Center for Studying Health System Change

Question & Answer Session

            DR.CHRISTIANSON:Paul, do you want to field questions from the audience now?
            DR. GINSBURG: Sure. Actually, if you could start walking up to the microphones. While you’re getting ready for questions, I have an observation, and I want to run it by the panel.
            It seems as though all three of the ideas put forward from the marketplace entrepreneurs could work with the fixed contribution model, and that in some cases they could also work with voucher models, and yours is very much around the fixed contribution. And I just want to ask the panel is that correct?
            MR. HERSCHMAN: Yes.
            MR. NEWCOMER: Yes.
            DR. GINSBURG: Okay. I’d like you to state your name and affiliation before your question. Why don’t you begin, sir, and then we’ll go there and then there.
            MR. ZWILLICK: [ph]: My name is Todd Zwillick. I’m with Reuters.
            The impact on the individual insurance market has been mentioned by almost everyone now. In Congress, there are initial moves to decrease the number of uninsured by offering refundable tax credits. Part of the criticism of this is that if you give someone, an individual, a $1,000 tax credit, which is the proposal that’s being thrown around in a lot of committees, that they’ll be able to purchase their plan. That plan will have $3,000 in premiums and about $6,000 in deductibles.
            I’m curious, from each of the three panelists, to hear about what your business, what your plan could do for an individual purchasing individual insurance with a $1,000 refundable tax credit that they’re going to use to try to purchase insurance which they do not have right now. What could you do for these people?
            MR. HERSCHMAN: Well, I think that if the amount is $1,000, you’ll get at least some coverage versus zero. So I think it’s at least a more efficient use of the thousand dollars than the way it works right now. I think beyond that you have to step back and say either the government is going to mandate some minimum benefit design--we’re not going to do that, okay. That is outside of our role. I think that’s much too intrusive for our business.
            I think the other is is that if there is a product that lets somebody get more value for their thousand dollars, then that product will come about, and it’ll be available in the marketplace. So I would say that at least it’s a move in the right direction. How the thousand dollar number is coming about, that’s what I would challenge more. What does the government think they’re going to get for a thousand dollars? Because that’s exactly what you’ll get.
            So I think it’s the right move. It’s how it’s deployed and how does that voucher get realized? Is it through payroll deduction? On a practical, applied basis, how does that work?
            MR. NEWCOMER: For $1,000, you can’t get insurance coverage. What you get, you could got to a product like Steve’s and try and find a better price for your $1,000. The people who get income tax credits, by the way, have a whole lot of things to buy that they’re barely making it in the first place like shelter and food, in addition to health care. So I’m not a big proponent that a $1,000 tax credit is really going to move dealing with the uninsured.
            DR. GINSBURG: Actually, before you go on, I was sitting in a meeting last week of some group that’s coming up with new tax credit ideas. And I think the thinking is not that anyone thinks $1,000 will buy insurance, but that with the poor covered by Medicaid and for children, as CHIP, there’s a notion that there’s a population that perhaps is just $1,000 subsidy away from buying insurance, that they have some of their own money that they’re willing to pay. So, in a sense, we shouldn’t dismiss it because obviously you can’t get anything for a $1,000.
            MR. HERSCHMAN: So I think if it could be married up with some employer contribution, you’d have more money as well. So it’s not only what somebody is willing to take out of their paycheck. But if the employer is saying, hey, this is a better benefit, at least I am able to provide some access to coverage.
            MR. WIGGINS: I think you’re talking about the individual market. There’s no employer involved. I think--
            MR. HERSCHMAN: Seventy-five percent of uninsured work.
            MR. WIGGINS: Right. What he’s talking about here though is the proposals right now are that you’d get $1,000 tax credit if you’re an individual purchaser of health insurance because your employer did not provide it.
            First of all, that’s a wonderful policy initiative. I don’t care what party you back, you should back that. It’s fair, it’s the right thing to do for the individuals that lack insurance, and it will just stimulate more coverage, less uncovered care. It does not, however, have any impact on affordability of health insurance. So there would still be a marketplace out there that competes on price.
            What some of us are trying to do is create insurance products that are very powerful products that cost a lot less. We have a $100 health plan that’s a very comprehensive family health plan. But you probably don’t have enough in your allowances, if you’re in that 17 percent of the people that has allowance limits, you probably can’t get your health care service in midtown Manhattan. You can get it if you commute to less costly areas. There’s wide variance in cost levels for health care across the U.S. and nobody knows that. Nobody knows that you can go to the Mayo Clinic for one-third the price that you can go to Columbian Presbyterian in New York unless you paid for it. And it makes you want to make sure everybody knows that, hey, you know what, the Mayo Clinic is a great deal for health care, and it’s probably the best health care in the country.
            DR. GINSBURG: Actually, there was another part of your question. One was $1,000, and that’s what everyone has focused on. But the other one was the individual markets. And I was wondering if any of you, and you don’t all have to speak, have any views about the status of the individual market now and how well it would work for someone of modest means for whom the $1,000 tax credit made the difference, that they would consider getting health insurance.
            MR. WIGGINS: The individual market right now is shrinking. It’s a problem. It’s a little bit like the reinsurance markets right now are going away. There’s a crisis right now in the financing of health care in America that’s gone unnoticed. And that’s the shrinking capacity of insurance underwriting capacity out there. It’s hitting the health plans first. It’s hitting the self-funded employers with premium hikes that are going through the roof. And it’s hitting the individual market.
            So there’s already a shrinking universe of payers, insurers, that will write in that market. So we first need to address that. We need to make it a more attractive environment. I think you do that at the state level with state laws that govern underwriting of individual policies. And right now there’s a patchwork quilt in the United States where it’s the Wild West if you write products.
            In some states you have pre-ex, you have all kinds of special conditions you can exclude forever. And even now HIPAA has created even further dysfunction in that you can buy short-term policies in the 6- to 36-month variety that allow permanent pre-ex.
            And so the marketplaces need I think what HealthSync is doing, they need rules that are standard.
            MR. NEWCOMER: Steve, isn’t that the problem, though, is that in the individual market it’s very, very hard to underwrite risk? Because as you get the risk factors in, you either have unaffordable insurance or you only are able to insure those people that are healthy and running marathons. Until we solve that problem, the individual market needs a lot more than just a $1,000 tax credit.
            MR. HERSCHMAN: And I think that that can be addressed the same way issues with small employers would be addressed. If there’s some aggregation or affiliation or the equivalent of a credit union, but for health care, where you could aggregate, there has to be risk adjusting within that pool, but there is a way you could think about creating pooling so you could address that issue. But I don’t think that’s going to happen without the government.
            DR. GINSBURG: Sure. Thank you.
            Next question?
            MR. SCANDLEN: I’m Greg Scandlen with the National Center for Policy Analysis.
            Actually, that discussion ties into my question. I would argue that because employer-based coverage has a 40-percent subsidy on average, anyone who can possibly get employer-based coverage will do so, leaving only those people in the individual market that are too sick to work, who can’t keep a job, who are in very high-risk occupations where their employers don’t provide coverage, that sort of thing.
            And I would argue that that’s contributing to the problems in the individual market more than the lack of regulation because there’s no lack of regulation.
            [Laughter.]
            MR. SCANDLEN: But Ray raised a question of portability, and this is a connection, I think that’s really critical in defined contribution. And, in fact, to the extent we’re using a pension--defined contribution pension programs as a model for this, that is characterized by individual ownership. And I’m afraid that HIPAA--actually, Ray used it--you didn’t think there were many regulatory obstacles towards that. I’m afraid HIPAA, which is ironically called the Health Insurance Portability and Accountability Act, prohibits portability.
            MR. HERSCHMAN: Yes. Well, I’m, unfortunately, too familiar with HIPAA. The intent was good, the execution was brutal for employers and carriers. So I think until the financing mechanism changes, you will not see portability.
            MR. SCANDLEN: Well, I think without portability, without individual ownership, all you have is managed competition.
            MS. CAPPS: My name is Katherine Capps with Health2 Resources. I’ve got ten questions, but I think I can summarize it with one question, I hope.
            With all of the products and services that your companies offer, who do you see as the primary customer? And I’m not referring to the end user, I’m referring to the primary customer. This is a two-part question. If each panelist would answer that.
            And the second part of the question is, how will your products and services, as you are proposing the rollout of them, increase accountability for consumers and not diminish accountability for consumers?
            DR. GINSBURG: Who would like to start?
            MR. HERSCHMAN: I keep starting, so I thought we’d flip it to the other side.
            MR. WIGGINS: You’re flipping it to me, okay.
            Well, first of all, on the second question I think that obviously when you give people the right to control the insurance dollar, you are moving quite a bit of opportunity for them to have responsibility over to the patient. And our customer is clearly the patient. We believe that all of these moves by employers, whether it’s to define contribution or if you’ve been selling health plans for 18 years, employers are already using some type of limit on what they pay. There’s already a defined contribution model out there that shifts quite a bit of cost to the individual employee.
            And we’re trying to--and so when you run a health plan, you have a two-tier sale. First, you have to sell to the employer, but your main sale, particularly in the large-case market, is to the individual. What Ray is doing, and others, is maybe bringing that direct-to-consumer decision making down into smaller employers, which is my hope that Ray is successful in that model.
            What Hillary couldn’t do, Ray is doing by creating purchasing cooperatives that any employer or any individual can opt into. Generally, right now it’s sold through employers, but there should be no reason his model doesn’t lend itself to the individual market or anyone. So our customer is the individual. And with the whole idea of an episode allowance, you have as much or as little responsibility and control as you want. You can punt out of it if you just say I don’t want to pay attention. I like the managed care model where somebody tells me what to do. Fine, we’ll tell you what to do.
            DR. GINSBURG: Lee, do you want to go next?
            MR. NEWCOMER: I think our customer, we maintain, is still the provider community. That’s where our financing comes from. Yet the problem with that answer, of course, is if there are no employees with pools to draw off of, what business is there? So you still have to think of the actual consumer employee also as a customer of ours.
            For accountability, I think the physician and hospital accountability is quite clear in our model. But the consumer also is quite accountable. I call it skin in the game without road rash. They have first dollar coverage for care, basically, a deductible, and they can access care. But every year they have to deal with a budget just like you do at your house. We know our income is going to be "X." What are we going to spend it on? And every year when the defined contribution is established, that employee has to think responsibly about how they will spend their money or how much money of their own personal dollars they want to bring into that fund so that they can purchase the kinds of physicians and hospitals they wanted.
            So the accountability for them is to be pretty smart purchasers of their relationships.
            MR. HERSCHMAN: I think, from a pragmatic standpoint, our customers right now are employers and carriers. Those are the decision makers right now. We want providers, we want consumers. That doesn’t happen unless the two primary constituents, employers/carriers, say this is a better model. So that’s the first.
            I think on the second point of the consumer, I think that consumerism, the mind-set of consumerism is going to be over time. I don’t think people are going to just jump in and say, and this is not in any way a criticism because I would buy this plan, but picking 22 different specialists and with the 1,900 other things you’ve got going on all day I don’t think is--that’s a quantum jump. I think similar to 401(k), initially, people put their money in low risk. Information became available, people got more comfortable, and it’s driving a lot of how people make their decisions about their pensions.
            If you would have asked me when I was an altruistic 24-year-old, would it be more likely that employers would allow their employees to manage their pensions or their health care, I would have thought for sure health care, and it hasn’t happened that way.
            So I think that people will be able to make those decisions. A lot of them they make already. It’s just that the data-intensive decision making I think is going to be over time.
            MR. NEWCOMER: Ray, I’ve got to respond to 22. It was my worry, took, when I first joined the company, until the focus groups, when the employees came in and said, you know, the first thing the employers are going to say is that we aren’t smart enough to make these 22 choices. And they all got it. The guy from Midas Muffler got it in about 22 minutes.
            MR. HERSCHMAN: I agree with that for some consumers, not all of them are going to--some want Kaiser still. They’re comfortable with it.
            MR. NEWCOMER: Oh, sure. That I’ll agree, yeah.
            MR. HERSCHMAN: So I think you need both. You can’t have just one.
            MR. NEWCOMER: I agree.
            DR. GINSBURG: Yes, sir?
            MR. GROSSMAN: Jerry Grossman from the Kennedy School, Harvard.
            MR. WIGGINS: And Squam Lake, yes.
            [Laughter.]
            MR. GROSSMAN: I just want to comment on the question about the $1,000. Massachusetts, which is, of course, renowned for the highest costs in the country, does also now, or until yesterday, had a diminished uninsured. They now can’t agree whether or not we had a 3.5-percent decline from 10 to 6 and something. Nevertheless, you had CHIP, you add a million people in Medicaid. And if you were to have we just started something called the Health Insurance Partnership, in which if you show up as a small business with a 1040 that says you don’t have the money to pay for insurance, they’ve set some limits, they’ll give you a 50-percent voucher to give to your employees. And if your employee then shows up with his or her 1040 and shows they can’t afford it, they get a graded personal payment as low as $50 a month for their family. It just started now, but it sort of picks up the gray space of the employed people who work in companies who can’t afford it.
            Using size is a terrible thing. We have a four-person office. We give health insurance. We shouldn’t be eligible for a government subsidy. So you need to have means-tested companies and means-tested employees. Some people don’t like that. And then we have buying cooperatives, the chamber of commerce, and all of those things.
            So you can put together a package that would allow everybody in the bottom third, I think, to play in any of your arenas. So I think there has to be a clarity that there is a strategy to get as close as we could to universal access for people at prices they can afford. But the more you guys present options, the closer we’re going to get. Massachusetts can’t ever get there. We’re going to have the highest cost system in the world until you die and he dies because I’m dying faster.
            MR. WIGGINS: Is it easier, by the way, to have four employees than 10,000 like you used to have?
            MR. GROSSMAN: Oh, much, because I took them from the 10,000. I took the best four.
            MR. WIGGINS: You had your pick, didn’t you.
            DR. GINSBURG: He took the four healthiest people.
            MR. WIGGINS: By the way, everybody missed you this year in the Cosumpi [ph] Open.
            DR. GINSBURG: Sir?
            MR. WOLFF: Bruce Wolf, Hogan and Hartson.
            I applaud enormously the object of moving toward a marketplace and giving the consumer an enormous amount of choice. It’s clear, though, that in some of these models an essential element of choice, particularly in yours, Lee, I think has choice made in advance of the onset of the episode or, Steve, in yours at the onset of the episode, but not during it.
            And I wonder, in two respects, what are you doing about feeding into the loop not just price and not just kind of objective quality measures, but people’s experience with the providers, the choices they’re making; and, two, when people are in the middle of an episode, having chosen a package provider, Steven, yours, or, Lee, having chosen a provider, how do you move out? I mean, what do you do about the denial of care, the skimping of care, the feeling that you’re not being well served in those models?
            MR. WIGGINS: In our case, you can opt out whenever you want. The payments go out pretty much on a fee-for-service basis to the providers in a care team. If that care team has given a fixed price, the payments still go out on a fee-for-service basis to them until they hit a max. So you could be a third of the way through a $50,000 allowance, and you would still have $35,000 left that you would take if you didn’t like--you’re going to know right away. And generally speaking, the large-dollar consumption in an episode, you’ve made the decision and it’s over. It’s the hospitalization and it’s the surgery, if it’s a procedure intervention.
            So you do pick. It’s very different. In an episode, you’re quite a ways along before you have to make any decisions. You’ve already had the diagnostic work done, and you’re deciding to have a treatment. You may be a man with prostate cancer, and you’ve decided to have high-dose seed implantation. And you’re going to go shop and pick and decide who you go to. And once the implants are there, they are there. You are not likely to make big switches.
            MR. NEWCOMER: I hope you aren’t, anyway. It’s tough to take them out.
            MR. WIGGINS: Yes. Yes.
            MR. NEWCOMER: Remember that not only do we allow the consumer to look at some data, but the way they got to most of their choices was through somebody they trusted already. What we’re doing is really just automating a process that happens every day. I call Sam Carlson to find out who to go see for my seeds if I needed them, and I still use that same mechanism in ours. So we think we’re going to emulate pretty carefully a system that already works relatively well.
            Now, when there is a conflict, and I don’t like the guy that I was sent to, you have two choices in our system; one, you can change your providers. There is a waiting period determined by the other provider you are going to. That’s to prevent them from getting adverse selection; or you can use your wraparound insurance policy. So you can use that just like you did with point of service in a health plan to select another provider. You’ll have to pay a little more money out of your pocket, but you can do it immediately without any other approvals.
            DR. GINSBURG: Before I go to the next question, I want to say I think we’ve got two people here, and I’ve got a question. I think that will exhaust our question time for this session.
            So, yes, sir?
            MR. WALKER: Greg Walker, American Cancer Society.
            In these models, what would be in place, what would drive prevention and early detection to prevent or to mitigate catastrophic illnesses down the road and not increase that 17 percent of people who are receiving care for catastrophic illnesses?
            MR. HERSCHMAN: Several things. One is that if the carrier is going to want to keep their customer. So it’s always less expensive to keep your customer than to get a new customer. They will be directly involved in that process. I think the provider, because in an individual purchasing their coverage, most often, if you ask individuals, will first select on provider. There is a relationship there.
            I think the third is, and this is where we’re going, is that we are migrating from kind of global aggregate actuarial variables for risk adjusting to population-based diagnosis risk adjusting, which is to say if a carrier and their provider network, they have a partnership, not an adversarial relationship, the way it is now, and they can prove better outcome for cancer, and they go and market that, they will get a corresponding higher premium based on getting more cancer people. And that will be what drives the real innovation in health care. So I think that there is movement.
            If you are able to prove you have a better result, then you will attract those that are already sick. If you are able to proactively mitigate risk, therefore, keeping your population healthy over a longer period of time, people will stay with that carrier.
            And therefore you will incent the carriers and the providers to actually work, for the first time, as a team. Because there’s data that’s aggregated at the carrier level that the providers don’t have, there’s competencies that the providers have that the carriers don’t have. And right now it’s kind of adversarial by design. The point is that right now the way it is, if Dr. Jones cancels a carrier, they lose their patient. In the future world, they could keep their patient because that patient will be able to change what carrier they have based on who does the best job.
            So I think that it’s kind of a broad answer. You have a very specific question.
            MR. WALKER: So the assumption is that the provider will inform the patient what they need and not look down the road and say, there’s more money to be made--
            MR. HERSCHMAN: I’ll use myself. For example, I’m on Lipitor. Thirty-seven years old, and I have incredibly high cholesterol, genetic. There’s nothing in my diet or whatever. Right now, the carrier is looking at me as a loss leader. They’re for sure losing money on me being on Lipitor. Because the reason why I’m on Lipitor now is so that when I’m 55, I don’t have a heart attack. The carrier is looking at that as a negative right now. If they know that they could keep me, earn my value, and I stay there, they’ll get their return on investment. So it changes the dynamic.
            MR. NEWCOMER: In our model, it’s consumer marketplace again. You would pick physicians who took prevention seriously, if that as an important value to you. If a physician that you chose as a primary care, you walked in and said, "Well, I’ve got risk factors for heart disease, and my cholesterol is a little high," and the guy says, "Fine. You don’t need to do anything," if you’re a consumer-savvy person, you’d say, "Hey, this guy isn’t interested in prevention. I’ll go to someone who is and change."
            Now, having said that, the other incentive that occurs in our plan is to look carefully at whether prevention really works. Let’s take the Lipitor example again. His chances of having a heart attack are reduced by one out of 1,000. Now, in the study, that is a 50-percent reduction. So I can say to this patient two things. I can say I can really lower your chance of having a heart attack by half, boy that sounds pretty good, or you have a two in a 1,000 chance of having a heart attack. I’m going to take it down to a one in a 1,000.
            And you know what, when you present it that way, the vast majority of patients say, "Forget it. I’m not taking Lipitor for the rest of my life for that kind of reduction."
            So what happens in our model is the incentive becomes to be realistic about prevention, to talk to patients in a way that doesn’t say the easy thing, oh, I’ll reduce your chance by 50 percent. Here, take this pill. But say let’s talk about this. We have a pill that we can take. Here’s the consequences of that pill for you. They’re pretty mild, except for expense, and here’s what you’re really going to gain from that. And prevention is overblown. I think I’m the only physician. Are you a physician? I didn’t look.
            MR. HERSCHMAN: No.
            MR. NEWCOMER: I’m the only physician on this panel with a whole bunch, two years of master’s work in preventive services. And quite frankly, prevention is seriously oversold in this country right now.
            So the things that would really make a difference, seat belt and cigarettes, we choose to ignore, and we spend more time thinking about things like Lipitor. That’s where the incentives are.
            MR. HERSCHMAN: Well, I was an informed consumer. I also had a large number of my family die of heart disease. So I was an informed consumer. I’m just saying that the incentive to focus on where you can minimize and give that option is--there’s no economic reason to do that right now.
            MR. WIGGINS: Ray, I’m not a physician, but I think I can lower your risk even more than the drug. I think you should get out of starting a company.
            [Laughter.]
            DR. GINSBURG: Next question.
            FLOOR QUESTION: Two quick questions. Steve Ferenti (ph) from the University of Minnesota. First of all, are any of the pending or proposed medical privacy laws going to affect any of your business models as well as the HIPAA implementation rules? And the second question is: Are the connectivity companies that are showing up in the health care space going to help assist, have no effect on your business models?
            MR. WIGGINS: Well, first of all, on the privacy issue, yes, there are a number. We might want to convene another panel for the privacy dialogue. We spent two years on the Clinton patient protection bill, a lot of it on the issue of privacy, and unfortunately, the practical reality of what’s getting implemented is making it more difficult to move information around, movements that might benefit patients. And so there’s a lot of protections and there’s a lot more expense now associated with privacy.
            MR. NEWCOMER: We don’t have a privacy consideration because we don’t get any medical data. There are no claims. The only thing that we have is the name of the physician you’ve chosen. So we think there’s very little in the way of privacy issues.
            I’ve forgotten your second question.
            FLOOR QUESTION: Connectivity companies help you on--
            MR. NEWCOMER: Again, irrelevant for us because claims data and transactions don’t occur.
            MR. HERSCHMAN: Data is less important from our perspective. I think actually the privacy issues actually act as a catalyst a little bit. I think employers are starting to say, well, why do I have this information on my employees at such an intimate detail level. That’s an exposure area. In fact, I want to get the heck out of that area. It’s not my core competency.
            So there are some positive and negative that’s coming out of the regulatory side.
            FLOOR QUESTION: The risk adjustment stuff you talked about earlier that you would hope to use, what data is going to fuel that model?
            MR. HERSCHMAN: That would be diagnosis based--population based, diagnosis based. That will leverage some standardization from HIPAA on data. That goes into effect in another 19, 20 months. I think that how you design systems and where that scoring of relative risk, where that happens, is a key aspect. And if you compile the HIPAA security standards on your system, then I think you address part of those issues.
            DR. GINSBURG: I have a question I want to address to the panelists in different ways. I’ve been sitting here thinking a lot about risk selection, and I think each of you have different exposure to risk selection.
            I guess in your case, Ray, you’re exposed to attracting employers that know that they have fairly high-risk workforces. And in the other cases, basically there’s the notion that the sickest people want to go to the best providers for their care and whether the best providers wind up saying, well, we can’t handle this, we have to--we’re on a death spiral. We have to keep raising our rates because we attract the sickest patients.
            Any comments on those risks?
            MR. HERSCHMAN: Sure. The reality is that this is as or more attractive to employers in the technology industry who have empowered workers. They’re younger. They want choice. They’re narcissistic by default, and employers, for everything else in their business, have shifted more responsibility, more process, more decision making onto their employee. And so there’s something that needs to be trued up. You can run the business, you can improve the business, you can have ownership of the process of the business, but you can’t pick your health care. So I think it’s more of a philosophy than are my health care costs high.
            DR. GINSBURG: I just meant what about Joe’s Welding Shop that has a bunch of people that haven’t taken Lipitor and--
            MR. HERSCHMAN: Okay. There is a part of the process--and this is why we’re dealing with large- and medium-size groups until somebody deals with the small group from the regulatory side--where the carriers still apply their own experience factor for that group. Okay? There’s all the normal variables of rating, plus an experience factor. So the higher the risk, the higher price their employees will see out in the marketplace, based on the group.
            DR. GINSBURG: Okay. Any comments from Steve or Lee?
            MR. NEWCOMER: I would just mention that we have actually--the price that’s posted by the provider is factored up by the underwriting carriers for the group. So if we sign up a small group of 15 employees and their risk is 1.3 average, when they go into our system, they will see every provider’s bid up by 1.3 in order to help provide the providers with some protection against that increased risk that they would be seeing in that pool.
            MR. WIGGINS: In our case, we’re not sure yet. We’ve had the top three actuarial firms in the country, two on behalf of carriers, one, M&R, that’s our permanent--that’s on retainer with us permanently, they even disagree. Some believe that episode allowances will attract people that have had a lot of bad experiences in managed care and that we will attract sicker people that are higher risk.
            My experience in new products in the health insurance arena is that it’s a lot like any early adopter model. Early adopters tend to be younger, healthier people, and so I think we’ll probably get a little bit of both, is my guess. But it doesn’t matter in the end because--it matters in the first few years, but in the HMO movement years ago--I’m sure, Lee, you remember--everybody thought, well, you HMOs are going to get all the good risks. And then once you got past about 15 percent of an employee population, you began to distributions that were more normal.
            I know Mathematica, you know, sponsored this, but the Mathematic study of the Medicare program, which I think is maybe one of the most flawed studies and led to some of the worst policy decisions in the history of health care, but it essentially said that the HMOs were getting better risks in the Medicare risk program when we had hard data, many health plans had hard data that would show that, in fact, if you used DRG case mix as a surrogate index, or if you used symmetry-based groupers as another index of risk mix, that, in fact, we were certainly getting far sicker than average Medicare patients enrolling in our health plan.
            And so I don’t think you can make any gross generalizations. It’s probably going to vary by employer. It’s going to vary maybe even by region. But in the early days, we expect to figure that out. But it’s a guess to get started.
            DR. GINSBURG: Okay. Well, this is a difficult area, but I’ll conclude that neither of you feel that that’s your Achilles heel, that if you don’t succeed it’s not going to be because you’ve attracted higher risks but because of other reasons.
            Good. It’s time for us to take a break. The panels will be switching for the second half of the meeting, and I just want to mention the panelists will be available after the meeting to answer your questions informally. And I see those orange pieces of paper around, and I want to ask you to start thinking about filling out your evaluation because we make heavy use of those.
            Thank you.

           [Break.]

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