Sacramento Business Journal, March 22, 2016. Kent Hoover

It’s as if the Affordable Care Act’s tax credits for small businesses were designed to fail: Six years after Obamacare was enacted, few companies are taking advantage of tax breaks that were supposed to make health insurance more affordable.

Only 181,000 small businesses claimed the Small Employer Health Insurance Tax Credit in 2014, according to the Government Accountability Office. That’s only a fraction of the 1.4 million to 4 million small businesses that were estimated to be eligible for the tax break, which covers a portion of an employer’s contributions to their workers’ health insurance premiums.

Businesses with fewer than 25 employees with average wages of less than $50,000 (adjusted for inflation — $51,800 in 2016) are eligible for the tax credit if they cover at least 50 percent of the cost of individual coverage for their workers.

So why aren’t more small businesses taking advantage of the tax credit?

The reasons vary from the credit being too small compared with the overall cost of health insurance, to it being too complicated to figure out. (Only companies with fewer than 10 employees and average wages of $25,900 or less are eligible for the full tax credit, which is worth up to 50 percent of premiums paid by the employer. The value of the credit phases down as a company’s size and wages go up.)

Also, beginning in 2014, you had to buy insurance through a Small Business Health Options Program exchange in order to qualify for the tax credit. These SHOP exchanges were supposed to give small businesses a better deal on insurance by increasing competition in the small group market, but they’ve proved to be a flop.

The SHOP requirement proved to be the reason why Buffalo Supply Inc., a medical supplies and equipment company in Lafayette, Colorado, couldn’t take advantage of the health insurance tax credit. Executive Chairman Harold Jackson told the House Small Business Committee in a hearing entitled “Lip Service but Little Else: Failure of the Small Business Health Insurance Tax Credit” that he ran into problems when he tried to enroll in Colorado’s SHOP exchange last year. First, the online application asked for a lot of information he didn’t have — such as the Social Security numbers, dates of birth and tobacco use of his employee’s spouses and dependents. Then, after he spent two or three days gathering this information, and 10 hours entering it into the SHOP system, he couldn’t figure out how to review the insurance plans that were available.

“I called the 800 number, and they told me they don’t give quotes to small businesses. The SHOP representative said I needed to go through a broker. When I called a broker, clearly he had heard from businesses like me about the SHOP. Even though the SHOP referred me to him, he told me, ‘I can get you a quote, but I don’t want to go through the exchange, it’s too much hassle.’ ”

Jackson ended up with a policy with a $16,380 annual premium for family coverage — more than 25 percent higher than what it paid in 2010, when the ACA was enacted. Plus, deductibles and out-of-pocket maximums are higher.

“So we are paying more in premiums and sadly our employees are also paying more when they need medical care and services,” Jackson said.

Then there are small businesses that employ too many workers or pay too well in order to qualify for the tax credit. Michael Ricco, quality manager of AEEC, a Reston, Virginia-based professional services firm, told the committee that these types of small businesses could use help with insurance costs as well.

“The size standard for companies to use this health care tax credit is on the woefully low side and should be increased so that many more legitimate small businesses can take advantage of this credit,” Ricco said.

In AEEC’s case, however, it still wouldn’t qualify for the tax credit because its workers make more than the $50,000 annual wage cap.

“We question the fairness of this cap because, it essence, it punishes our company for paying our employes a higher wage,” he said.

Even businesses that pay well need help covering health insurance costs, he said, especially since workers’ expectations for benefits increase with their salaries.

“For example, a cashier at McDonald’s is going to be thrilled with any health care coverage while a senior data architect expects a platinum health plan. So small businesses like ours are among the most in need of a tax credit,” Ricco said.

But Holly Wade, director of research and policy analysis for the NFIB Research Foundation, said the tax credit was designed in such a way that the biggest beneificiaries are small businesses that are the least likely to even offer health insurance. The tax credit isn’t likely to sway even them because it’s temporary and complicated to use.

“The small business tax credit is a much better talking point than it is a financial incentive for small businesses,” Wade said.

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LABJ Largest Insurance Agencies in LA 2016

SFVBJ Largest Insurance Brokers 2016

March 20, 2016

The Los Angeles Business Journal and the San Fernando Valley Business Journals released their lists of Largest Insurance Brokerage Agencies for 2016 and Corporate Strategies was ranked in both lists for 2016.

For the San Fernando Valley edition, the agency ranked as the 12th largest agency, while the Los Angeles edition ranked the agency as #32 amongst 50 agencies.

Corporate Strategies provides employee benefits, insurance, payroll, HR, and technology planning to business owners and professionals. The agency is a leading producer for Anthem and Blue Shield of California, as well as a distributor for Crump, American General Life, and MetLife.

Who’s the Boss of Workplace Culture?

HR professionals, managers, and employees have very different opinions about workplace culture: who drives it, what’s important to creating a great culture, and what can destroy it, according to a study by Kronos Inc. and WorkplaceTrends.com. The survey reveals the following:

Who Defines Workplace Culture?

• About one-third of HR professionals say that the head of HR defines the culture while only 10% of managers and 3% of employees agree.
• 26% of managers say their executive team defines the culture while only 11% of HR professionals and 9% of employees agree.
• 29% of employees say the employees define workplace culture while only 9% of HR professionals and 13% of managers agree.
• 40% of Millennial employees say that employees define the culture – an indication of an evolving view of workplace culture where employees feel they have more power.
• 28% of employees say that no one defines the workplace culture while only 5% of HR professionals and 7% agree.

What Improves Workplace Culture

Employees say that the three things that matter most to having a good workplace culture are pay (50%), coworkers who respect and support each another (42%), and work-life balance (40%). HR and managers are off base on their assumptions. HR professionals say the top three things that matter to employes are managers and executives who lead by example, employee benefits, and a shared mission and values. Managers say say that what matters most to employees are managers and executives who lead by example, a shared mission and values, an emphasis on taking care of customers. Twenty-five percent of HR professionals and 29% of managers say that pay is a top factor in how employees view workplace culture.

What Kills Workplace Culture

HR professionals and managers say that a high-stress environment and company growth are the most damaging to workplace culture. Employees say that not having enough staff to support goals, dealing with unhappy/disengaged workers who poison the well, and having poor employee/manager relationships are most damaging.

Other Factors

The survey also reveals that technology, job hopping, and Glassdoor-like pressure have changed the culture. Forty-three percent of HR professionals and 39% of managers say that using technology to improve culture is the biggest difference compared to a decade ago. Forty percent of HR leaders say there is more pressure to maintain an attractive culture for recruiting because more information about organizations can be easily found on sites like glassdoor.com. Twenty-three percent of HR professionals and 22% of managers say that their employees switch jobs too much to establish a solid culture.
Seventy-two percent of HR professionals and 61%, managers say that training and development improve workplace culture. Forty-five percent of HR professionals and 46% managers say that getting feedback from employees and acting on it improves workplace culture.

Dan Schawbel, founder, WorkplaceTrends says, “Among all of this interesting data, what struck me most is that 40% of Millennial employees believe that employees create the workplace culture, compared to 29% of employees. This is important. Each generation changes the workplace as they rise up the ranks. Millennials…believe the power to impact workplace culture lies predominantly with the people who do the work. HR professionals and managers should take note of this, look for ways to involve employees in the development of workplace culture, and be on the lookout for disengaged workers who may be poisoning the well – they wield more power than you may think.”

 

Source –  www.workforceinstitute.org

Death spirals loom for health insurers

Obamacare enrollment is already millions of people below original forecasts, and we could see two sorts of death spirals in the insurance exchanges of the Affordable Care Act because of premium inflexibility mandated by law and partisan unwillingness to make the necessary compromises to fix it.

It helps to think first about buying car insurance. If auto insurers were mandated to subsidize higher bad-driver premiums with lower good-driver premiums, and the penalties for not carrying insurance were negligible, good drivers would see insurance as a bad deal and would begin leaving the market. Eventually, only the bad drivers would be left, and the premiums would be so high that the car insurance market would collapse.

Now think of selling health insurance. The worst cases mean paying hundreds of thousands per patient for expensive drugs for multiple chronic illnesses and repeated hospital admissions and specialist consultations every year. In health care, the difference between a “safe driver” (i.e., a consumer who might spend a few hundred dollars a year on medical care) and a “risky driver” (i.e., a very sick consumer) is far greater in terms of costs. For every 100 health insurance customers, the rule of thumb is that just one of them will account for 30 percent of all costs, and that just five of them will account for 50 percent of all costs.

As an insurer, you don’t know how sick your customers could end up, and you’re on the hook if you get it wrong. Worse, with the ACA’s state insurance exchanges, you’re limited to pricing the riskier, sicker older customers at no more than three times the least-sick customers. That makes it a bargain for the sick and a bad deal for the young healthy customers. While the penalty for not having health insurance is the maximum of either $695 or 2.5 percent of family income, that’s a lot less than the cost of health insurance.

If an insurer gets its pricing wrong, it will make a loss and be forced to exit the business or increase premiums. But if you raise prices, those customers who don’t value your services as much as others will drop out. And who will be left? The sicker customers who know they’re going to get a better deal by staying insured with you.

But to make a profit, you also need those healthier folks onboard, contributing premiums but using fewer medical services. Without them you’ll make more of a loss, or you’ll fall victim to the death spiral of rising premiums, declining customers and higher costs. This isn’t theoretical; a generous Harvard health plan experienced such a classical death spiral some time ago.

Also, the same way a death spiral can occur within a health insurance company, it can also occur among a bunch of health insurance firms operating on the ACA’s insurance exchanges, like Covered California. If individual firms make a loss on their business or fail to make enough profit, they will withdraw from the insurance exchange. Their previous customers would seek insurance from the remaining participants, who can’t decline them. This would reduce the other firms’ profits and potentially prompt them to leave, too.

Could such a uber-death spiral occur in the insurance exchanges? Chances are yes, despite ACA design features to share losses. We know United Healthcare lost $2 million a day on that business in 2015; Highmark, $1 million a day; and Aetna lost 3 percent to 4 percent on each dollar of ACA business. Blue Cross and Blue Shield of North Carolina may lose more than $400 million on its Obamacare business and is sharply limiting ACA enrollment.

What can be done? On one extreme, a Medicare-for-all approach such as Sen. Bernie Sanders’ proposal dispenses with insurance completely. A more realistic market-based alternative would remove the mandate to purchase insurance and provide credits to poor, high-risk customers. Still other policies could include increasing competition by allowing insurers to sell across state boundaries, or better meeting customers needs by changing plan benefits and making them more affordable.

In an industry as important as health care, we need good, stable trajectories. But with the relentless partisan fights over Obamacare, don’t count on Republicans helping to prevent these ACA death spirals from speeding up.

Joel Hay is professor at USC School of Pharmacy. Marco Huesch is an assistant professor at USC Price School of Public Policy. Both are affiliated with USC’s Leonard D. Schaeffer Center for Health Policy and Economics.

Read Martin Levy’s article in CSQ January, 2016 – Why buying a mattress and life insurance are very much the same – and strikingly different. And, why life insurance companies have not embraced consumerism.

CSQ- Who Do You Love? January 2016

Source: Forbes January 2016

Consumerism in healthcare just can’t work. It can’t work because seriously ill patients are under incredible stress and can’t shop around for the best care. It can’t work because information on quality and cost isn’t easily accessible. It can’t work because healthcare spending is heavily concentrated–just 5% of the patients account for 50% of the cost. What’s the point in having a $6,000 deductible when you need a $500,000 surgery?

Of course, most of the people who tell you that consumerism can’t work in healthcare tend to work in healthcare themselves. But if they were doing such a great job, maybe our healthcare system wouldn’t be riddled with high costs, fatal medical errors, and hundreds of billions of dollars in waste and fraud.

Companies in other industries–from Wal-Mart to Trip Advisor, Amazon, andGoogle GOOGL +1.11%–have figured out ways to simplify incredibly complex systems to lower the amount of time and the cost for consumers to identify affordable, quality products. Those companies have just one thing in common: they answer to consumers.

Advocates for consumer-driven healthcare often argue that patients need more “skin in the game” in terms of actual purchasing power–and they do–but what about the biggest of big ticket healthcare items, like cancer, major surgeries, or other complex chronic illnesses? Paying one co-pay could cancel out your entire deductible. No incentive to shop after that.

Or is there?

Technology is already changing healthcare in ways that point to how market competition can work for all patients–including those with serious chronic illnesses–and could work even better if government focused on just two critical roles: lowering barriers to entry for innovative start-ups and enforcing transparency in pricing and quality metrics.

But first things first. Let’s take the argument that patients can’t shop around when they are sick. That might be true if you’ve suffered a car accident or a heart attack, but 85% of U.S. healthcare spending goes to long-term chronic diseases–when patients have the time and the necessity too make informed choices. And they will make better choices if we make the right information easily accessible first.

Companies like Best Doctors already offer expert second opinions for complex illnesses and injuries–correcting wrong diagnoses, poor treatment plans, and misguided surgeries that proliferate in our fee-for-service system. Best Doctors is a supplement to employer-based insurance, but accessible online second opinion services, from prestigious providers like the Cleveland Clinic and Mass General to start-up companies like SecondOpinionExpert are springing up as well–some for as a little as $300.

Start-up doctor finder Amino is aggregating the experience of 188 million Americans–based on health insurance claims data–and allows consumers to find doctors with the most experience treating their particular medical condition given their location, and insurance plan. Amino even sets up appointments for users.

Apps are also helping patients with chronic illnesses stay healthier, longer.Diabeo is a smartphone app (available on iTunes) for patients with Type 1 Diabetes that processes users’ data on carbohydrate intake, pre-meal blood glucose, physical activity and plasma glucose targets with “automatic algorithms for the adjustment of carbohydrate ratio and basal insulin or pump basal rates” when glucose levels are too high or too low.

Diabeo also transmits users’ data to secure websites monitored by medical staff that can provide real-time consultations. A study in Diabetes Care, the journal of the American Diabetes Association , concluded that “the Diabeo system gives a substantial improvement to metabolic control in chronic, poorly controlled type 1 diabetic patients without requiring more medical time and at a lower overall cost for the patient than usual care.”

Hospitals are even getting into the act. Driven by the increasing prevalence of high deductible health plans among employers and the Obamacare exchanges, hospitals are finally starting to review their own prices and analyze “how much those services actually cost to deliver, something that providers have rarely done before,” according to Modern Healthcare.

Of course, they’re not being altruistic. The growing prevalence of cost calculators like Castlight and Guroo, and the growing push for all payer claims databases (APCDs), are shedding more light on the enormous cost differences for the same services at different hospitals–some of which are across the street from each other.

Another strategy gaining steam is reference pricing–reimbursing high quality, affordable healthcare services 100%, but requiring patients to pay for higher cost providers out of pocket (think of it as a reverse deductible). Reference pricing can be applied to a wide range of “shoppable” procedures and services, “including hospital procedures, ambulatory surgical procedures, laboratory tests, imaging procedures, and drugs.” James C. Robinson, an economist at the University of California, found that for the diagnostic tests covered by reference pricing at Safeway, a large self-insured employer, “reference pricing resulted in declines in the average price paid by Safeway of 18% in the first year, 22% by the second year, and 28% by the third year, compared to the prices paid for tests not subjected to reference pricing.”

Here’s where the government could tip the scales even further in favor of consumers. Entrepreneurial governors and legislators can strip away Certificate of Need laws, allowing new facilities to compete with incumbent hospitals, and repeal prohibitions on the corporate practice of medicine–allowing new firms to enter healthcare markets and offer more affordable bundles of goods and services. States can also do a lot more to encourage provider competition by allowing all practitioners to practice at the top of their licenses, paying for the same service at the same price, regardless of who delivers it. Encouraging telemedicine would be another step in the right direction.

As of December 2015, 18 states have enacted APCDs, with about a dozen more waiting in the wings. With appropriate privacy protections, APCDs should be opened to commercial researchers that want to leverage big data to help patients navigate the healthcare system by benchmarking provider networks to help identify high-quality, lower-cost providers. Consumers and employers could then find centers of excellence that may not have recognizable names, but provide top-quality care for specific conditions.

States should also prohibit anti-steerage contracts that limit the information that insurers can tell patients about competing doctors or hospitals–blocking consumers from knowing which in-network hospitals might have lower co-pays or co-insurance.

Finally, Congress should get into the act, too. It should repeal the ACA’s prohibition on physician-owned hospitals. While traditional hospitals have argued that physician-owned facilities cherry pick their patients, there’s little evidence to support this contention–and a lot of evidence that for the services they do offer, they offer very high quality services at lower cost.

Rather than focusing on how healthcare worked in the past, policymakers should encourage competition by clearing away outdated regulations that prevent savvy, tech-based entrepreneurs from empowering patients with the information they need to find the providers who deliver the best outcomes–often at a more affordable cost.

In short: power to the patients.

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