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Consolidation in Health Insurance Carriers – Who will be the king of risk management?

Posted Apr 09 2009 6:21pm

Consolidation has been going on in all areas of healthcare and insurance has been no exception, but now the stakes seem to be a bit higher as it’s not a matter of taking over a small entity, they are getting bigger.  With bigger comes bigger patient data bases, bigger negotiating terms…bigger…bigger…and bigger. 

You would almost have to be living underneath a rock today not to see what happens when this occurs.  The original plan of sharing cost with private insurers may not have been a bad idea initially, until the greed factor set in with the race to product bigger profits over the years, and that’s pretty much where the problem lies, and if you take a look at how much money is found in the rainy day reserve funds, that could offer a clue here over what has happened over the last few years.

This comes back to the use of business intelligence, and perhaps not the best for healthcare for humans, but they have done a fine job on figuring out where they want to place their money, and sometimes it’s not always directed at claims.  They all have venture capital entities to invest in even more risk management systems and software.  It’s a race to see who can offer the latest convenience features for the patients, and yet when it comes to the chopping block on healthcare, the cherry picking still continues.   This week in Michigan, the folks who have had a sex change operation can no longer be insured by Blue Cross, so what’s the next criteria to be assigned?  The same Blue Cross group also contributed funds to the Blue Cross Venture Capital group.  The criteria for coverage is getting tougher to qualify as well as drumming up the dollars to pay.  If a woman is pregnant, there are some pretty stringent algorithms in place to get right down the the point of whether or not a woman is pregnant and if before the beginning date of the policy, well she is out of luck.  So what’s the next answer here, a device that records and determines the exact date a woman conceives?   This type of scenario could be much closer than you think as much of this technology is out there, but perhaps not formally introduced. 

Devices hold a big interest with risk management, and some of it falls under what I call “intrusive” technology.  Here’s a company exploring those areas with their offerings and they just received a big lot of of investment funds.  Is this acceptable behavior?  Sure the choice is up to the employer, but are there additional dollar incentives to provide proof? 

The Health Coach/Insurance Company – Employer plan to uses devices and phones for employees to prove their physical activity

This device company states right on their web site that their target market is employer insurance, a device that is in essence a human audit trail.

The Muve Gruve Device Measures your Inactivity – Intrusive Technology with a Human Audit Trail?

Again, I believe in education is the best tool for people to learn about better healthcare without being punished, which is what appears to be an emerging foundation here.  The bigger the carriers get, the more funds available for additional venture capital investments too?   The examples above are only a couple and there’s more, just search on the web and read up on business models.  A couple weeks ago there was story on the web about all the guidelines for one carrier being posted on the web by mistake. 

Some of the results of risk management being over calculated:  Desperate Hospitals

One other additional item that enters the picture here too is the merging of Science and Clinical care, it is here to stay and there’s a lot of stimulus money going toward research so we can enhance healthcare and cure diseases, but again with the imbalance we have today, this area too just don’t seem to mix very well with risk management and again you would have to live under a rock not to see this if you read the news.  Risk management, Science and Healthcare as an entire entity are just not patient friendly a they should be; and as long as we have this imbalance and inability to work together, not much hope on the horizon it appears.  As stated in this article, it’s false promise.  BD 

Talk of potential mergers in the medical insurance industry has doctors and hospitals worried about health plans having too much clout over consumer choices and prices.
Speculation has run rampant that some of the nation's biggest health plans may be looking to consolidate, including a possible takeover of Humana Inc. by Aetna Inc., as well as UnitedHealth Group's interest in Coventry Health Care Inc.
Already, one in six metropolitan areas in a 2008 study of more than 300 U.S. markets is dominated by a single health insurer that controls at least 70 percent of enrollees in health maintenance organizations or preferred provider organizations, according to the American Medical Association.

"The promise of saying we are going to come together and have administrative efficiencies and these other projected savings never materialize," Rohack said. "Most of these [health plans] have different IT platforms and software, so it is a false promise of being more efficient compared to what their track records are."

Health insurance: Consolidation of insurers a concern for medical providers -- chicagotribune.com

Related Reading:

Physicians are not a real happy group today - survey

The 2 New Hot Words in Healthcare: Algorithms and Whistleblowers

Doctors fight balance-billing ban on out-of-network costs to survive
Will Greed lead to Meltdown of the Health System?
“Beware of Geeks Bearing Formulas”…Warren Buffett

Blue Cross Blue Shield No Longer Covering Gender Reassignment - Michigan

The AMA and the California Medical Association file legal suit – WellPoint and Ingenix
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