lower-cost drugs are kept out of the market by drug companies gaming regulatory processes and the patent system in order to unfairly maintain monopolies.
Lack of transparency in drug pricing benefits special interests and prevents patients from being able to make fully informed decisions about their care.
Other countries use socialized healthcare to command unfairly low prices from U.S. drug makers. These lower prices place the burden of financing drug development largely on American patients and taxpayers and subsidizes foreign consumers.
- The United States pays more than 70 percent of branded drug profits among OECD countries.
The drug companies claim this behavior by other countries reduces innovation and the development of new treatments. They have to make the loss of revenue up by increasing the price of drugs.

The HHS executive summary outlines not only the problem it outlines the Trump administration’s solution. President Trump’s HHS team which includes CMS has spent many years studying the abuses that have led to dysfunction of the healthcare system. I believe HHS figured out the solution.

HHS has identified four challenges in the American drug market:

High list prices for drugs

Seniors and government programs overpaying for drugs due to lack of the latest negotiation tools
High and rising out-of-pocket costs for consumers
Foreign governments free-riding of American investment in innovation

Under President Trump, HHS has proposed a comprehensive blueprint for addressing these challenges, identifying four key strategies for reform:

Improved competition

Better negotiation
Incentives for lower list prices
Lowering out-of-pocket costs

There is nothing sinister about these goals. Some will work. Direct negotiation with drug companies certainly will work. The middlemen get more money per capsule than the drug company that invented and manufactured the drug. The middlemen, who are marketers, are terrified that President Trump is going to destroy their business.

HHS’s blueprint encompasses two phases:

1) actions the President may direct HHS to take immediately.

2) actions HHS is actively considering, on which feedback is being solicited.

The president and his administration are not a heartless group of politicians who don’t care about cancer drug cost. They are interested in patients receiving the best care at an affordable price. They care about fair pricing. Their goal is to eliminate the mechanisms by which multiple stakeholders game the system. This includes the multiple middlemen and the tremendous bureaucratic load.

Is the diagram complicated enough? Can you visualize all the areas of potential abuse? Do you think a government bureaucracy can control the potential abuse?

Phase one of the blueprint:

Lower prices on some Medicare Part B drugs could be negotiated for by Part D plans
Leveraging the Competitive Acquisition Program in Part B.
Working across the Administration to assess the problem of foreign free-riding.

The administration is aware of foreign free riding. They have not published a definite free market solution to change the situation yet.

Further Opportunities

Considering further use of value-based purchasing in federal programs, including indication-based pricing and long-term financing.
Removing government impediments to value-based purchasing by private payers.

“Value–Based Purchasing (VBP) Linking provider payments to improved performance by health care providers. This form of payment holds health care providers accountable for both the cost and quality of care they provide. It attempts to reduce inappropriate care and to identify and reward the best-performing providers.”

This is a stupid idea. It might save money but it tries to direct care and eliminate physician judgement. Healthcare providers will figure out how to game the system.

Requiring site neutrality in payment.

Site neutrality payment means “Under OPPS 2019, reimbursement for clinic visits in outpatient hospital settings would be capped at the rate paid for clinic visits in physician offices.”

It is about time this is happening. Hospitals are buying more and more physicians’ practices. Hospital systems bill the government hospital reimbursement prices. These prices are twice the government and private insurance companies approved office prices.

I suspect the hospital systems do not credit the physicians with this increase in reimbursement. The hospital systems leverage physicians’ intellectual property and outpatient surgical skills for the hospital systems’ own profit.

Hospital systems will fight this change tooth and nail. President Trump has the courage to go at it. Almost everyone in medicine has known about these unfair payments. However, past U.S. presidents have been afraid of the blowback from the powerful hospital lobby.

President Obama knew that this would drive physicians into selling their practices to hospital systems. The result is obvious. It would be easier to institute a single party payer system.

Evaluating the accuracy and usefulness of current national drug spending data.

Phase two;

Incentives for Lower List Prices Immediate Actions
FDA evaluation of requiring manufacturers to include list prices in advertising
Updating Medicare’s drug-pricing dashboard to make price increases and generic competition more transparent.

Further Opportunities

Measures to restrict the use of rebates, including revisiting the safe harbor under the Antikickback statute for drug rebates.

“The anti-kickback statute has been in place since 1971, but these specific safe harbors, protecting drug companies from anti-kickback laws, were introduced more than 2 decades ago.

The federal government provides an excellent resource for information about these safe harbors at the Federal Register website. It tells everything one needs to know about the opportunities for fraud and abuse in the current system. The website describes how the Trump administration plans to eliminate the government support of fraud and abuse.

https://www.federalregister.gov/documents/2016/12/07/2016-28297/medicare-and-state-health-care-programs-fraud-and-abuse-revisions-to-the-safe-harbors-under-the

In brief, the safe harbors define exceptions to situations where organizations are receiving “remuneration” for providing goods or services.

A rebate given as an incentive to provide a drug (i.e., on formulary) or to utilize more of a product (i.e., “performance rebates”) would currently qualify for safe harbor protection.”

I will discuss this in more detail in the future. This is another act of courage by the Trump administration. It is also a common sense move to reduce the cost of healthcare in our dysfunctional healthcare system.

Additional reforms to the rebating system.

Using incentives to discourage manufacturer price increases for drugs used in Part B and Part D.

The high retail pricing of new drugs on the market must be control. Many of the new drugs are a reformulation of two old drugs. The reformulation does not change the effectiveness of either drug.

The retail price of drugs used to treat cancer must be controlled someway.

Considering fiduciary status for Pharmacy Benefit Managers (PBMs)
Reforms to the Medicaid Drug Rebate Program
Reforms to the 340B drug discount program
Considering changes to HHS regulations regarding drug copay discount cards

Lowering Out-of-Pocket Costs Immediate Actions

Prohibiting Part D contracts from preventing pharmacists telling patients when they could pay less out-of-pocket by not using insurance
Improving the usefulness of the Part D Explanation of Benefits statement by including information about drug price increases and lower cost alternatives.

Further Opportunities to Reduce Drug Costs to Consumers

More measures to inform Medicare Parts B and D beneficiaries about lower cost alternatives

Providing better annual, or more frequent, information on costs to Part D beneficiaries
Insurance Contract Reimbursement for Consumers’ Rx
Share of Manufacturer Rebates.
Consumers Payers Drug Manufacturer Pharmacies
Pharmacy Benefits Manager Formulary Agreement
Copayment Network Agreement
PBM Agreement Payment for Dispensed Drugs Formulary
Rebates & Other Fees Premium Drugs
Money Contracting Dispensed Drugs
Prime Vendor Agreement Shipped Bulk Drugs Payment for Wholesale Drugs Distributor
Payment for Wholesale Drugs Shipped Bulk Drugs Distributor Agreement

Most physician do not know about this complicated system. All they care about is taking care of the patients. It is time physicians understand how ancillary providers have been ripping off the patients. Somehow, the ancillary providers manage to blame drug prices on physicians.

Finally, we have an administration that not only recognizes the problems but is not afraid to fix them.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.  

Copywrite 2006-2018

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Dear President-elect Donald Trump: Part 1

November 17, 2016

inMedicine: Healthcare System

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Dear President-elect Donald Trump: Part 1

Stanley Feld M.D.,FACP,MACE

Repairing the Healthcare System

Dear President-elect Donald Trump: Part 1

In 2008 I wrote to President-elect Obama and told him what has to be done to repair the healthcare system from a practicing physician’s point of view.

He did not listen to one suggestion.

I am going to try to help you out also. You are correct to want to repeal and replace Obamacare. It is a failure. It is also a disaster to both America’s healthcare system and economy.

The healthcare reforms you propose on you website are good so far. However they are incomplete and inadequate if your goal is to achieve a viable market driven healthcare system.

I will list the others elements with links to the documentation in future letters to you.

Patients and physicians are the two most important stakeholders in any market-driven healthcare system. They are the only stakeholders that can drive the market in an affordable way.

The insurance industry, the government, hospital systems and the pharmaceutical industry are all secondary stakeholders.

You have told a biased media that you will repeal and replace Obamacare.

They are now trying to make fun of you because of your threat to the establishment. Please ignore them.

The progressive spin machine using Ezekeil Emanuel and other surrogates are wrong when they keep repeating that neither you nor the Republican Party have not offered a viable replacement plan.

You might remind them that their plan was not very viable. What makes Ezekiel Emanuel an expert when he has never practiced medicine in a private office setting?

You and the Republican house have some very viable suggestions. Democrats refuse to read them or recognize them. They have not analyzed their economic effect on the healthcare system.

However, you do not go far enough in including the patients who are essential to drive the healthcare system. Patients must assume the responsibility for their health and care of their diseases.

Patients must be provided with treatment options and potential outcomes in order to be responsible for their health. They must also be provided with financial incentives to take care of their health.

Consumers must be in control of their health and healthcare dollars to achieve an efficient market driven healthcare system.

Obamacare treats the two most important stakeholders as economic commodities. It disregards patients’ feelings.

Healthcare policy should be built around patients’ needs and not the needs of secondary stakeholders.

The key to Repairing the Healthcare System is the promotion of individual consumer responsibility for their care. Patients must feel physicians and their healthcare team care about them.

The physician patient relationship is the most important healing element in a therapeutic equation. It can lead to patients understand and adhering to recommended treatment.

Patients must be the captains of their therapeutic team. Physicians must be the head coaches with their nurses and physician assistants being the assistant coaches.

Only then will we have an efficient and affordable healthcare system. I have written in detail about the mechanisms necessary to achieve an affordable healthcare system.

A successful and affordable healthcare system must be a consumer driven healthcare system using my ideal medical saving accounts .

Medical Savings Accounts are different than Health Savings Accounts.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

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More On The Public Option

August 4, 2016

inDisinformation and the healthcare system, Medicine: Healthcare System, Stakeholder Mistrust

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Stanley Feld M.D.,FACP,MACE

Hillary Clinton is a tax and spend Democrat. She will be an extension of the Obama administration.

Her list of promises and expenditures will continue in healthcare without success in providing better cost effective care to Americans.

Her plans for healthcare will result in increased government control of Americans’ lives and freedoms while escalating the federal deficit.

The expansion of President Obama’s failed programs will simply accelerate the path toward total collapse of our healthcare system.

Dr. Robert Kocher was special assistant to President Obama for health care and economic policy from 2009 to 2010. He was instrumental in promoting the consolidation of healthcare systems. He also encourage these healthcare systems to buy physicians practices in order to consolidate networks.

The rational was the government would then deal with one provider (the hospital system). The communications within the network would improve the quality of care and decrease the cost of care.

Theoretically, this should be true. However, the differences between the culture of hospital administrator and physicians made Dr. Kocher’s goals impossible to achieve.

“I believed then that the consolidation of doctors into larger physician groups was inevitable and desirable under the ACA.”

This last week he admitted that he was wrong and individual practicing physician groups are more efficient and less expensive than “hospital controlled networks of physicians.”

“I, along with Ezekiel Emanuel and Nancy-Ann DeParle, argued that “these reforms will unleash forces that favor integration across the continuum of care.”

“We thought only hospitals or health plans can afford to make the necessary investments” needed to provide the care we will need in a post-ACA world.”

“Now I think we were wrong to favor it.”

“What I know now, though, is that having every provider in health care “owned” by a single organization is more likely to be a barrier to better care.”

In 2010, I predicted hospital systems owning physicians would not work. Anyone with an understanding of hospital politics and hospital administrators thinking knew it could not work.

The only reason physicians let hospital systems buy their practices was because the physicians were disgusted with the intrusive government rules and regulations and they were afraid they would be left out of the growing future trend.

It was clear to me the trend was misguided political manipulation.

The best of the clinicians tried to make it work but failed. ACO’s controlled by hospital systems were destined to fail and not save money.

ACO’s that are owned by private group practices are barely saving money and profiting by that savings.

President Obama and his administration fell for the concept because they visualized it as a path to control physicians and the healthcare system.

The Obama administration and its experts never considered what the consumers might want or need.

The healthcare insurance industry is now suing the government because the government is reneging on its reinsurance commitment totaling billions of dollars.

President Obama and Hillary Clinton are calling for a public option. This is a diversionary tactic The public option is certain to fail.

The government will continue to remain totally dependent on the healthcare insurance companies for administrative services.

The reintroduction of the public option will accelerate the collapse of the healthcare system. It appears that Ms. Clinton has no idea of the unintended consequences.

The unspoken reality of the “public option” is to destroy private healthcare insurance. It is not a good idea. It will accelerate the collapse of the healthcare system.

I have written extensively about the consequences of the public option.

The government would squeeze private insurance out of the marketplace through regulatory control over access to care, premium control over consumers, and financial control over providers. The government would undercut the marketplace.

The government will remain dependent on the healthcare insurance industry to administer the services provided for all of the existing government healthcare services including Medicare, Medicaid and Obamacare.

The healthcare insurance industry would be in better shape because all the insurance risk would be transferred to the government.

The government programs are unsustainable at the moment. This unsustainability will escalate.

“While private plans must negotiate market rates with doctors and hospitals, a Medicare-like “public option” would fix payment rates by fiat, well below the rates that would otherwise prevail in a real market.”

President Obama said just the opposite in his Journal of the American Medical Association article.

“Adding a public plan in such areas would strengthen the Marketplace approach, giving consumers more affordable options while also creating savings for the federal government.”

President Obama’s statement is a total lie. However, the mainstream media is repeating the lie as a fact.

I hope President Obama and Hillary Clinton’s public option is no more convincing today to the public than it was in 2009.

It should be less convincing in the face of all the Obamacare failures to date.

Taxpayers are realizing that the public option will put them at more real financial risk. Taxpayer financial risk was clearly stated in the first version of the public option with no congressional questions asked.

The public option does not create a competitive marketplace and level the playing field. The competition will disappear at the taxpayers’ expense.

“Using a market mechanism, like a “health insurance exchange,” then adding a “public option” to undercut private plans and destroy a competitive private market was a political strategy.”

“All the public relations rhetoric about expanded “consumer choice,” promoting “market competition,” and keeping private plans “honest” was, of course, classic boob bait.”

It is clear that both Barack Obama and Hillary Clinton think the American public is stupid.

President Obama has been playing the American public for 71/2 years. He was correct when he told Senator Kerry and Representative Barney Frank that we don’t need a public opinion.

Obamacare was enough to get central government control of the healthcare system.

Let us think about it a little.

The federal government mandated coverage. The problem is the mandates didn’t work.

Then, Obamacare defined what healthcare plans are permissible.

These Obamacare regulations escalated the premiums and the deductibles to unaffordable heights.

The federal government determined what health benefits consumers could receive.

It didn’t work. If a benefit was not included, consumers bought that benefit outside the system or did not buy healthcare insurance if the benefits where too many.

Physicians started to not participate in the Obamacare system. This non-participation has caused a shortage of providers.

Some medical procedures or treatments were not covered. The government decided what should be covered, what level of coverage should exist and what copayments and deductibles were to be allowed.

Consumers have been protesting. The government has not been listening.

Obamacare has all the tools and power of the law to control the healthcare system without a public option.

However, the Obama administration and another future Clinton administration feel they must destroy the healthcare insurance industry in order to give the public no choice and compel them to comply.

The public option will also fail. It will lead to restrictions on freedoms and liberty. When this is clear the public will get very angry.

The cost of healthcare will rise, not fall, because of greater inefficiency and bureaucratic control.

There will be reams of red tape and unenforceable provisions as a result of government control.

There will be special deals to certain providers in order to avoid uncontrollable protest.

Who will lose? The poor and the middle class!

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

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President Obama Continues to Deceive i.e. The Public Option

July 27, 2016

inMedicine: Healthcare System, Politicians,Healthcare and Vested Interests, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust

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Stanley Feld M.D., FACP,MACE

President Obama continues to deceive the American people about Obamacare’s success as his term in office is winding down.

He is trying to use his charming personality to erase the fact tat Obamacare is failing.

The public must keep their eyes and ears open.

Obamacare is falling apart as the months continue. President Obama and the liberals are queuing up to pour more money into a failing healthcare reform model by reintroducing the need for a public option.

On June 30, 2016“CMS division of the HHS Dept. released the HHS Dept. released the actual Q1 effectuation report,

Each year the Obama administration has lied to Americans about enrollment in the health insurance exchange program.

As of June 30,2016, only 11.1 million people have signed up and continued to pay their premiums for Obamacare coverage in the 38 federal health exchanges as opposed to over 13 million that were published. State exchanges are closing monthly.

The latest prediction is that only 10.2 million will have insurance through Obamacare for the entire year. Eighty-seven percent of those insured through the federal health insurance exchanges have government subsidies in the government’s attempt to make health insurance purchased through the exchanges affordable.

If President Obama is correct about Obamacare providing insurance for 20 million people who did not have healthcare insurance previously then 9 million new people have signed up for Medicaid coverage.

Medicaid coverage is completely free to the recipients and is a single party payer system. The federal government presently pays for Medicaid coverage. The increased enrollment is also increasing the federal deficit.

Soon the federal government is going to dump some of the financial responsibility on participating states that are already running budget deficits.

It is only a matter of time before all the 23 state Co-Ops will go out of business and the federal health insurance exchange will take over.

Illinois is the 16^th state to close its Co-Op doors. It followed one week after Oregon Health Co-Op closed its doors.

Land of Lincoln Health received $160.1 million in loans from the Centers for Medicare and Medicaid Services. More than 54,000 enrolled in coverage from the co-op through March 31.

Where are these 54,000 people going to go for healthcare insurance?

“It’s a bad day for the marketplace in Illinois and our consumers,” Jason Montrie, Land of Lincoln Health’s CEO said. “This is the end.”

Who is going to pay CMS back for these federal loans? The state of Illinois cannot afford to pay CMS back. The American taxpayers will re-pay the loan.

So far the total number of federal loans given to the failed nonprofit insurers is more that $1.5 billion for an experiment that was destined to fail from the start.

When are the liberals and progressives going to learn? You cannot keep spending other peoples’ money. You will eventually run out.

These last two weeks have been a big distraction because of party conventions.

Hillary Clinton announced her healthcare proposals. She has proposed an increase of $40 billion dollars in mandatory federal spending insulated from annual budget fights over the next 10 years to develop community health centers.

Hillary Clinton also wants to expand Medicare by letting people age 55 years old or older to opt into Medicare.

In addition she wants a public option.

“Bernie Sanders tweeted. “Together these steps will get us closer to the day when everyone in America has access to quality, affordable health care.”

Who is paying? The middle class taxpayer will pay the burden of the increase in taxes. It will not be paid by the 50% of the entitled citizens who do not pay taxes.

This is an attempt by Hillary Clinton to expand coverage for middle-aged adults. It also gives us a glimpse at how she wants to make Obamacare her own.

President Obama was not taking this lying down. He published an article in the Journal Of the American Medical Association, a “scientific journal.” This article is complete progressive propaganda. Why the AMA permitted this publication is beyond my understanding?

In his “special communication” President Obama once more presents another Trojan Horse (A destructive program that masquerades as a benign application.) to the physicians of America and the consumers of healthcare.

“Some parts of the country have struggled with limited insurance market competition for many years, which is one reason that, in the original debate over health reform, Congress considered and I supported including a Medicare-like public plan.

Public programs like Medicare often deliver care more cost-effectively by curtailing administrative overhead and securing better prices from providers.⁵⁹^,⁶⁰

The public plan did not make it into the final legislation. Now, based on experience with the ACA, I think Congress should revisit a public plan to compete alongside private insurers in areas of the country where competition is limited.

Adding a public plan in such areas would strengthen the Marketplace approach, giving consumers more affordable options while also creating savings for the federal government.⁶¹^”

In 2009 Barney Frank and John Kerry insisted that a public option was essential for Obamacare to evolve into a single party payer system.

President Obama told them they would get to a single party payer system without a public option.

He has now changed his mind.

https://youtu.be/f3BS4C9el98

I have written extensively about the defects in a public option. http://stanfeld.com/?s=public+option

The New York Times writers did not describe the meaning or consequences of the public option in articles about both Hillary Clinton’s and President Obama’s call for a public option.

The American people should be told the real reason for the public option.

The combination of a “public option” within a health insurance exchange system was originally developed by liberal health policy analysts as a dual action mechanism to secure a “single payer” system. It presents the facade of a free market system but the end game is a full-scale government monopoly.

“If a public option became part of government-run health, the Health and Human Services secretary would establish such a plan, set its benefits, and fix its payment rates.

While private plans must negotiate market rates with doctors and hospitals, a Medicare-like “public option” would fix payment rates by fiat, well below the rates that would otherwise prevail in a real market.”

The “public option” would be a better deal for consumers rather than private healthcare coverage. The government would artificially force premiums down with subsidies. It could indiscriminately lower non-negotiated reimbursement to physicians and hospitals and force insurance companies out of the healthcare market.

It would result in an increase in federal taxes.

Additionally, the result will be a defacto single party payer system with less choice and access to care.

President Obama continues to ignore the fact that the government is dependent on the healthcare insurance industry to perform the administrative services for this government program. He ignores the fact that he needs doctors and hospitals to treat and care for sick patients.

He is only interested in financing the healthcare system and controlling the consumer’s ability to choose.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

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What Are The 3R’s?

July 22, 2015

inDisinformation and the healthcare system, Healthcare Insurance Industry, Medicine: Healthcare System, Politicians,Healthcare and Vested Interests

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Stanley Feld M.D.FACP,MACE

The 3R’s are the Risk Adjustment, Reinsurance, and Risk Corridors program built into The Accountable Care Act (Obamacare). The 3R’s were meant to encourage the healthcare insurance industry to participate in providing insurance to participants in the State Health Insurance Exchanges. President Obama has extended the 3R’s to included Federal Health Insurance Exchanges.

The 3R’s were activated because of the poor enrollment in the State and Federal Healthcare Exchanges. It was billed to offer protection to the healthcare insurance industry against any losses incurred by participation in Health Insurance Exchanges.

The healthcare insurance industry’s participation in Obamacare’s Health Insurance Exchanges was negative at first.

The Health Insurance Exchanges were viewed as a trap set by the Obama administration to control the healthcare insurance industry. In the process the healthcare insurance industry would ultimately lose money.

The healthcare insurance industry did not participate widely in the health insurance exchanges at first.

“These risk-sharing programs are often called the “3 Rs” because they are Risk Adjustment, Reinsurance, and Risk Corridor.” The three risk-sharing provisions were intended to protect insurers financially, especially in the first few years the Exchanges are in effect if activated.”

The ACA includes various mechanisms to accomplish this goal including requiring insurers to cover everyone who applies, prohibiting insurers from imposing preexisting conditions limitations, and severely limiting the factors insurers can consider in setting premiums. Obviously, these mechanisms put insurers at financial risk, since their underwriters won’t have sufficient data to predict claims costs, such as the number of people likely to enroll, their health status or claims history, or other demographic information on enrollees.

The Obama administration included this safety net for healthcare insurers. It also set the traps for the healthcare insurance industry.

Purpose of Permanent Risk Adjustment

To combat overall adverse selection since health insurance is now guaranteed to anyone who applies. Healthcare insurance carriers cannot impose pre-existing conditions limitations. They cannot vary premiums based on individual’s health status.

The trap is that the government will redistribute money between insurance carriers. The Permanent Risk Adjustment scheme is supposed to redistribute profit from insurers with lower claims enrollees to those with higher claims enrollees and losses.

All non-grandfathered insured plans in the individual and small group market, in or out of the health insurance exchanges, are supposed to pay for this redistribution of money. This redistribution is to be monitored by the federal government. (Another bureaucracy)

Does anyone think this can work? I don’t.The second R is the Transitional Reinsurance Program. It is to run from 2014-2016 and then stop running.

The Transitional Reinsurance Program’s purpose is to stabilize premiums in the individual market during the first 3 years the exchanges operate, because higher-cost (sicker) individuals are more likely to enroll early.

This program’s purpose is to redistribute money from group health plans that make a profit to certain insurers with Qualified Health Plans on the individual State and Federal Exchanges that have high cost (claims) enrollees to prevent loses for those insurance companies. This is supposed to encourage insurance companies to join the exchanges.

All group health plans are required to pay for losses in 2014. There has been no reporting as yet to let anyone know how this has worked out in 2014. This provision further exposes President Obama’s lie that “if you like your plan you can keep your plan.” He knew no one could keep their healthcare plan as the bill was written.

A specific waiver was provided for 2015 & 2016. There are a few self-insured plans that self-administer their claims. Most corporations use healthcare insurance companies as third party payers. Therefore, the wavier is essentially eliminated.

The traditional reinsurance program is going to be very difficult to administer.

The Temporary Risk Corridor for 2014-2016 makes the 3R program even more complicated and more difficult to administer.

The goal of the temporary risk corridor is to limit insurer gains and losses in first 3 years of Obamacare and place all healthcare insurance company risks on a level playing field. The healthcare insurers have a limited amount of data on the risk of claims for Health Exchange enrollees. The healthcare companies have histories of claims for Qualified Health Insurance Plans and the expected enrollment. The health Insurance companies have to guess at their actuarial risk if they participate in Obamacare in order to set premiums.

Limiting the healthcare insurance industry’s risk will be complicated for the government.

Insurers who have actual claims more than expected claims will be paid the excess if funds from these insurers are not sufficient. HHS is directed to pay the excess.

The problem is Obamacare (ACA) did not provide for creation of a specified source of funds or a revolving fund for HHS to pay this excess.

In 2014, the first year of the exchanges insurers received $450 million dollars. The source of the government funds is unclear.

An important concept about insurance reimbursement is always ignored. Insurance claims have nothing to do with the actual insurance reimbursement. Reimbursement is usually 50% less than the claims.

Therefore, the amount of supposed payment is doubled using claims to calculate payment and probably future premiums.

The government is hoping that the entire scheme is budget neutral. It will collect and redistribute the profit made by one insurance company to the insurance company that loses money from the high-risk patients.

The government thinks it will have no out of pocket reimbursement obligation.

The government plans to compare insurers within a state based on the average financial risk of their enrolled population.

“ To more evenly spread the financial risk among insurers, government payments are made to insurers who cover a higher-risk population (e.g., people who are older, sicker or have more chronic conditions) from the profit of lower risk insurers. “

Theoretically, the insurers who make a profit from the lower risk population pay the insurers who make less from their older, sicker population with many chronic diseases.

This is called redistribution of profit and wealth. I have a tough time believing that profit making companies will sign up for that.

Below are the formulas that will be used in 2014 and 2015 for the redistribution of profit of healthcare insurance companies.

“2014: Once an insurer has paid $45k in claims for an individual (the attachment point), the insurer is reimbursed for 80% of costs between $45k & $250k per person. (Originally $45k was $60k)”

“2015: $70k attachment point per insured, then insurer will be reimbursed for 50% of costs between $70k & $250k per person. HHS publishes a Notice of Benefit & Payment Parameters each March, with the numbers for following year.”

“If actual claims are within 3% of expected claims, insurers in Exchanges keep the profits or bear the risks. If claims are 3-8% more (or less) than expected, insurer pays the gov’t (or is reimbursed by the gov’t) 50% of the gains (losses) and keeps (or bears the loss of) the other 50%.”

“If claims are at least or > 8% more (or less) than expected, insurer pays the gov’t (or is reimbursed by the gov’t) 80% of the gains (losses) and keeps (or bears the risk of) the other 20%.”

It is all very complicated. It will be impossible to enforce. This is another Obamacare trick to fake out the very profitable healthcare insurance industry.

I think the healthcare insurance industry knows all this. They are taking steps at this very moment to dodge the Obama administrations trap.

The losers will be the American people who will experience an increase in healthcare insurance premiums and higher taxes.