Remember the 1946 Tort Reform act says you can't sue doctors on government payroll.
Consequently less than half the doctors practice defensive medicine as they KNOW they won't get sued.
But non-government physicians 92% order duplicate tests, etc. practice defensive medicine and the COST is paid by the insurance companies as they simply raise the premiums.
Remember all insurance companies are regulated by states.
All states require companies to have reserves for future claims.
Reserves come from premiums that aren't used to pay claims...
(average insurance company pays out about 80% of premiums in claims...
i.e. defensive medicine included) and of the balance of 20% revenue pays salaries,etc.
AND then if any profits add to reserves... and then any profits left out of the 6% after salaries, etc., taxes reserves... Again a major reason many companies pulled out of Obamacare because the idiots forced companies to pay 85%...i.e. called medical liability ratio.
Left no money for profits which are used to build reserves required by states!
85% for group, 80% for individual plans.
Prior to the passage of the ACA, the
majority of insurers were within the 80 percent MLR range.
However, roughly one-third of insurers in the individual market were required to make some changes in order comply with the new rule.
Between 2011, when the rule went into effect, and 2013, the median MLR in the individual market
increased by 2.4 percent,
while in the small and large group markets the median MLRs increased by 0.4 percent and 0.1 percent, respectively.
This shows a moderate shift in
spending away from administrative expenses and profit, and towards provision of care in the individual market to comply with the rule, but less of an impact in the small and large group markets which were largely already in compliance.
This could be an indication that individual market plans previously offered insurers exceptionally high profits,
that these insurers found ways of limiting administrative expenses,
or that the insurers who were unable to adapt to the rule left markets where their profit margins would be substantially impacted by the rule.
The MLR rule puts pressure on insurers to limit administrative overhead in order to preserve profit without running afoul of the MLR minimum.
Insurers may achieve this new goal by reducing expenditures on fraud protection measures, limiting “quality improvement” activities to those that satisfy the ACA requirements, limiting networks to reduce administrative burden, or shifting to more managed care-style plans which require care providers to take on responsibility for more administrative duties.
The inherent limitation on corporate revenues could also contribute to consolidation in the insurance market by discouraging investors and new entrants.
Without the ability to rapidly recoup start-up costs, competition with already-established players in a market is less likely to prove financially worthwhile.
The reduced number of insurance carriers entering new markets since 2011 may, in part, be attributed to this market restriction.
CONCLUSION
As one economist put it, “
The Medical Loss Ratio is an accounting monstrosity, a convolution of data from myriad products, distribution channels, and geographical regions that enthralls the unsophisticated observer and distorts policy discourse.”
[2]
Medical Loss Ratio Under the ACA - AAF