As you might have guessed from my previous posts, I’m more or less in favor of the health care reform mandates, but there are still individual rules I’m concerned about, and some I’m definitely confused about. This post focuses on one such confusing rule--the requirement for payers to use 85 percent member premiums toward the MLR (Medical Loss Ratio). Simply, payers must spend at least 85 percent of the amount they collect toward the cost of care.

On the surface it’s a very admirable goal. Restrict your administrative overhead to 15 percent by making the organization more efficient and hence reduce the overall cost of care. Not bad. But when I start thinking about it a bit more, certain flaws in the logic emerge that could render the whole mandate impotent.

The success or failure of any mandate hinges on the incentives and penalties associated with it. In the case of the MLR, there doesn’t seem to be much of an incentive, but the penalty is pretty drastic:  i.e., reimbursing members the difference between 85% percent and the actual spend on the MLR via monthly reimbursement checks. Basically, if a payer can’t maintain the 85 percent MLR and is sitting at somewhere around 83%, the payer will be required to distribute reimbursement checks for 2 percent (the differential) of the premiums they collected.

Also, payers can’t combine different lines of businesses and other corporate entities to calculate overall MLR. Doing so would have enabled payers to consolidate some efficient and some not-so-efficient units together in order to protect themselves from MLR-related penalties.

Let’s take an example (I promise you, it will get a bit complicated, so please bear with me) to try to figure this out. Industry research indicates the average payer is sitting at somewhere around 78 percent of MLR. But for the sake of example let’s put one at 80 percent. That means the payer spends $80 for every $100 it takes in premiums on the reimbursement for medical costs, and around $20 on administrative costs, including the cost of sale (such as brokerage fees), salaries, I.T. systems and infrastructure support, profits, etc.

Category

Dollar

% of premium collection

Premium

100

100%

MLR

80

80%

ALR

20

20%

 

Now to bring the MLR up to 85 percent, there are two things a payer could do,

1.       Reduce the overall premium revenue by $5.89, so that the $80 being spent on the MLR side will represent 85 percent of overall premiums.

Category

Dollar

% of premium collection

Premium

94.11

100%

MLR

80

85%

ALR

14.11

15%

 

2.       Maintain the premium dollars but redirect an additional $5 from the administrative loss ratio (ALR) costs to MLR costs, thereby increasing the reimbursements being made to providers.

Category

Dollar

% of premium collection

Premium

100

100%

MLR

85

85%

ALR

15

15%

 

In the first scenario, the positive is that the premium is going down and hence the consumers (employers and employees) are benefitting. The downside is the cost of actual health delivery has not been reduced, i.e., providers are still not incentivized/penalized for redundant or non-standardized procedures. This means the inherent ills of the health care delivery are not being resolved, just a pseudo-reduction is being achieved through tightening the belt on the payer side.

Under the second scenario, it’s even worse. Instead of striving to penalize the providers for non-performance, we are actually incentivizing them to increase the reimbursement by 6.25 percent.

Under both the scenarios, once the required balance (85/15 ratio) is achieved, the payer would not be interested in reducing the cost of care any further by focusing more on preventive rather than curative routes. Why? Because for every 1 percent you cut from the MLR, you have to cut the equivalent amount in the ALR in order to maintain an 85/15 ratio. After already been squeezed by the initial shift from ALR to MLR to achieve the 85/15 ratio, the payer wouldn’t want to reduce the ALR any further hence would have no incentive to reduce the MLR (since an equivalent cut in ALR will be required). This will lead to a situation where payers see reduction in the MLR as a penalty rather than an incentive, and wouldn’t try to reduce it. Providers wouldn’t care about standardizing care delivery and the consumer part of health reform will continue down the current path, with no improvement whatsoever.

So, unless somebody explains to me another path of logic, I’ll continue to believe that the MLR mandate is actually going to do more harm than good.

Rajiv Sabharwal is the chief solution architect in the Healthcare and Life Sciences unit at Infosys Technologies LTD. He can be reached at Rajiv_Sabharwal01@infosys.com.

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