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HARDLY A WEEK PASSES without a health maintenance organization announcing that it is getting out of the Medicare risk HMO market.
Just the other week, for example, Aetna U.S. Healthcare said it is pulling out of the Medicare risk HMO market in six states and parts of three others. The pullout will affect some 58,000 plan members.
That withdrawal comes on the heels of exits from other risk HMO markets by Foundation Health Systems Inc. and PacifiCare Health Systems Inc., and a signal by United HealthCare Corp. that it will curtail its marketing efforts.
Most major insurance markets, and the risk HMO market is no exception, are witness to moves in and out of the markets as insurers constantly evaluate their efforts and success, or lack thereof.
Indeed, the Medicare risk HMO market has grown so rapidly in recent years that some kind of shakeout probably is inevitable.
Undoubtedly, some HMOs rushed into markets convinced that the payment rates they received from the federal government to provide coverage to Medicare beneficiaries were so high that they could offer very rich benefits and still do exceptionally well in the business. Employers welcomed the growth of risk HMOs, as they have often offered excellent benefits, reducing the need for companies to provide plans to retirees supplementing Medicare.
Then reality intruded, and some HMOs found the cost of providing coverage to a population of high users of medical services was greater than anticipated, or they had more difficulty in getting favorable contracts with providers in certain parts of the country. Hence their pullout.
No doubt that is part of the reason for some HMOs' exodus from the Medicare market.
But just as important is that HMOs perceive -- and we agree -- that the government payment rates they receive are inadequate. This year, many HMOs received a rate increase of just 1.5%, and rate increases next year are likely to be no more than 2%. As just about anyone knows, health care costs are going up by a lot more than 2% annually.
These paltry increases are the result of legislation Congress passed in 1997 that changed, among other things, the payment methodology for Medicare risk HMOs. Some of those changes, most notably boosting payment rates for risk HMOs that provide coverage in rural areas, were welcome and long overdue. But the legislation was written in such a way as to limit, at least for the foreseeable future, annual rate increases to about 2%.
By capping rate increases, the government, in the short run, saves money in what it pays risk HMOs. But what it saves now will be far offset by what it loses in the future. If rate increases remain paltry, more HMOs surely will drop out of this market, leaving the burden of providing coverage to Medicare.
We believe it is far less costly for the government to pay risk HMOs to take over the role of providing coverage to retirees than for Medicare to provide that coverage.
If risk HMOs continue to exit the market, that means more retirees will go back to the traditional, and very costly, Medicare program. The result in the long term is higher costs for the financially strapped Medicare program.
That can't, and shouldn't, happen. Congress needs to take another look at the payment structure to ensure that the rates risk HMOs receive are fair.