Self-Insurance In Times Of Growing And Retreating Managed Care. When enrollment in indemnity insurance declines, so does self-insurance.

Transcription

1 Helth Trcking MrketWtch Self-Insurnce In Times Of Growing And Retreting Mnged Cre When enrollment in indemnity insurnce declines, so does self-insurnce. by Jon R. Gbel, Gil A. Jensen, nd Smnth Hwkins ABSTRACT: This pper exmines trends in self-insurnce nd in the content of self plns from 13 to The percentge of employees enrolled in self- plns fell during these yers. Much of the decrese ws ttributble to the decline of indemnity insurnce nd the rise of HMO nd point-of-service pln enrollment. If the product mix hd remined constnt throughout these yers, self- enrollment would hve grown between 13 nd 16 nd then declined to its current 50 percent level. As result of the Helth Insurnce Portbility nd Accountbility Act (HIPAA), the use of preexisting condition cluses declined drmticlly in self- plns. Self- nd purchsed plns cost similr mounts nd provide similr benefits. Cost shring is somewht lower in self- PPO plns. During periods of rpid infltion, premiums increse more slowly for self- thn for fully plns. The source of coverge for more thn 159 million ctive workers nd their dependents s well s sixteen million retirees, employer-sponsored helth insurnce hs been shped by two historicl ccidents. 1 The first occurred during World Wr II, when federl officils ruled tht incresed helth benefits were not subject to federl wge controls or regrded s txble income. 2 The second took plce in In n ttempt to protect workers pensions from employers fulty prctices, Congress pssed the Employee Retirement Income Security Act (ERISA). Section 514() of ERISA would in the course of subsequent court decisions preempt self- plns from stte insurnce regultion. Consequently, self- plns would be subject to oversight from the U.S. Deprtment of Lbor. The second historicl ccident promoted the growth of self- plns. Employers tht opt to self-insure re not subject to stte finncil reserve requirements to minimize the risk of insolvency; stte-imposed premium txes to finnce stte gurnty funds to py clims for insolvent plns; stte chrges to finnce high-risk pools tht provide coverge for uninsurble people; stte-mndted benefit requirements to ensure coverge for essentil services; vrious consumer protection lws; or stte insurnce reforms intended to minimize hrsh medicl underwriting. 3 Concerns bout self-insurnce. Critics of self-insurnce cite three concerns bout the growth of self- plns. 4 First is the issue of equity to employers. ERISA hs Jon Gbel is vice-president, Helth System Studies, t the Helth Reserch nd Eductionl Trust (HRET) in Wshington, D.C. Gil Jensen is professor of gerontology/economics t Wyne Stte University in Detroit. Smnth Hwkins is reserch nlyst t HRET. 202 Mrch/April Project HOPE The People-to-People Helth Foundtion, Inc.

2 MrketWtch unintentionlly yielded two seprte (nd unequl) regultory systems. Second, employees in self- plns lck the sme consumer protections tht employees in purchsed plns hve with regrd to pln insolvency, frudulent pln behvior, nd refusl to py for tretments nd services promised by the employer. Third, becuse roughly hlf of U.S. workers re enrolled in self- pln, sttes find it extrordinrily difficult to ssume their role s the ntion s lbortories in designing helth policy. This limittion pplies to host of criticl issues: cost continment, progrms for the un, stte insurnce reform, nd consumer protection lws. Difficulties in observing trends. Self-insurnce is not phenomenon unique to the 10s. Ptrici McDonnell nd her collegues reported from n nlysis of survey of employers in 14 tht mjority of employees covered by job-bsed insurnce were enrolled in self- pln. 5 Becuse different surveys use different methods to estimte the extent of self-insurnce, it is difficult to observe trend over the pst two decdes. The Ntionl Medicl Expenditure Survey (NMES) estimted tht 42 percent of employees were in self- plns in Susn Mrquis nd Steve Long estimted tht 40 percent of employees were enrolled in such pln in 13 nd tht 33 percent were in Impct of legisltion. Recent ntionl legisltion my hve removed some of the dvntges of self-insurnce nd thereby encourged shift bck to fully plns. The Helth Insurnce Portbility nd Accountbility Act (HIPAA) limited the use of preexisting condition cluses for both fully nd self plns. 8 The Mentl Helth Prity Act nd the Newborns nd Mothers Protection Act mndted specific benefits for both types of plns. 9 Congress encted ll of this legisltion in 16. Stte legisltion in the 10s, in contrst, my hve encourged more firms to selfinsure. Twenty-one sttes pssed legisltion setting minimum length-of-sty stndrds for inptient cre of mstectomy ptients. Thirtyfour sttes pssed lws mndting direct ccess to obstetricins/gynecologists (OB/ GYNs), while fourteen sttes mndted direct ccess to chiroprctors, dermtologists, or eye cre providers. Eleven sttes pssed nywilling-provider lws tht require insurers to contrct with ny provider willing to meet the terms of the greement. 10 Impediments to self-insurnce. In trcking trends in self-insurnce, nlysts need to be wre tht chnging insurnce product mix cn obscure underlying trends in self-insurnce. Indemnity plns fce comprtively few impediments to self-insurnce. The employer simply ssumes the finncil risk for pyment of medicl clims. More commonly, the employer purchses stop-loss insurnce whereby reinsurer ssumes the finncil risk once ggregte medicl clims exceed given threshold or clims for n individul exceed predetermined level. The employer cn rent the services of utiliztion mngement compny in n ttempt to limit inpproprite hospitliztions nd other high-cost services. There re greter impediments to selfinsuring helth mintennce orgniztion (HMO) pln. In ddition to ssuming finncil risk, the employer needs to rent network of providers, qulity ssurnce progrm, nd more complex set of utiliztion mngement nd disese mngement progrms. In some sttes employers re prohibited from contrcting with providers on cpitted bsis. From 13 to 16 employer-bsed insurnce completed the rpid trnsformtion from indemnity to mnged cre hevy. In 13, 49 percent of employees were enrolled in indemnity plns, 22 percent in HMOs, 20 percent in preferred provider orgniztions (PPOs), nd 9 percent in point-of-service (POS) plns. By 16 plurlity of U.S. workers were in HMOs, nd indemnity plns ccounted for only 26 percent. From 16 to 2001 employers nd employees retreted from hevily mnged cre nd moved towrd hybrid-type mnged cre plns. PPO enrollment rose from 28 percent to 48 percent of employees, HMO enrollment fell from 31 percent to 23 percent, while enrollment in indemnity plns fell to just 7 percent, nd enrollment in POS plns rose HEALTH AFFAIRS ~ Volume 22, Number 2 203

3 Helth Trcking from 14 percent to 22 percent. 11 Knowledge gps. Becuse self- plns re preempted from stte-mndted benefits nd insurnce reforms, some observers hve questioned whether there re differences in pln design mong fully nd self plns. Are self- plns sfe hven for low-benefit plns nd more onerous underwriting ctivities? A previous nlysis of the 13 Robert Wood Johnson Foundtion (RWJF) Employer Helth Insurnce Survey by Gregory Acs nd collegues reported tht self- plns hve more preexisting condition cluses, more mentl helth/substnce buse benefits, more mternity nd drug benefits, lower deductibles, nd similr premiums, compred with purchsed plns. 12 More recently, Mrquis nd Long concluded tht the cost of coverge for self- nd fully plns ws similr in Others hve sked if there hs been differing trend in the content of selfnd fully plns in recent yers. There hs been no comprehensive nlysis of these issues for This pper hs three objectives. First, bsed on surveys with consistent questionnires nd methods, we trck trends in self-insurnce over the eight-yer period Second, we investigte the role of chnging product mix for self-insurnce trends over this period. Third, we exmine the chnges in the content of self- nd fully plns during the study period. In ddressing these issues, the pper updtes findings from erlier studies, none of which uses post-17 dt. The pper lso provides preliminry glimpse of the impct of the 16 federl legisltion HIPAA, the Mentl Helth Prity Act, nd the Newborns nd Mothers Protection Act on the content nd prevlence of self- plns. Study Methods Dt on employer-bsed helth insurnce re from the ntionl surveys conducted by KPMG Pet Mrwick in 13 nd 16 nd the Premiums incresed more rpidly mong fully thn self- plns over the study period. Henry J. Kiser Fmily Foundtion (KFF)/ Helth Reserch nd Eductionl Trust (HRET) in 19 nd The core questions for these surveys re nerly identicl throughout the study yers. They include (1) the definition of self-insurnce; (2) the definition of indemnity, HMO, PPO, nd POS plns; (3) the nnul increse in the cost of coverge for ech type of helth pln; (4) estimted enrollment in ech of the pln types; nd (5) the cost of single nd fmily coverge in ech helth pln. The survey s questionnire ech yer sked series of questions bout the firm s lrgest indemnity, HMO, PPO, nd POS pln. With the exception of 16, the Wshington-bsed survey firm Ntionl Reserch LLP conducted telephone interviews with employee benefit mngers. The unit of nlysis on ll surveys is the firm rther thn the estblishment. 14 Dun nd Brdstreet provided the smple frme for the list of U.S. public nd privte employers tht employ three or more workers. Firms were rndomly selected from strtified rndom smple, where firm size nd industry defined the smpling cells. Smple sizes rnged from 1,3 in 13 to 2,001 in 17. Response rtes rnged between 50 percent in 16 nd 60 percent in 19. Becuse firms were rndomly selected, it is possible to use sttisticl weights nd thereby clculte ntionl, firm-size, industry, nd regionl verges. All dt reported here re employee weighted (unless specificlly noted) to be ntionlly representtive of U.S. workers with employer-sponsored helth benefits. In clculting stndrd errors, we used SUDAAN to mke djustments for design effects. We use percent confidence intervl nd compre whether the individul figure is sttisticlly different from the previous yer for the ctegory in ech exhibit. A fundmentl concern of our nlysis is the role of pln mix over the study period. Hypotheticlly, the percentge of workers covered by self- plns could increse for 204 Mrch/April 2003

4 MrketWtch ech type of pln over the study period nd yet the totl percentge of workers in self- plns could decline. This prdox could result from drmtic shift in enrollment from indemnity plns, which tend to be self-, to HMO plns, which tend to be fully. Hence, our nlysis ddresses wht trends in helth insurnce would hve been if the mix of plns hd remined unchnged over the study yers, rther thn shifting from conventionl to other types of plns. Study Findings Trends in self-insurnce. The percentge of workers covered through self-insurnce in firms with three or more workers declined slightly over the study yers (Exhibit 1). Fifty-five percent of workers were enrolled in self- plns in 13; tht number grew to 57 percent in 16 nd then fell to 50 percent in Trends by type of pln. Different types of plns exhibited different trends during the study yers. The percentge of workers in self conventionl nd PPO plns declined generlly throughout the study period, while the percentge of HMO employees enrolled in self- plns rose from 13 to POS enrollment shifted shrply to self- plns between 13 nd 16 nd then fell drmticlly fter 17. Self- enrollment for firms with fewer thn 200 workers grew during the study period but fell slightly for firms with 5,000 or more workers (Exhibit 2). Pln mix. Pln mix plyed n importnt role in determining overll estimtes of the self mrket shre. If the distribution of pln enrollment by pln type hd held constnt to its pttern in 13, time when indemnity enrollment constituted roughly hlf of covered workers, then in 2001 the percentge of workers enrolled in self- plns would hve been roughly five to six points higher thn it is with current weights. Hence, in 2001, insted of hving hlf of employees enrolled in self- plns, 56 percent would hve been enrolled. If pln enrollment throughout the study period hd been distributed s it ws in 16, yer when HMO enrollment reched its pek, enrollment in self plns would hve been nine points lower thn its ctul figure ws in 13 but lmost identicl in subsequent yers. Trends by firm size. A few notble trends nd ptterns stnd out in self-insurnce from 13 to 2001 by firm size (Exhibit 2). Throughout the study yers, rtes of self-insurnce hve remined reltively stble for firms with 1,000 or more workers. In fct, chnges in product mix hve counterblnced trends in self-insurnce by firm size nd pln type. For exmple, selfinsurnce hs grown mrkedly mong HMO EXHIBIT 1 Percentge Of Covered Workers In Prtly Or Completely Self-Insured Plns, By Yer And Pln Type, Selected Yers Pln type/weight Conventionl HMO PPO POS Totl current weights Totl 13 weights Totl 16 weights Totl 2001 weights 74% % % % SOURCES: For 13 nd 16, KPMG Ntionl Survey of Employer-Sponsored Benefits nd Robert Wood Johnson Foundtion Employer Helth Insurnce Survey; for 19 nd 2001, Henry J. Kiser Fmily Foundtion/Helth Reserch nd Eductionl NOTES: HMO is helth mintennce orgniztion. PPO is preferred provider orgniztion. POS is point-of-service pln. Estimte is sttisticlly different from the previous yer, for 13 16, 16 19, nd HEALTH AFFAIRS ~ Volume 22, Number 2 205

5 Helth Trcking EXHIBIT 2 Percentge Of Workers Enrolled In Self-Insured Helth Plns, By Firm Size, Selected Yers Number of workers ,000 4,9 5,000 or more 13% % % % SOURCES: For 13 nd 16, KPMG Ntionl Survey of Employer-Sponsored Benefits nd Robert Wood Johnson Foundtion Employer Helth Insurnce Survey; for 19 nd 2001, Henry J. Kiser Fmily Foundtion/Helth Reserch nd Eductionl Percentge is sttisticlly significnt from the previous yer s observtion t lph =.05. plns for firms employing 5,000 or more workers. Yet the decline in HMO mrket shre since 16 hs offset this increse, so tht the overll percentge of self- workers in the lrgest firms dropped slightly. Cost of coverge. Premiums incresed more rpidly mong fully thn self plns over the study period, with the single exception of 16 mong HMOs (Exhibit 3). In 16 the verge premium chnge ws ctully negtive for fully HMO plns. The helth insurnce underwriting cycle in 16 hd reched its soft phse. Six consecutive yers of underwriting profits (profits before investment income) from 19 to 15 hd induced the entry of insurers into new geogrphic mrkets. During this period helth insurers viewed HMOs nd POS plns s their growth products. They fought for mrket shre by underpricing their competitors, EXHIBIT 3 Averge Monthly Cost Of Single Coverge And Averge Premium Increse In Self- Insured Versus Insured Plns, Selected Yers Monthly cost of single coverge Conventionl HMO PPO POS Yer Self Self Self Self $ $ $ $ b 201 $ $ b $ $ b 223 Annul premium increse % % 1.1 b 3.7 b % % b % % b b 9.7 b 0.1% % SOURCES: For 13 nd 16, KPMG Ntionl Survey of Employer-Sponsored Benefits nd Robert Wood Johnson Foundtion Employer Helth Insurnce Survey; for 19 nd 2001, Henry J. Kiser Fmily Foundtion/Helth Reserch nd Eductionl NOTES: HMO is helth mintennce orgniztion. PPO is preferred provider orgniztion. POS is point-of-service pln. Not sufficient dt becuse of smll smple size (fewer thn twenty observtions). b Difference between self- nd fully plns for tht yer is sttisticlly significnt t lph =.05. c Dt not vilble for tht yer. 206 Mrch/April 2003

6 MrketWtch nd this fierce price competition drove premiums so low tht by 17, 68 percent of U.S. HMOs were suffering underwriting losses. 15 Chnge in insurers strtegies. Underwriting losses spurred insurers to lter their strtegies during the ltter yers of the decde. Their focus becme one of restoring profitbility rther thn obtining lrger mrket shres. Some insurers exited from locl mrkets where they were losing money; others prcticed ctch-up pricing with their fully products to offset the underwriting losses. Premium increses for self- products reflected expected increses in clims expenses. 16 Thus, by 2001 premium increses for self- plns were pproximtely three percentge points less thn increses for fully plns. For exmple, the verge premium increses for fully PPO plns in 2001 exceeded the corresponding increses for self- plns by five percentge points (15 versus 9.7 percentge points). Cost of single coverge. Yet the cost of single coverge in ny given yer ws sttisticlly equivlent mong self- nd fully plns. Presumbly, the chnging mix of employers purchsing different products nd conversions to self-insurnce explin this seeming prdox. For some yers HMO nd POS self- plns were more expensive thn fully plns were. As we show in the subsequent section, these differences my be ttributble to more generous coverge within self- plns tht is, lower cost shring or richer set of covered benefits or both. Richness of benefits nd ptient cost shring. We compred deductibles for ech of the four study yers by pln type mong selfnd fully plns (Exhibit 4). In 2001 deductibles in PPO plns were 39 percent higher in fully thn self- plns for use of in-network providers nd 18 percent higher for use of out-of-network providers. There were no sttisticlly significnt differences EXHIBIT 4 Annul Deductible Amounts In And Self-Insured Plns, By Pln Type And Single Versus Fmily Coverge, Selected Yers Conventionl PPO POS Yer Self Self Self 2001 Single Fmily 19 Single Fmily $ $ $ $ $ $ Single Fmily Single Fmily SOURCES: For 13 nd 16, KPMG Ntionl Survey of Employer-Sponsored Benefits nd Robert Wood Johnson Foundtion Employer Helth Insurnce Survey; for 19 nd 2001, Henry J. Kiser Fmily Foundtion/Helth Reserch nd Eductionl NOTES: PPO is preferred provider orgniztion. POS is point-of-service pln. Dt for PPO nd POS plns re for in-network providers. Estimte is sttisticlly different from the previous yer, for 13 16, 16 19, b Not sufficient dt becuse of smll smple size (fewer thn twenty observtions). HEALTH AFFAIRS ~ Volume 22, Number 2 207

7 Helth Trcking mong fully nd self- conventionl plns in ny yer, nd there ws only one yer in which differences were sttisticlly significnt for POS plns. Per visit copyments within HMO plns did not vry between purchsed nd self- products over the study yers (dt not shown). The scope of covered benefits in self plns tended to be similr to those in fully plns (Exhibit 5). We compred the percentge of employees covered for specific benefits, such s prescription drugs, for ech of the four study yers by pln type. Of twelve pirwise comprisons, differences were sttisticlly different in only four, nd self plns hd richer benefits in three of the four cses. Preexisting condition exclusions. HIPAA, encted in 16, precluded employers nd insurers from imposing preexisting condition cluses on new employees who hd helth insurnce coverge prior to their employment with their new firm. Severely limiting the number of employees subject to preexisting condition cluses gretly reduced the potentil svings to employers nd insurers from such cluses. This legisltion hs led to drmtic decline in the use of preexisting condition cluses (Exhibit 6), but the decline hs been more drmtic mong self- employers. For exmple, mong employees with PPO coverge, between 16 nd 2001 the percentge subject to preexisting condition exclusions declined from 53 percent to 46 per- EXHIBIT 5 Trends In Richness Of Benefits Among And Self-Insured Plns, For Specific Benefits, Selected Yers Conventionl HMO PPO POS Self Self Self Self 2001 Prescription drugs Outptient mentl helth % 89 % % 91 % % 93 % 93% 97 % Prescription drugs Outptient mentl helth Well-bby cre Prescription drugs Outptient mentl helth Well-bby cre Prescription drugs Outptient mentl helth Well-bby cre SOURCES: For 13 nd 16, KPMG Ntionl Survey of Employer-Sponsored Benefits nd Robert Wood Johnson Foundtion Employer Helth Insurnce Survey; for 19 nd 2001, Henry J. Kiser Fmily Foundtion/Helth Reserch nd Eductionl NOTES: Dt for well-bby cre were not vilble for HMO is helth mintennce orgniztion. PPO is preferred provider orgniztion. POS is point-of-service pln. Estimte is sttisticlly different between fully nd self- plns t the level of lph =.05. b Not sufficient dt becuse of smll smple size (fewer thn twenty observtions). c Dt not vilble for tht yer. 208 Mrch/April 2003

8 MrketWtch EXHIBIT 6 Percentge Of Pln Enrollees In And Self-Insured Plns Subjected To Preexisting Condition Cluses, By Pln Type, Selected Yers Conventionl Self- HMO Self- PPO Self- POS Self- 57% 51 54% % 34 30% SOURCES: For 13 nd 16, KPMG Ntionl Survey of Employer-Sponsored Benefits nd Robert Wood Johnson Foundtion Employer Helth Insurnce Survey; for 19 nd 2001, Henry J. Kiser Fmily Foundtion/Helth Reserch nd Eductionl NOTES: HMO is helth mintennce orgniztion. PPO is preferred provider orgniztion. POS is point-of-service pln. Dt not vilble for tht yer. b Not sufficient dt becuse of smll smple size (fewer thn twenty observtions). cent in fully plns, compred with decline from 70 percent to 44 percent in self plns. During the erly 10s mny sttes encted smll-group reforms tht limited the use of preexisting cluses. Becuse of ERISA s preemption, however, self- plns were not subject to such stte legisltion. In ddition, few firms tht self-insure hve fewer thn fifty workers, common threshold for defining smll firms in stte legisltion. Consequently, HIPAA, which pplies to ll plns regrdless of funding sttus, hs hd lrger impct on self- plns. Discussion Comprisons with previous studies. Severl of our findings echo those of Acs nd collegues study of self-insurnce in 13 nd Mrquis nd Long s study of self- plns in 17. However, there re notble differences. We find tht the bsolute percentge of employees covered by self- plns declined from 56 percent to 50 percent during the study yers. This decline is lrgely ttributble to the chnge in product mix, s employers switched from indemnity plns, which lend themselves to self-insurnce, to HMO nd POS plns, which fce more impediments to self-insurnce. Indemnity nd PPO plns were less likely, but HMO plns more likely, to be self- t the end of the study period thn t the beginning. If the product mix throughout the period hd held constnt s it ws in 16, the high-wter mrk of hevily mnged cre, the percentge of workers covered by self- plns would hve grown from 46 percent in 13 to 57 percent in 16 nd then declined to its current 50 percent level. As reported by Acs nd collegues nd by Mrquis nd Long, we find tht the verge costs of self- nd fully plns re roughly equivlent. However, self- plns hve somewht lower deductibles. Hence, self- plns re not sfe hven for employers seeking to offer low-benefit ctstrophic coverge to their workforce. One drmtic chnge hs occurred mong self firms in recent yers: In response to HIPAA, the use of preexisting condition cluses hs declined rpidly more rpidly thn mong fully plns so tht self plns tody re no more likely to im- HEALTH AFFAIRS ~ Volume 22, Number 2 209

9 Helth Trcking pose such cluses on their workers thn fully plns re. Impct of underwriting cycle. As the helth insurnce underwriting cycle moves from the soft phse, chrcterized by insurer underwriting losses nd fierce price competition, to the hrd phse, chrcterized by rpid infltion nd restortion of insurers profitbility, the comprtive ttrctiveness of self-insurnce chnges. Reltively smll differences in the rte of infltion between fully nd self- plns become more drmtic. The counterviling force t the moment is sluggish economy recovering from recession. Will midsize firms opt to tke on greter finncil risk during period when profits re declining? Likely impct of shift in product mix. Lstly, with helth insurers retreting from hevily mnged cre nd seeking products tht promote greter employee choice nd cost shring, HMO enrollment is likely to decline, while PPO enrollment is likely to increse. This shift in product mix will rise the number of employees enrolled in self- plns. Consequently, the two-decde-old controversy bout the merits of ERISA nd selfinsurnce is unlikely to fde wy. Sty tuned for more debtes t the stte nd federl levels. The uthors thnk the Robert Wood Johnson Foundtion for finncil support through the Helth Cre Finncing nd Orgniztion project, under Grnt no NOTES 1. P. Fronstin, Sources of Helth Insurnce nd Chrcteristics of the Un: Anlysis of the Mrch 2001 Current Popultion Survey, Issue Brief no. 240 (Wshington: Employee Benefit Reserch Institute, December 2001). 2. EBRI, Fundmentls of Employee Benefit Progrms, 5th ed. (Wshington: EBRI, 17), G. Acs et l., Self-Insured Employer Helth Plns: Prevlence, Profile, Provisions, nd Premiums, Helth Affirs (Summer 16): Reders interested in more comprehensive discussion of the pros nd cons of ERISA should refer to U.S. Generl Accounting Office, Report to Congressionl Requesters, Employer-Bsed Helth Plns: Issues, Trends, nd Chllenges Posed by ERISA, Pub. no. GA 1.13:HEHS--167 (Wshington: GAO, 15). 5. P. McDonnell et l., Self-Insured Helth Plns, Helth Cre Finncing Review 8, no. 2 (16): Reported in Acs et l., Self-Insured Employer Helth Plns. 7. M.S. Mrquis nd S.H. Long, Recent Trends in Self-Insured Employer Helth Plns, Helth Affirs (My/June 19): B. Atchinson nd D. Fox, The Politics of the Helth Insurnce Portbility nd Accountbility Act, Helth Affirs (My/June 17): R. Frnk, C. Koyngi, nd T. McGuire, The Politics nd Economics of Mentl Helth Prity Lws, Helth Affirs (July/Aug 17): S. Ludicin nd K. Prdo, Stte Legisltive Helth Cre nd Insurnce Issues: 19 Survey of Plns (Wshington: Blue Cross nd Blue Shield Assocition of Americ, December 19). 11. J. Gbel et l., Job-Bsed Helth Insurnce in 2001: Infltion Hits Double Digits, Mnged Cre Retrets, Helth Affirs (Sep/Oct 2001): Acs nd collegues nlysis lso includes dt from the 11 Helth Insurnce Assocition of Americ survey of employers nd the 17 Ntionl Medicl Expenditure Survey. See Acs et l., Self-Insured Employer Helth Plns. 13. Mrquis nd Long, Recent Trends. 14. In 13 KPMG did not sk employers with HMO plns bout self-insurnce sttus. Therefore, for HMO plns in 13 we hve used dt from the RWJF Employer Helth Insurnce Survey. 15. InterStudy reported tht 68 percent of HMOs suffered underwriting losses in The exception to this sttement is the premium for stop-loss protection pid to reinsurers. 210 Mrch/April 2003