Official slams insurer over exchanges: Experts react

Back in November, UnitedHealth Group noted an estimated $425 million reduction in earnings in the fourth quarter of 2015 “driven by 2015 and 2016 individual exchange product pressure.”

Related: UnitedHealth Group may exit ACA exchanges: What to Know

But California marketplace leader Peter Lee recently publicly bashed UnitedHealth for placing the earnings reduction blame on its participation in the health insurance exchanges.

He scolded the nation’s largest health insurer for “throwing the ACA under the bus,” and feeding “this political frenzy that ObamaCare doesn’t work,” according to Kaiser Health News. Lee, a defender of the health law and a former Obama administration official, went on to say that UnitedHealth should take responsibility for nearly $1 billion in losses and stop blaming the Affordable Care Act.

In a statement to Managed Healthcare Executive, UnitedHealth said: “Our actions are consistent with our long-stated approach to continually evaluate the dynamics of exchanges as they evolve, and to refocus our resources as necessary so that we can provide consumers with quality access to care.”

Three sides to every story

Managed Healthcare Executive asked industry watchers to react.

Brill

“In any argument, there are three sides: yours, mine, and the truth, which is usually somewhere in the middle-this is one of those situations,” says Managed Healthcare Executive Editorial Advisor Joel Brill, MD, chief medical officer at Predictive Health.

“Mr. Lee, previously the deputy director of CMMI [Center for Medicare & Medicaid Innovation] before becoming the executive director of Covered California, has every incentive to make the exchange work in California, and has no qualms about public shaming,” Brill says. “At the same time, the

that some of UnitedHealth’s troubles may have been self-inflicted; offering broader provider networks that tend to attract sicker customers who incur big medical bills can result in losses if the premiums aren’t priced correctly.”

Graham

John R. Graham, senior fellow at the National Center for Policy Analysis, believes that there is no hope for managed care executives to resurrect their Obamacare business plans.

“The current Congress will not stand for it,” Graham says. “I expect the exchanges are dwindling into high-risk pools. For a large insurer like UnitedHealth, exchanges can be written off and they can retreat into their traditional markets. However, some insurers will find it harder to extract themselves. And those that made a big commitment and decide to withdraw in the next year or two, thereby threatening the careers and reputations of political appointees like Mr. Lee, can expect to be publicly eviscerated by them.”

Next: Experts share key takeaways

When it comes to the exchanges, the experts offered these lessons:

• Price products accordingly.

• Manage your business, including select networks, aggressive medical management, early care management, Medicare Advantage, such as drug plans, etc. 

“Provide data to identify providers that are guilty of overuse and unnecessary services,” Brill says. “Embrace providers who are willing to develop bundle/episode payments for outpatient conditions; their success in managing conditions will be your success.”

• Be prepared to provide assistance to those who may (still) have pent-up diseases that have been sub-optimally treated for years. 

“Be aware of the social service needs of these patients,” Brill says.  “Offering preventive services at no cost is of no value if people can’t get to providers and the network is to narrow and unable to accommodate those with complex conditions.”

• “Ostrich behavior” (putting your head in the sand and wishing problems will go away with a new administration) isn’t going to happen, according to Brill.

“The [country] needs a healthy and productive workforce, and we need to control healthcare costs in order for our products to be competitively priced in the world markets-exports drive our economy,” Brill says.

• The exchanges are here to stay.