And given that the payouts are very nearly a function of how hard the insurance company can negotiate, they can simply choose to call off the negotiations when they reach their target amount.
Private medical insurance in the US is a horridly inefficient system. Separating the claims process from insurance companies hands might help, but their incentives are never going to line up with consumers.
Money spent on paperwork comes out of the same pile as profit. The MLR cap preserves incentive to reduce paperwork, wherever premiums and payouts sit.
Of course insurance companies are also in competition so they have individual incentives to keep premiums cost competitive.
With R = revenue, P = profit, A = administrative expenses, and M = medical expenses, we have:
R = P + A + M
P = R - M - A
P₂ = R - M - (A + δ) = P - δ
P₃ = (R + δ) - M - (A + δ) = P
Does the MLR cap have an impact?
MLR = M / R
MLR₃ = M / (R + δ)
MLR₃ < MLR
P = (R + δ) - M - (A + δ)
Of course if I believe that my company is better able to handle the new paperwork than my competitors, that could help - but if the whole industry believes that's the case then most of them are wrong, and in any event I believe this incentive is weakened not strengthened by the MLR cap.
If paperwork keeps new entrants out of the market, that is something current participants can probably agree on, but that's true in any case and I don't see how the MLR cap makes it stronger.
I don't think this analysis changes if we pull executive compensation out of "administrative expenses" and treat it as something we're maximizing in addition to (or instead of) profit.
So while thinking in terms of total administrative costs seems reasonable there are two different numbers here, administrative costs for the insurance companies and administrative costs for the healthcare industry and that matters.
So again, assuming it’s the regulation not market forces limiting profits increasing Ma directly increases profits. Up to some limit rather than P < (Mm + Ma) * X% it’s P = (Mm + Ma) * X%. Thus creating incentives to increase Ma.
It is true that the MLR cap does nothing to motivate insurance companies to avoid increasing hospital paperwork. I don't see that it produces incentive to create it - yes, increasing payments to hospitals increases allowable profit, but in order to make that profit you need sufficient revenues and customers aren't paying because they want hospitals to do paperwork. I'm of a mind that (at the margin) increasing legitimate (or nearly legitimate) medical spending is typically pretty easy so there is no need to find alternative ways of paying hospitals more; if I'm mistaken about that then you raise an important point that probably deserves attention (if it hasn't got it in some way I'm unaware of).
If the payouts are dropping because there's a massive reduction in claims, then there's a pretty decent chance that paying the policy maximum on each claim still won't be enough.
Plus, profits don't come directly from the premiums anyway. They come from the investments the insurer makes with the premiums. So sure, they can try to convince policy holders to increase coverage which allows them to charge a higher premium, or they can work on their loss modeling and investment strategy to better predict their actual loss ratio (which means they can have less money in reserve and more money in investments) or get better returns on the investments. And those 2 are usually a better use of resources since increasing coverage means an individual conversation with each policy holder. That's a lot of human-hours compared to the modeling and investing.
Or they just stone wall and increase premiums anywhere they can until they hit targets. Like at a previous job I had at a 250 employee company where premiums went up $150/m one year because the previous year had two families had a kid get (very different kinds of) cancer out of the blue. You'd think that shopping around would've helped in that case, but the word got out somehow to the other insurance companies and they were giving us similar quotes.
The power relationship is very very tilted in the insurance company's favor and they can more or less dictate terms.
It's bad enough that I've heard office gossips complain about other employees leveraging their healthcare turning into higher premiums the year after. Like, as evil as complaining their coworker's kid got cancer.
When employees go through big health events it's hard to keep it under wraps in a work environment... especially in this "race to the bottom" society we happen to live in. You can bang on about privacy all you want, but people talk.
I guess I'm shocked it happened in an office of ~250 as I've always seen it happen at much smaller places.
That is how it would have to work if the employer wants to restrict the risk pool to the company's employees. After all, money has to come from somewhere.
But employers are welcome to participate in healthcare.gov plans where the risk pool is much larger (across the whole state), and where individuals in the company cannot be solely blamed for increases in healthcare costs:
It's bad enough that I've heard office gossips complain about other employees leveraging their healthcare turning into higher premiums the year after. Like, as evil as complaining their coworker's kid got cancer.
Employers are welcome to purchase healthcare.gov plans that are not allowed to price based on pre existing conditions:
https://www.healthcare.gov/how-plans-set-your-premiums/
If an employer wants to self insure and restrict their risk pool to only their employees, then they have to pay for it.
Which are stupid expensive for anyone much above the poverty level.
> If an employer wants to self insure and restrict their risk pool to only their employees, then they have to pay for it
A 250 person company wasn't self insuring or restricting their risk pool to only their employees. They wouldn't be negotiating premiums with an insurance company if they were self insuring.
When I was shopping around for health insurance for my businesses, the premiums were the same as what they would have been individually on healthcare.gov. Kaiser has a good report showing the costs are not that different based on firm size:
https://www.kff.org/report-section/ehbs-2020-section-1-cost-...
The cost of healthcare is pretty predictable, and spread over a sufficient population converges to the same numbers. Only option I can think of is people were thinking that the employer reduced their portion of healthcare they were subsidizing, and so people thought premiums were going up since the size of the portion they were expected to pay went up? Most people do not really know to look at box 12 code DD of their W-2 to know what is happening with their healthcare insurance premiums.
And I'm going to guess that your businesses had very, very few employees? To the point of not being worth negotiating with from the insurance company's perspective?
And Kaiser isn't run like most insurance companies.
>And I'm going to guess that your businesses had very, very few employees? To the point of not being worth negotiating with from the insurance company's perspective?
Yes, but that was my point about businesses being able to just buy the health insurance plans available on healthcare.gov. Earlier you mentioned the healthcare.gov plans were:
>Which are stupid expensive for anyone much above the poverty level.
But the data does not support that. Average annual employer sponsored insurance is $7,675 for single PPO coverage in 2019:
https://www.kff.org/report-section/ehbs-2019-summary-of-find...
And average lowest cost monthly gold premium on healthcare.gov is $516 ($6k annual) in 2019:
https://www.kff.org/health-reform/state-indicator/average-ma...
So employers can probably save money going to the healthcare.gov plans, albeit with higher out of pocket maximums probably. But at least a couple kids with cancer would not throw off the premiums.
Unlike property and life insurers, medical insurers generate very little income from investments. Premium revenue comes in at about the same rate as claims are paid out. They don't have large reserves to invest. And most large employers are self insured anyway, so the ”insurance" company just acts as a claims administrator.