Health Insurance


June is Pride month and our annual round-up of the latest insurance news around the LGBT (lesbian, gay, bisexual and transgender) community takes on added significance with today’s U.S. Supreme Court decision on same-sex marriage.

The Supreme Court decision in Obergefell v Hodges means that the U.S. Constitution guarantees a right to same-sex marriage in all 50 states. This has a number of implications for health, life, and auto insurance.

For example, health and life benefits that currently exist in states that recognize same-sex marriage will–once the law goes into effect–extend to all states.

Some of these benefits include: coverage of a same-sex spouse and children under health insurance plans; equal tax treatment of health insurance premiums for married gay couples; and recognition of a spouse for survivor benefits, including social security and life insurance.

For auto insurance offerings, too, this means that LGBT customers who are married will be entitled to the married rate, regardless of where they live.

Esurance, one of the first car insurers to extend the married rate to LGBT customers, points to what equality means for auto insurance in a just-issued press release here.

For LGBT couples who are married or are planning to get married, Esurance offers the following advice:

In addition to saving money with the married rate, married couples in states newly recognizing same-sex marriage can be identified as a spouse on their partner’s insurance policy. This will allow them to receive additional benefits on that policy such as coverage while driving a rental or borrowed car.

Until the ruling goes into effect in individual states, Esurance will continue to extend its married rate to either married gay couples, domestic partners or those in civil unions—even in states that have yet to recognize same-sex marriage. Something it has done since 2011.”

I.I.I. chief actuary Jim Lynch brings us some surprising numbers on America’s addiction to opioids:

Americans are grossly misinformed about the dangers of opioid drugs, according to a recent survey by the National Safety Council (NSC).

Opioids are commonly prescribed painkillers like Vicodin, OxyContin and Percocet. The drugs are meant to mimic the nervous system actions of heroin and morphine and all too often lead to similar levels of addiction and suffering. More than 170,000 Americans have died from opioid overdoses this century, nearly triple the number of U.S. military deaths in Vietnam (see my earlier post).

I wrote about the epidemic in Contingencies magazine, focusing on the toll the drugs have taken in the workers compensation system.

Too few Americans are aware of this risk, according to the survey of 1,014 adults, reported in the March 24 edition of Workers’ Compensation Report. Just one in five considered opioids to be a serious safety threat. Only 12 percent said addiction was a concern; two-thirds were unconcerned about any side effects from the drugs.

Education is part of the problem. Only 29 percent of respondents said they had taken or been prescribed an opioid in the past three years, though the number jumped to 42 percent once they were provided with a list of common opioids.

Nearly 60 percent of users had at least one addiction risk factor. Common risk factors include alcoholism, depression, use of psychiatric medication or being the victim of physical, mental or sexual abuse.

Users held opioids in high esteem. For example, 78 percent said they were the fastest method of pain relief, 74 percent said they were stronger pain relievers than alternative prescriptions, and 71 percent said they were the best way to relieve pain.

They underestimate the risk. Though 16,235 people died from prescription drug overdoses in 2013, just 19 percent of survey respondents said they had major concerns about the risk of injury or death from the drugs.

That’s less concern than they had about injury or death from severe weather or a natural disaster, from which 586 people died in 2013, and about the same level of concern as riding in a commercial airliner in the U.S., an activity that in 2013 killed eight, roughly 0.5 percent as many as opioids.

Details on the NSC survey can be found here.

Here’s a simple chart that compares the number of people killed in the opioid epidemic from 2000 to 2013 with the number of soldiers killed in the Vietnam theater, writes I.I.I. chief actuary Jim Lynch.

2015.03.20 LYNCH opioid graphic

Opioids are legally prescribed drugs designed to safely mimic the painkilling effects of heroin and morphine. They have not proved as safe as had been hoped.

The drugs killed more than 170,000 over 14 years, about three times as many as this country lost in Vietnam. The Centers for Disease Control and Prevention (CDC) provides the data for opioids, and Vietnam statistics come from the Congressional Research Service (CRS) and National Archives.

I compare the epidemic to warfare because I became aware of the issue at a 2014 Workers Compensation Research Institute (WCRI) conference, when a Boston poll noted (if memory serves) that for every Massachusetts fatality in Iraq or Afghanistan, there were eight opioid victims. It’s also valuable, I think, to compare the War on Drugs with the more traditional battlefront.

Sometimes opioids like OxyContin, Vicodin and Percocet are referred to with the general term narcotics, as I did in an article for Contingencies magazine that traced the epidemic’s impact on workers compensation insurance:

Chances are good that if you’ve made a workers comp claim, you’ve had opioids in [your] medicine cabinet. Narcotics made up 25 percent of workers comp drug costs, according to the National Council on Compensation Insurance (NCCI), and more than 45 percent of narcotics costs pay for drugs containing oxycodone.”

There is some relatively good news. Opioid deaths appear to have peaked in 2010 at 16,917, the CDC reported last month. In 2013 the toll was 16,235.

By contrast, 16,899 died in Vietnam in 1968, the most violent year of the war. So the opioid epidemic has leveled off to deliver tragedy as frequently as the worst year of the Vietnam War.

On another front the news is not good. Opioid addicts often turn to heroin when their prescriptions run out, and the number of heroin-related deaths rose 39 percent last year, to 8,257, the CDC reports. That’s in addition to the opioid toll.

Together, opioids and heroin killed 215,031 between 2000 and 2013, about 80 percent more than the approximately 120,000 U.S. military deaths since World War II.

I.I.I. chief actuary Jim Lynch reports from the Workers Compensation Research Institute (WCRI) annual conference:

An important cost-control mechanism of the Affordable Care Act could end up annually shifting hundreds of millions of claim dollars into the workers compensation system, preliminary research by the Workers Compensation Research Institute (WCRI) indicates.

The mechanism is the Accountable Care Organization (ACO), and WCRI researchers used the ACO’s similarity to Health Maintenance Organizations (HMOs) to estimate the nature of the cost shift as well as give a general idea of its magnitude.

An ACO is a network of doctors and hospitals that share the financial and medical responsibility for a group of patients. The ACO receives a set amount per patient for a year, regardless of the services each patient receives, a structure known as a capitated plan. HMOs are another type of capitated plan. The difference: an ACO can be paid more if it saves money while providing high quality care.

This difference gives some health experts hope that ACOs can rein in healthcare costs better than HMOs do. They believe healthcare will respond to the profit incentive ACOs offer.

The Affordable Care Act encourages ACOs and other capitated plans.

WCRI’s research indicates that capitated plans tend to push sprains, strains and other soft tissue injuries into the workers compensation system, WCRI Executive Director Richard Victor told about 300 attendees at the organization’s annual conference in Boston on March 5.

Often it is hard to tell exactly what caused a strain like a sore back, Victor said. It may have come while at work or at home. Usually the classification is the doctor’s decision.

In an ACO or any other sort of capitated plan, the doctor has a choice: call the injury work-related and bill the workers compensation insurer or decline to do so and collect no additional fee. The financial incentive is obvious.

The WCRI study looked at a nationwide sample of more than 700,000 claims from 2008 to 2010, about 17 percent of which came from HMOs. It classified states into two buckets, depending on how prevalent HMOs were.

In states with a relatively large HMO presence, HMO doctors put 26 percent of soft tissue injuries into workers comp. That was 30 percent more often than doctors in traditional fee for service arrangements.

For injuries like a broken arm, where it was easy to know what caused the injury, HMO and fee-for-service doctors put about the same percentage of claims into workers comp.

States with fewer HMOs didn’t exhibit the same shifting, the study indicated.

It is harder to estimate the financial impact, because it’s hard to say how popular ACOs will become. To develop an estimate, Victor hypothesized that ACOs could increase the percentage of workers in capitated plans by 25 percentage points. Such an increase would allow capitation plans to regain the 15 percentage points of market share they have lost since 2000 and then some.

Under that scenario, cost shifting in Illinois would push $90 million of claims into workers comp. In Pennsylvania, the shift would cost workers comp insurers $55 million.

I.I.I. chief actuary Jim Lynch previews the Workers Compensation Research Institute’s (WCRI) Annual Issues & Research conference:

This time last year, property/casualty insurers worried how the Affordable Care Act’s rollout would affect workers compensation insurance. The debate seemed to disappear as the law took hold, but research to be unveiled at a March workers compensation conference in Boston might return the issue to the limelight.

The big fear a year ago was cost-shifting, and both health insurers and comp insurers felt costs would be shifted onto them. The issue was the borderline claim, one that could arguably be a health claim or a comp claim.

Consider a person with a lingering back injury. The injury could have been caused by heavy lifting at work or at home, and the injured person might be able to make a claim on either health insurance or workers comp.

Comp insurers worried that the ACA was tightening health insurance cost controls better than comp insurers were allowed to. As the cost containment took hold, cases that straddled the border might drift into the workers comp world.

Health insurers, meanwhile, worried that they would take on claims of the previously uninsured, some of whom used to find a way to make that borderline case into a workers comp claim.

Research swung both ways. As the law has rolled out, the issue dissipated, at least among the mainstream media. If there was an impact, it appeared to be too small to measure.

Now the Workers Compensation Research Institute (WCRI), a Cambridge, MA, not-for-profit organization has looked at the ACA/comp issue again, specifically the potential effect of accountable care organizations on the workers comp system.

Accountable care organizations add to health care’s alphabet soup by being known as ACOs. They are groups of doctors, hospitals and other health care providers that combine to form networks that coordinate patient care. If they can save money while keeping quality high, they share in the savings. Kaiser Health News has a Q&A with details on how ACOs work.

The health care law offers incentives to create ACOs, but WCRI’s research indicates that “as ACOs become the norm, the number of workers compensation claims is very likely to increase,” said Richard A. Victor, WCRI executive director. The dreaded cost-shifting may be on its way.

Details of WCRI’s analysis will be released at the organization’s annual Issues and Research Conference March 5 and 6 in Boston. Other sessions at the conference will cover physician-dispensing of drugs, low fee schedules, a look at workers comp reform over the past two decades and look at challenges the line of business faces in the years ahead.

The I.I.I. has an Issues Update on workers compensation, one of the oldest casualty lines of business and one of the most complex.

As we look ahead to tonight’s State of the Union address, I.I.I. chief actuary Jim Lynch brings us a book review on the perennial issue of health insurance:

When Target wants to sell more shirts, it puts them on sale. The retailer knows that the less something costs, the more likely you are to buy it.

Health care is more complicated, in no small part because the customer is buying something he or she would rather not need. If your doctor halved the fee for open-heart surgery, for example, you wouldn’t submit to it twice.

For other procedures, the situation is murkier. Most people would submit to an extra blood stick to ensure they were disease-free, particularly if somebody else (read: the insurance company) paid the bill.

To an economist, the possibility that consumers run up a tab on health insurers is a moral hazard. Another moral hazard is the tendency of insured people to smoke and eat more, because someone else will pay for the resulting maladies. Both were an important points in Moral Hazard in Health Insurance, a book culled from lectures at Columbia University in 2012. I reviewed the book in the latest issue of Contingencies, the magazine of the American Academy of Actuaries.

The main lecture, by respected MIT economist Amy Finkelstein, dissected a natural experiment that resulted from a funding shortage in Oregon. The state only had enough money to put 10,000 people on Medicaid, but it had far more people who qualified for the program.

The state held a lottery. Some people held the metaphorical winning tickets, and they got health insurance. The rest did not.

Though potentially tragic for the losers, the lottery created something social scientists like, a randomized sample that let them study how the behaviors of the insured and uninsured differ in the real world. They found that the insured did indeed consume more health care than the uninsured.

This finding is important because it supports ideas long held in the insurance world that higher deductibles and other forms of cost sharing reduce losses by giving all participants “skin in the game.”

My review also noted that some medical professionals participate in their own variety of moral hazard.

To find out more about health insurance, check out this Facts and Stats item at the I.I.I. website.

I.I.I. chief actuary James Lynch brings us a grim story on drug abuse and how it affects insurers:

This week Contingencies magazine published my article tracing how America’s latest drug epidemic has affected workers compensation insurance.

The epidemic comes from 20 years of gradually increasing use (and abuse) of opioids, a special class of prescription drugs that mimic many of the effects of heroin. Some you may have heard of, like Vicodin or OxyContin. Prescribed legally but highly addictive, they have become the most commonly abused class of drugs in America.

More people die from drug overdoses in America than from car accidents, and opioids lead the tragic parade. In 2010, for example, 16,652 people died from opioid overdoses, more than from heroin and cocaine combined. Opioids toll has tripled since the late 1990s.

My article shows how the growing epidemic played out in workers comp. Narcotics make up 25 percent of workers comp drug costs, and more than 45 percent of narcotics dollars pay for drugs containing oxycodone, according to the National Council on Compensation Insurance.

Insurers have acted as the crisis emerged, and now they as well as federal, state and local officials may be making headway against the problem.

Last week, after my article went to press, AIG’s new chief executive, Peter Hancock, noted his company had teamed with Johns Hopkins University to study opioid abuse among the company’s 23 million workers compensation claims.

“It is a terrible cost to the industry, a terrible cost to employers, and it’s a terrible cost to society,” Hancock told The Wall Street Journal. AIG has medical professionals working with doctors to find ways to alleviate pain without turning to opioids.

The most recent federal action reclassifies any drug containing the opioid hydrocodone as a Schedule II drug, meaning its prescriptions are more tightly controlled than before.

Unfortunately, these actions may be too late to prevent many opioid addicts from switching to heroin. Opioids tantalize the same brain receptors as heroin, and there are signs that addicts deprived of their Oxys switch.

American businesses lose an average of 2.8 million work days each year due to unplanned absences, costing employers more than $74 billion, so it’s with interest that we read of a significant increase in absence due to obesity and skin cancer in a just released study by Cigna.

According to Cigna’s analysis of 20 years of short-term disability claims, claims related to obesity increased by 3,300 percent between 1993 and 2012.

In 1993, obesity ranked 173 out of 267 diagnostic drivers of absence, accounting for 0.04 percent of claims that year. By 2012, obesity had jumped 133 places to number 40 on the list, accounting for 0.70 percent of claims.

Hat tip to Business Insurance which reports on this story here.

Cigna also reports that new claims and absence related to skin cancer increased more than 300 percent in the 20-year period.

Between 1993 and 2012, skin cancer jumped from 91 to 27 on the list of diagnostic drivers of absence, and its share of claims had increased to 0.9 percent in 2012, up from 0.2 percent in 1993.

The analysis also shows a 45 percent increase in work absence due to the surgical treatment of herniated discs, the most significant increase in short-term disability claims among sedentary occupations over the 1993 to 2012 period.

Cigna notes that the most frequently approved short-term disability claims both 20 years ago and today, remain musculoskeletal disorders, which make up 25 percent of all non-maternity absence.

In a press release, Dr Robert Anfield, chief medical officer for Cigna’s disability insurance unit says:

The aging workforce and a trend towards growing waistlines has made some medical conditions more dominant factors for short-term disabilities than they were 20 years ago. For example, arthritis and tendonitis-related absences have both increased more than 50 percent since 1993.”

However, the study found significant changes in short-term disability rates for obesity, cancer, depression and herniated discs that uncover the impact of medical advances on absence and productivity.

Check out I.I.I. facts and statistics on disability.

Check out an I.I.I. study on obesity, liability and insurance here.

I.I.I. chief actuary James Lynch reports from Day 2 of the WCRI annual conference in Boston:

Health insurance and workers compensation are sort of kissin’ cousins, in that changes that affect one inevitably affect the other.

But that’s my metaphor. Dr. Richard Victor, executive director of the Workers Compensation Research Institute (WCRI), likens the impact of health care reform to a hurricane.

Like a storm whose path is not quite defined, health care reform could take a significant toll – but we don’t know precisely where. Since workers comp differs from state to state, the impact of the Affordable Care Act (ACA) will differ from state to state. Like a good weatherman, Dr. Victor told an audience of about 400 at WCRI’s annual conference in Boston on Thursday he could make some educated guesses what might happen.

He is assuming the ACA is enacted exactly as written – a tough assumption but as good a starting point as any. In that case, the increase in insured Americans will increase demand.

The marketplace might decrease the use of doctors, relying instead on well-trained nurses or even sophisticated computers to help provide care.

Or doctors might raise prices in the face of rising demand.

What actually happens will differ by state. Some states make it difficult to take diagnosis and treatment out of the doctors’ hands. In those states, medical costs – and their kissin’ cousin, comp costs — are likely to rise. Elsewhere, the effect will be muted.

Other insights:

● Health care reform will result in a healthier work population. This will tend to help the comp system, because healthy workers are less likely to get hurt on the job, and if they do get hurt, they get well faster.

● Changes in billing, Dr. Victor said, will “absolutely” lead to upcoding – in which a doctor exaggerates the severity of a treatment to receive a bigger reimbursement. The practice is well-documented in workers comp, he said, citing examples from Florida and California.

● Changes are likely to shift into workers compensation. That’s because many employers are increasing deductibles that employees pay for treatment. Workers comp, meanwhile, has no deductibles and no co-pays – giving an employee the incentive to label an injury as work-related.

I blogged about Day 1 of the conference here. Other highlights from Day 2:

● Alex Swedlow, president of the California Workers Compensation Institute (CWCI) noted that even after all appeals are exhausted only about five percent of denials of comp claims are overturned. Swedlow also said evidence-based pain management guidelines effectively control costs; and a comparison of California and Washington pharmaceutical costs show that more cost savings are possible.

● Harry Shuford, chief economist of the National Council on Compensation Insurance (NCCI), argued that underwriting cycles are closely linked to bond yields and that when it comes to managing their business, insurers in the long run “do a much better job than other financial intermediaries” like banks.

Workers compensation insurance will have to move quickly to keep from being a net loser from health care reform, said Dr. Jonathan Gruber, one of the architects of what ultimately became the template for the Affordable Care Act (ACA).

Dr. Gruber, an MIT economist who helped construct the Massachusetts health reform that the ACA modeled, spoke to more than 400 attendees at the Workers Compensation Research Institute (WCRI) conference in Boston.

Health care reform should help the workers compensation system, he said. Fewer workers will be uninsured, so fewer people will get injured over the weekend and then claim on Monday they got hurt at work.

But Dr. Gruber, an MIT economist, noted that the comp system is incredibly inefficient. It pays higher rates for services than most health plans. And it changes slowly, which could be a big disadvantage as the ACA forces efficiency on the other parts of the health care system – hospitals, doctors and health insurers. If the comp system can’t keep up, the rest of the system will find ways to dump costs on it.

Dr. Gruber said it will be three years before we can tell whether ACA has been successful. At this point – in ACA’s early days, its proponents and opponents are “saying too much.”

Gruber also gave a nod to researchers like those at WCRI. With ACA’s many moving parts, he said, it will be important to intelligently determine which of those parts are truly working.

Day One of the WCRI conference also featured two examinations of how changes in state comp laws play out.

The first showed how Texas successfully reduced the rate of claims through changes enacted in 2002, 2003 and 2005. The changes brought individual claims under greater scrutiny.

The good news: the rate of claims in Texas lagged those of 15 states studied, said WCRI senior analyst Carol Telles. The rate of claims from chiropractors fell more sharply than other professional services, though Texans continue to use chiropractors more than the other states.

Costs per claim, though, increased, in part because the changes aren’t free. It costs money to review claims. Any changes to a workers comp system must consider whether savings will be able to justify those costs.

The second study showed how Illinois took a more blunt approach in 2006. It cut fee schedules 30 percent across the board. One interesting result, said senior public policy analyst Rebecca Yang: costs per claim fell, as you might expect, but only by 24 percent overall.

Among the reasons: the rate of claims increased, and there were signs that doctors were billing for more complex office visits than before.

Day Two of the conference will take a longer look at the impact of ACA on workers comp. Other sessions will look at how the economy drives workers comp results; accountable care organizations; and medical dispute resolution.

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