A healthy conversation with Lisa Guertin

In January 2004, 43-year-old Lisa Guertin became the head of Anthem Blue Cross Blue Shield of New Hampshire. Since taking over as vice president and general manager, New Hampshire’s controversial Senate Bill 110, which eliminated community rating for small business health insurance, proposals for association health plans, health savings accounts and a myriad of other sweeping health-care reforms have come to the forefront, making for a challenging inaugural year for Guertin.

Q: What do you see as some possible solutions or at least areas to explore to control rising health-care costs?

A: The true drivers are the increased costs of medical care. It all just costs money. I think controlling costs begins with an understanding of the underlying causes. When you ask people what a doctor’s office visit costs, most people answer $10, because that’s what they pay.

You can address it by moving cost around. That will get you some gain in the short term, but unless we find ways to fundamentally keep cost out of the system, what have we really accomplished? One thing we are convinced of is that we’re not going to solve this unless you get all of those voices [employers, providers, consumers] working together.

So when we talk about solutions, I think it begins with information and education, and understanding what is driving these cost increases, so that the solutions we focus on are really going to address the right things.

Q: How has SB 110 affected you as a provider?

A: I have to say that SB 110 fundamentally represents a shift in risk-pooling. Group insurance is about spreading risk. It’s really a question of how you want to spread it.

Community rating spread it very, very broadly, kind of homogenized it, if you will. What SB 110 does is take that rate increase and redistribute it differently among those small employers.

We know it’s good news for some and bad news for others. For us, it’s a bit of a zero-sum game. It’s a question of how you want to spread that risk and that cost around. That is really what it’s about.

Q: Association health plans — good or bad?

A: We think bad. I think as we look for solutions, there are some that look really tempting because they will give small employers another option and, if taken on face value, AHPs look like a good thing.

Again, what this is about is cherry-picking. This is about associations being able to set up, in a very unregulated fashion, and take in good risk.

For some, for the “healthies,” this could be a boon. If they, then begin to have medical problems, they can be essentially kicked right out of that association health plan and back in to the fully insured, state health plan.

Q: That core group will get sicker and sicker?

A: That pool gets sicker and sicker. As they bear more and more cost, it becomes more and more unaffordable. We could drive ourselves into a place where the people who truly need insurance can’t afford it. This is another example of where something that might have some short-term benefit could fundamentally hurt us for the long run. I don’t think that’s the right solution.

Q: Association health plan proponents say they’ve built into the legislation provisions forbidding cherry-picking, everybody has to be covered to some degree, that there must be maternity care. Do you still think that there’s risk?

A: I still think there’s disparity between the mandates, the regulations, the reserve requirements and other things between the traditional insurance system and this kind of subsystem. Over time, that imbalance will create larger problems in the overall affordability for all.

I understand that when we say we are opposed to AHPs, there’s an immediate knee-jerk reaction that says, “Well, that means it’s not good for you, Anthem.” This is not from a self-serving place that we’re weighing in. We are always concerned with fair competition. Competition is good. Unfair competition? Not so good, from any business’s perspective. Our concerns are more fundamental than that. It’s about what it’s going to do the health system overall and the ultimate affordability for all, not just for some.

Q: What are the advantages of health savings accounts over other medical pre-tax contribution plans? Who should use them, who shouldn’t?

A: The big advantages are the rollover and the tax implications. The ability to roll over the fund is different from other plans.

Q: Who shouldn’t use them?

A: It is a sophisticated product. It’s like a 401k. It’s going to take some education of the workforce. I don’t think there’s any employer type or size or group that should or should not look at HSAs. I think its something that each employer evaluate in terms of what’s right for their employees, what are their cost-savings goals. If you’re looking to get your employees more involved in the cost of care, I just think it’s a really good, viable new option.

Q: You’ve been working with the New Hampshire Healthcare Purchaser Partnership. Has there been any progress in building their quality-driven tier product?

A: Many of the things that are driving their conversations, the desire to get consumers more involved, the desire to have more affordable products, cost and quality transparency, the alignment between them and us is incredible.

Their specific desire to build a product right now is where we differ. We think that we should continue together on some of the infrastructure, if you will, that makes that possible. For example, the full repository of information. If you’re going to tier a product based on cost or quality information, then you really have to be sure that you have that complete and credible information from an objective third party. We think that working together on what is the source of that information and how it will be populated is critical.

We’ve actually invited them to have input into our enterprise efforts. We are really trying hard to be a listening organization. One of my priorities moving into this job in January was to get out and listen. We need that input. We are continually to try to work and be easier to do business with, to try to be a part of the solution in terms of affordability. You don’t do that in a vacuum.

Q: Exorbitant malpractice lawsuits are seen as a contributing cause to the overall cost of health care. By having a panel limiting what malpractice lawsuits will and will not move forward, aren’t we giving away our rights if we feel we’ve been wronged by a physician?

A: If you look to states that have done some similar things, there are appropriate kinds of screenings that drive unnecessary cost out of the system while still affording consumers protection. It is a balancing act, and right now we’re tipped too far toward the court system and these massive settlements that feed cost back into the system. A carefully crafted screening mechanism will ensure that those things that really need to get through get into the court.

Finding a balance that offers adequate consumer protection and access to the courts when appropriate, that to me is a happy medium. I don’t think it’s a trade-off that’s ultimately bad for consumers.

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