Small state health insurers fear a provision of Obamacare will take money from their pockets and hand it over to the state's largest insurer based on flawed data — upending the Massachusetts marketplace.
"It's a reverse Robin Hood," said Thomas D. Policelli, chief executive of 9,000-member Minuteman Health. "The cheap are paying the wealthy. The calculation itself is simply a mess."
The risk adjustment provision in the Affordable Care Act would require insurers to pay into a pool that would be distributed among companies based on the overall health of their members. Insurers with healthier populations will pay, and those with sicker members, such as Blue Cross Blue Shield, will reap those benefits, small health plans say.
Lynn Ostrowski, director of corporate responsibility for small insurer Health New England, said member health is calculated based on unfair coding practices, counting patients who receive treatment using a higher level of technology and more testing — such as at academic medical centers rather than community hospitals — as sicker.
But Jay McQuaide, spokesman for Blue Cross, said there will likely be checks in place to ensure the data is calculated properly.
"Is it important to get the data right? Absolutely. And we have confidence they'll be able to do that," he said. "We need tools to deal with risks. You can't pick and choose what parts of the law you can comply with."
There are already mechanisms to level the playing field, such as barring companies from refusing coverage to sick individuals, Ostrowski said.
The Health Connector Authority has discussed a phase-in option, set to begin June 30, bringing the pool of money down from $104 million to $52 million for the first year.
"The commonwealth shared a preliminary plan for implementing the risk adjustment program with the carriers and other stakeholders," a Health Connector spokesman said in a statement. The federal Centers for Medicare & Medicaid Services "has conveyed concern with any changes to our risk adjustment approach, and no final decisions have been made."
Brian Rosman, research director at independent nonprofit Health Care for All, said the organization "strongly supports implementation of the regulations, but we also think the state should look for ways that health plans are not affected so strongly."
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