Tuesday, April 07, 2009

Who Is Warning Us About the Perils of a Government-Run Public Health Insurance Plan?

There has been considerable discussion lately about whether the US government should offer a publicly run health insurance plan similar to the current Medicare program for the elderly and disabled. A recent report has thrown a bit of cold water on the idea, as noted in this AP article:

A public health insurance option for middle class families could help cover the uninsured but it may well put private insurers out of business, a respected consulting firm concluded in a study released Monday.

The report by the Lewin Group, a numbers-crunching firm that serves government and private clients, said it all depends on details that lawmakers are far from deciding. Nonetheless, the report could provide ammunition for critics who say a public plan would move in the direction of government-run medicine.

President Barack Obama and many Democrats want to create a government insurance plan to compete with private plans that now cover about 170 million Americans. The issue is major sticking point for Republicans and the insurance industry.

The Lewin study found that if such a plan were open to all employers and individuals, and if it paid doctors and hospitals the same as Medicare, the government plan would quickly grow to 131 million members, while enrollment in private insurance plans would plummet.

'The private insurance industry might just fizzle out altogether,' said John Sheils, a Lewin vice president and leading author of the study.

By paying Medicare rates the government plan would be able to set premiums well below what private plans charge. Monthly premiums for family coverage would be $761 in the government plan, compared with an average of $970 in private plans, the study estimated. Employers and individuals would flock to the public plan to cut costs.

This new report by the Lewin group also provided more ammunition to politically conservative commentators opposed to a public health insurance plan, e.g., see this link.

I am not going to comment on the substance of the report, or the argument over the merits of a public health insurance plan, save to note that in my humble opinion, the biggest danger of such a plan would be to further exaggerate differences in payments made to primary care and other "cognitive" physicians and to physicians who mainly do procedures. We have posted before (e.g., here) on how Medicare has come to fix payments to favor procedures and disfavor primary care and other cognitive services. Increasing the number of patients covered by Medicare or a Medicare-like plan, without changing the current Medicare payment system, would only make these discrepancies worse. Note that this potential problem with the public health insurance plan was not mentioned in the Lewin Group report.

Perhaps the nature of the Lewin Group influenced what this report did and did not emphasize. The group was described above as an independent consulting firm. Its web-site says it is "a premier national health care and human services consulting firm." It also claims:

The Lewin Group is committed to independence and integrity in our work. We combine professional expertise with extensive knowledge and a rigorous approach to analyzing and solving problems to deliver value to each of our clients and to the larger community as well.

That's a somewhat self-contradictory assertion. It seems that delivering "value" to specific clients might be hard to do while maintaining "independence."

Perhaps considering the nature of the Lewin Group's clients would clarify things. The group says its clients include "hospitals, health systems and providers;" "payers / insurers;" and "pharma/bio/device." The middle group seems most germane to a debate about The services provided to them include:

The Lewin Group helps payers and insurers succeed in complex government, commercial, and long-term care markets.

Based on our more than 20 years of experience, The Lewin Group offers our clients detailed understanding of the competitive marketplace and the expectations of purchasers. Based on rigorous, data-driven research, we provide our clients with actionable information grounded in practical, real-world advice.

Our understanding of public policy through our work with government entities, including Medicaid and SCHIP, helps us understand how policies are shaped and how they impact our clients. With this insight, we help our clients strategize and succeed in public programs and new product offerings.

So, the Lewin Group specifically offers to help insurers succeed in a complex market partially controlled by government. Maybe this orientation had some influence on the report they published now being used to support arguments for private, commercial health insurance.

Finally, who owns the Lewin Group? The description provided in the news story above suggests it is independent, and perhaps is even not-for-profit. Per Lewing Group web-site, it is neither:

The Lewin Group is an Ingenix company. Ingenix, a wholly-owned subsidiary of UnitedHealth Group, was founded in 1996 to develop, acquire and integrate the world's best-in-class health care information technology capabilities.

Ingenix has been in the news lately. See our posts here, here, and here about legal settlements of charges that large health care insurance companies used a database created and allegedly manipulated by Ingenix to underpay out of network claims. So, the Lewin Group is a part of Ingenix, an organization that just settled claims that it manipulated data about insurance payments.

Furthermore, Ingenix is in turn part of UnitedHealth. It is amazing how often UnitedHealth's antics have provided grist for the Health Care Renewal mill. See this post for a summary of the company's more recent escapades.

For balance, I must note that the Lewin Group web-page asserts:

The Lewin Group operates with editorial independence and provides its clients with the very best expert and impartial health care and human services policy research and consulting services.

But again, note that the focus is on making clients happy, not providing the public with unbiased knowledge.

So a report being used to support arguments against government-run health insurance was published by a subsidiary of one of the largest commercial health care insurance companies and managed care organizations, a subsidiary that just settled charges that it manipulated data to increase insurance company profits.

With a new administration in the White House, there is new interest in health care reform. It is not surprising that this has inspired some vigorous discussion. Nor is it surprising that some of the discussion comes from those with vested interests to protect. They have, of course, every right to make their views known. But it would be a more honest discussion if everyone were willing to put their vested interests on the table.


Unknown said...


The Lewin Group study estimated the shift to a public plan was conducted for the Economic Policy Institute, a progressive economics think tank in Washington, which supports the public plan option. I blogged on your post here: http://www.gooznews.com/archives/001379.html
Merrill Goozner

Roy M. Poses MD said...

See my comment on your post.
Are you sure that the report mentioned in the 2008 press release of the Economic Policy Institute is the same as that released in April, 2009, and that is the subject of the post above?

Emily said...

I used to work at Lewin, and these two authors - John Sheils and Randy Haught - frequently release internally-funded analyses of health policy proposals under discussion. I just checked with Lewin's media contact to be sure, and in fact, this report was not produced for a client. It's also separate from the EPI-funded report that Merrill found.

You noted that Lewin's parent companies aren't exactly admired for their integrity. I strongly agree with you on that, but a little context: Lewin was acquired by Ingenix less than two years ago. I don't doubt Lewin's claim of editorial independence. When I worked there, they were owned by Quintiles, a huge pharma services company. Personally, I never encountered or heard of interference by Quintiles. I'm not saying it absolutely can't or didn't happen, but Lewin really does pride itself on objectivity.

In your conclusion, you suggest that everyone should "put their vested interests on the table." Yet both Lewin's press release and the first page of the report state that Lewin is "part of Ingenix, Inc., which is a wholly owned subsidiary of the UnitedHealth Group." The AP article should have disclosed that information as well, but I don't see how AP's actions reflect poorly on Lewin.

All of this is to say that in this particular case, I don't think readers should take a shortcut and dismiss the report for its parentage. The report should stand on the merit of its content. (which, unfortunately, I am not qualified to review :))