Tag Archives: U.S.

What Makes U.S. Healthcare Different?

We in the U.S. spend a lot on healthcare. Whether expressed as the cost per service, the cost per person or as a percentage of the gross domestic product, the high cost of healthcare is well documented. While solutions to this situation have been suggested for many years, the expensive reality continues.

Is it possible that unique characteristics of the American healthcare environment create special challenges? This article discusses several unique aspects.

Geographic Diversity

The U.S. is a diverse country with population centers scattered throughout the country. The mean center of population currently lies in Missouri.

As the inset map shows, this is east and south of the geographic center of the U.S. The major population centers in the eastern half of the country pull it east. The major population centers in the south pull it south. More than 10% of the population is in one major southwestern state, California. Major metropolitan areas can be found throughout the country: San Francisco and Los Angeles in the Southwest, Dallas and Houston in the south Midwest, Chicago in the upper Midwest, Boston and New York in the northeastern part of the country, Atlanta and Miami in the Southeast. Why is this important?

More than 90% of the Canadian population lives within 100 miles of the U.S. border. The oft-touted Canadian system serves a population that is concentrated in a thin band of land. In a concentrated environment, it is possible to have a more efficient allocation of resources. In the Canadian provinces with significant rural populations (e.g., Alberta and Saskatchewan) the provinces use regional health authorities to take responsibility.

See also: A Road Map for Health Insurance  

American Definition of Quality

Quality is difficult to universally define. Many times people say, “I know it when I see it” or, more importantly “I know it when I don’t see it.” Over the past 15 to 20 years, quality has been objectively defined, to the point that it is consistently measured across health systems. One of the best definitions of quality is “providing the right service, at the right time, to the right patient as efficiently as possible.” The American definition of quality usually includes a high degree of access and a significant sense of urgency.

Other countries do not see waiting as a deterioration in quality. In fact, queuing, or waiting lines, are accepted. The American ideal is getting healthcare now, not tomorrow, not next week or next year. Most Americans see waiting as a reduction in quality. Health systems that require pre-authorization or approval of referrals are frequently viewed as substandard because those systems create barriers that patients have to work through. In countries with socialized healthcare systems, patients regularly have to wait. Much of this wait is associated with fiscal limits within the system restricting the available resources. In the U.S., the excess capacity in the system almost always provides an adequate supply of healthcare resources, so the required waiting time is very limited.

The waiting line is caused by either quotas or specific budgets for specific procedures, producing a rigid form of rationing. In the U.S., waiting occurs when the physician was booked or the schedule was full. This queue is not a budget-driven constraint.

The U.S. healthcare system is recognized as one of the highest-quality in the world (e.g., high cancer screening rates). Although the quality of care is generally quite high, some of the measured outcomes suggest that the U.S. health system is not advancing as much as would be hoped. One example is the efforts to eliminate breast cancer. Screening for breast cancer is higher than it has ever been, but so is the rate of breast cancer. Perhaps improved detection has identified more cases.

Freedom of Choice

Americans value freedom of choice; they like to make decisions for themselves. Americans value going where they want to get care, choosing who they want to provide that care, oftentimes deciding what care they want and getting it when they want to get it. This has resulted in broader networks offering more choices than needed. This has resulted in higher-than-necessary utilization of specific services, including new technology. The need for freedom of choice has limited the effectiveness of care management programs. Freedom of choice combined with limited cost sharing results in expensive healthcare. One unfortunate consequence is the negative opinion that develops regarding any administrative process that limits freedom of choice. Programs that focus on limiting medically unnecessary care are accused of disrupting the physician/patient relationship.

Healthcare Resource Planning

In most states, there is very limited overall resource planning. At various times, some states have implemented certificate of need programs for specific types of providers. But, for the most part, there are no formal limits to the number of providers or types of providers. In most urban markets, there is an oversupply of providers. Rural markets are often plagued with a shortage. Some markets are so desperate for providers that significant compensation is offered to lure them.

Why is this important? Healthcare tends to be a market that fails to respond to traditional supply and demand economics. In the general economy, the greater the supply, the lesser the demand and the lower the prices. In healthcare, the higher the supply, the greater the induced demand and the continuation of higher prices. Informal studies suggest that utilization levels positively correlate with supply.

One of the reasons for escalating costs is the continued oversupply of healthcare providers. One of the best examples of effective resource planning is the approach implemented by Kaiser Foundation Health Plan. Kaiser carefully plans the supply of professional services based on a long-established staffing model. As the associated membership grows, they move from a combination of “nearby owned facilities” and “rented facilities” to “owned facilities.” Kaiser carefully manages the strategic transition to a “wholly owned delivery system” and manages the resources based on membership growth. Kaiser avoids excess capacity and maintains a cost-effective delivery system.

Countries with socialized healthcare systems are much more involved with resource planning than the U.S. The competitive nature of healthcare in the U.S. is much more focused on capturing market share than defining appropriate resources for a region. Less effective resource planning drives up the cost of care.

Wide Variations in Efficiency

The efficiency of regional healthcare systems varies significantly from one geographic market to another. Delivery system care patterns have emerged based on local needs, regional care practices and the extent of provider involvement in the financing of care. Markets like Portland, OR, have developed extremely efficient in-patient care patterns with a larger portion of their healthcare dollar going to professional providers. Other markets have emerged at the same time with much less efficient patterns. In-patient utilization patterns vary by more than 35% to 45%. Analyses show no clinical rationale to support the observed variation. The U.S. is one of the few countries exhibiting this level of variation. Experts generally concur that much of this variation is caused by personal physician preference.

Tax-Sheltered Benefits

The current tax-sheltered employee benefit approach emerged during the post-WWII era where employers were seeking creative ways to attract, hire and keep employees. The tax law enabled employers to write off the cost of benefits and provide their employees a valuable tax-sheltered employee benefit. The tax law provides this favorable status only to employer-sponsored programs. Individual health insurance benefit programs do not enjoy this same tax advantage. Tax reform efforts have considered eliminating this difference. Self-funded employer-sponsored benefit programs, including those involving labor union negotiations (i.e., Taft -Hartley plans) are also tax-advantaged.

This is an important issue when discussing transitions to alternative systems. What role will employers play? What about programs negotiated by labor unions? How will we unravel the tax-advantaged funding of healthcare costs by the employer?

Diverse Insurance and Claims Administration

The employee health benefit marketplace has grown significantly with a large variety of organizations targeting the effective administration of such programs. Merger/acquisition activity has transformed the marketplace into a handful of major players and a large number of regional players. Third party administrators (TPAs) are active in the market supporting the self-funded and self-administered benefit programs. The federal government provides government-sponsored coverage for the elderly and disabled (Medicare) and for beneficiaries in lower socio-economic levels (Medicaid). Many of these programs outsource the administration and risk taking to the private sector. Healthcare administration in the U.S. includes a significant private sector involvement. There is little uniformity between different health plans. There are limited standards to streamline the process.

Public/Private Sector Cost Shift

The U.S. healthcare system incorporates a significant cost shift between the government-sponsored programs and the private sector programs. The private sector pays a much higher amount for identical services than the public sector. Within the private sector, each carrier/health plan is required to negotiate payment rates, which can vary substantially from one carrier to the next. The variability in reimbursement increases administrative costs for both the providers and the health plans or administrators.

See also: Healthcare Debate Misses Key Point  

Hesitancy to Declare Healthcare a Human Rights Issue

In the U.S., there has been a hesitancy to declare healthcare a human rights issue. In Canada, the Canada Health Care Act defines five principles:

    • Public Administration: All administration of provincial health insurance must be carried out by a public authority on a non-profit basis.
    • Comprehensiveness: All necessary health services, including hospitals, physicians and surgical dentists, must be insured.
    • Universality: All insured residents are entitled to the same level of healthcare.
    • Portability: A resident who moves to a different province or territory is still entitled to coverage from the home province during a minimum waiting period. This also applies to residents who leave the country.
    • Accessibility: All insured persons have reasonable access to healthcare facilities. In addition, all physicians, hospitals, etc., must be provided reasonable compensation for the services they provide.

A quick internet review will show considerable discussion defending both opinions: It is a right, or it isn’t a right. Dominant emerging thought focuses on what is called Triple Aim: a strong focus on quality and customer satisfaction, improving the population’s health status and reducing costs of care. They are admirable goals, but all require the definition or identification of a population. Who is the population? Is it everyone? Is it just the segment I am concerned about?

Recent healthcare reform efforts have focused on minimizing uninsured, which was a step toward universality. Ironically, the American’s demand for freedom of choice also includes freedom from being told that they must buy insurance and what kind of care they should pay for.


These nine issues provide an initial list of unique characteristics of the U.S. healthcare system. When working toward solutions to resolving the high cost of care, these issues must be considered. This is not an exhaustive list but does begin to highlight what makes American healthcare different.

Insuring What You Want, When You Want

DIAmond Award winner Trōv is one of the most widely referred to cases when speaking about disruption in the insurance sector. But what is Trōv exactly about? What is the business model? How successful is it? Trōv’s founder and CEO Scott Walchek will share his vision in a keynote presentation at DIA Amsterdam, this May. To warm up, I interviewed Scott last week.

Trōv is the world’s first on-demand insurance platform for single items. It is a mobile app that allows users to insure whatever, whenever. It empowers customers to insure “just the things you care about” for whatever period you prefer. Trōv users simply snap a picture of a receipt or the product code of a product. This creates a personal digital repository for all things tangible. For selected items, Trōv offers a quote to insure each individual item. Customers can then simply “swipe to protect” to purchase the insurance. It is equally simple to “swipe to unprotect.” With Trōv, long contracts are not necessary. Even the claims process is automated with the use of chatbots and available on-demand on a smart phone.

Trōv is founded by Scott Walchek. Scott is a successful technology entrepreneur. Over the past 25 years, he built companies such as Macromedia, Sanctuary Woods, C2B Technologies and DebtMarket. He was also a co-lead investor and founding director of Baidu, China’s largest search engine.

Scott is also one of the 75 thought leaders who contributed to our new book “Reinventing Customer Engagement. The next level of digital transformation for banks and insurers.”

What inspired you to create Trōv?

Scott: “At some point I realized there is an enormous latent value in the information related to the things people own. From obvious things such as receipts and warranties to actually having an overview of what you own and what the current replacement value of each item is. We want to curate ways to turn this into value for consumers. From keeping information on items up to date to, for instance, arranging insurance for these items.

We’re a technology company, not an insurance company. We’re new in this space. So I started with testing our first ideas about a proposition and the assumptions behind it with several senior executives of large P&C insurers such as AIG and ACE. What I assumed is that at the end of the day the core metric of success is the ratio of insurance to actual value. The better this ratio, the better the balance sheet.

Of course, this is an oversimplification, but everyone agreed that in essence this is how over the past 200 years value in insurance is created. Now, what is remarkable is that insurers do not really know what consumers own, and what the exact value of these goods is … What if they did know? This would disrupt markets. It would lead to much better risk assessment driven by real knowledge of the true value of what people really own.”

See also: Insurtech: The Approaching Storm  

Trōv’s main target users are millennials, a target segment that most incumbents find very difficult to reach and engage with. Why does Trōv strike the right chord among this generation?

Scott: “We’re in the Australian market for a year now and entered the U.K. market a few months ago. Around 75% of our users are aged between 18 and 24. It appears that we are successful in tapping into the specific needs of this group. We do this by explicitly tapping into four key millennial trends. The first is “on-demand.” We can see that from how millennials consume entertainment, shopping etc. Services need to be now, 24 hours a day, on my device. The second trend is, “Don’t lock me into a lengthy contract.” We enable micro-duration. Customers can turn their insurance on and off as they see fit. In practice, they hardly do. But it is about the psychological benefit of being able to do so. The third is what we call “unbundled convenience”: “Let me choose what to protect, the things I really care about.” The fourth is: “people/agent optional.” Millennials want to engage with their smartphone without having to talk to an actual person.”

Trōv is based in the San Francisco Bay Area. But you decided to launch first in Australia and the U.K. Why there?

Scott: “Ha ha – there’s a linear story and a non-linear story to that! The linear story is that microduration is still new to the industry, so our hypothesis requires testing. The regulatory environment is important if you want to get to market fast. Australia and the U.K. have a single regulatory authority versus the 56 bodies in the U.S. But we’re also in the process of filing in the U.S. The non-linear story is that I just happened to meet Kirsten Dunlop, head of strategic innovation at Suncorp Personal Insurance, at a conference in Meribel in France. She immediately understood the strategic impact of Trōv, and that is when it took off.”

Because the Trōv concept is so new to consumers, it must be extremely interesting to learn what exactly strikes the right chord …

Scott: “Customers just love the experience. Our NPS is +49. However, we’re learning every day. With a completely new concept such as Trōv, it is impossible to know exactly what to expect, honestly. It turns out that Trōv reveals new consumer insights. There is still a significant number of valuables that our audience wants to insure but that we cannot provide a quote for, for instance. Although more than 60% never turn off an insurance, the ability to switch an insurance on and off turns out to be an important psychological benefit. This appears to be category-dependent. Sporting goods are switched on and off more often than smartphones and laptops.

We’re constantly measuring and improving every step of the funnel. From leaving Facebook to downloading the app, to registration, to actual swipes. We will share concrete numbers on uptake and conversion rates at DIA Amsterdam. But to already share two big learnings: We designed Trōv for use on smartphones, but, much to our surprise funnel figures multiplied when we decided to add a web interface. And we are actually even attracting better-quality customers.”

In Australia, you decided to partner with Suncorp, in the U.K. with AXA and in the U.S. with Munich Re. What are the success factors of a partnership between an insurtech and an incumbent?

Scott: “At the end of the day, it is about relationships and people. We understand their internal challenges. Everyone agrees that real knowledge of individual insured goods and the actual value of those goods improves the loss ratio. But we need to figure out how this works exactly through experimentation. This requires internal dedication, throughout the whole organization, starting at the top. It is not about conducting small pilots, but the willingness to experiment while going all the way, invest for several years and learn as we go what insurance will look like in the future and how consumers want to engage.”

What are your future plans and ambitions with Trōv? We can imagine that Trōv could also be an interesting partner for retailers and producers of durables. With Trōv, they could seamlessly sell insurance …

Scott: “We have three lines of business. The first is what we call “solid.” This is about expanding the Trōv app geographically, covering more categories and continuously developing the technology. Trōv will be launched in Japan, Germany and Canada shortly. Then there is “liquid”; offering white-label solutions to financial institutions, for instance in relation to connected cars and homes. The third line of business is “gas”; basically Trōv technology embedded in other applications; insurance as a service. This could be attractive for all sorts of merchants, telco operators etc.”

See also: Understanding Insurtech: the ABCs  

This would make Trōv even more part of the context in which consumers makes decisions about the risk they are willing and not willing to incur. And it also taps into the exponential growth of connected devices, similar to how machine-to-machine payments are increasingly taking place …

Scott: “Yes. What we’re now doing with Trōv is really the beginning. Trōv is about providing our customers with exactly the protection they want, exactly when they want it. With more and more connected devices and sensors and new data streams everywhere we can make the whole experience so seamless they don’t have to do anything at all.”

Implications of Our Aging Population

Aging is a key force shaping our societies and the economy. Too often, the current debate on aging and demographic change narrowly focuses on the direct implications for pensions system and healthcare and neglects the broader economic implications. An understanding of the wide ranging economic implications of demographic change, however, is fundamental for insurers and policymakers in order to make sound long-term decisions.

The world of shrinking workforces

The world is quickly entering a new phase of demographic development. The new world is characterized by a shrinking or – at best – stagnating workforce due to the continuous decline of birth rates since the “baby boomer generation.” While Germany’s working age population peaked about 15 years ago, according to UN figures, China is currently at a record. In the U.S., the working age population is expected to continue to grow due to immigration, albeit at a much slower pace than in the past.

But decreasing birth rates not only mean that that the workforce is shrinking (or at least not growing). It also means that the average age of the workforce is increasing, especially until the baby boomer generation will be retired within the next decade. We refer to this phenomenon as “silver workers.”

Furthermore, as people live longer, the proportion of retirees in the total population is going to increase. This increase will be far more pronounced in the future than it was in the past. In developing economies, this trend is starting at a much lower level, but the eventual change will be far more rapid and dramatic than in developed economies.

The economics of aging

These demographic developments – shrinking workforces, the rise of silver workers and increasing share of retirees – will have profound economic implications.

In a world of shrinking workforces, we cannot expect the economy to expand rapidly, unless productivity can be increased far beyond long-term historical averages. In fact, past growth rates were driven considerably by an increasing labor force. This is especially true for some developing economies like Brazil and Mexico. But also in the U.S., more than 40% of economic growth over the past 25 years can be attributed to an increasing working age population. We will have to get used to low GDP growth rates.

See also: The Great AI Race in Insurance Innovation  

However, overall GDP growth says little about the development of individual living standards. To assess living standards, we need to consider the implications of demographic change on GDP per capita.

Three forces are at play:

First, because fewer workers will have to provide for more retirees, demographic change depresses GDP per capita. In the U.S., the share of working age population to total population is expected to decline from 60% to 54% over the next 25 years. In China and Germany, the decline is more pronounced: from 67% to 57% in China and from 61% to 51% in Germany. This implies that, as long as the production of each person of working age does not change, per capita GDP would decrease by 9% in the U.S. and by 15% in China and Germany by 2040.

Second, future GDP per capita will depend on the development of investments and savings. As people will have to live longer on their savings in retirement, we expect saving rates to increase. As these savings are invested, there will be more machines per person (i.e. the capital stock will increase relative to the labor force). This will partly compensate for the negative impact of the labor force development on GDP per capita.

Finally, advances in productivity may entirely or partially offset the demographic pressure on GDP per capita. Projections of productivity growth are fraught with high uncertainty. However, based on historical productivity growth rates (about 1.5% per year in most developed countries), productivity growth will likely compensate for the negative demographic impact on GDP per capita in most countries (Italy being a potential exception).

Taking these three factors together, we conclude that GDP per capita will continue to grow in most countries, albeit at a slower pace than in the past.

The next question is: How will this per capita income be distributed among workers and retirees?

We expect that aging will depress real interest rates as the demand for capital is likely to shrink relative to savings. In fact, real interest rates have been steadily declining over the last three decades. We will have to get used to a low-interest environment and, hence, low returns on retirement savings.

At the same time, the relative scarceness of labor should bolster wages. Hence, the future workers will likely benefit relative to future retirees (who are today’s middle-aged savers).

A threefold challenge

This analysis suggests that there is a threefold funding challenge from aging.

First, low interest rates make it difficult for individuals to accumulate sufficient savings to fund their retirement.

Second, the increasing share of retirees in society exerts a rising funding pressure on public pay-as-you go pensions systems. While in the U.S. there are currently 25 people of retirement age per 100 of working age, it will be 40 people of retirement age in 25 years.

Third, the increasing average age of the workforce raises the risk of disability. Inability to work due to critical illness or disability reduces the ability of individuals to accumulate sufficient savings to fund retirement.

Policymakers have to consider a number of policy measures to address this threefold funding challenge. Potential measures include increasing the retirement age, providing incentives for individual savings, enhancing productivity, increasing labor force participation and increasing pensions contribution or reduce benefits.

See also: Demographics and P&C Insurance  

In most countries, however, none of these measures seems desirable or politically feasible on its own. In the U.S., for example, pension contributions would have to be increased by 63% between 2015 and 2040 to compensate for the increasing share of retirees in the population. Alternatively, the retirement age would have to be increased by seven years.

Policymakers therefore need to develop strategies that combine a broad range of different measures in varying degrees. There is a risk, though, that measures to enhance productivity, namely investments in education, will be de-prioritized as public finances come under increasing strain.

For insurers, this analysis suggests that they must adapt to a world of slow growth and low interest rates in the longer term. Furthermore, in a world of aging workforces, products designed to protect the income against disability and inability to work will become more important. Hence we expect to see a stronger shift from savings products to protection products.

4 Ways Insurance Is Disrupting Itself

Coming from the Insurance Executive Conference earlier this month in New York, I am extremely excited by what I heard regarding where the industry is heading.

I attended both the life insurance and P&C tracks, picking up the following insights about how the industry is disrupting itself before others can:

  1. Insurance carriers are embracing change.
    Anwar Haneef, partner at IBM Watson, said, “We have not seen much disruption in the insurance industry in the last 100 to 200 years” and acknowledged that new technologies have the potential of changing that. Jeffrey Killian, vice president of in-force service and operations at New York Life, stated, “We could become Blockbuster (Video) if we don’t go through the change.”
  1. Insurance carriers are focusing on their customers in a new way. For example, Gerald Patterson, senior vice president of retirement and investor services at Principal Financial group, spoke of Principal’s move away from thinking about customer service to focus instead on the customer experience. Principal tries to provide value to the customer and understand that young consumers expect the same technology from insurance carriers that they experience with other service providers. He also stressed the importance of embedding experimentation in your customer experience on a regular basis.
  1. Insurance carriers are embracing technology and planning for a different future.
    At the highest level, for example, Jane Chwick, former partner in charge of global technology at Goldman Sachs, provides technology expertise as a board member of the relatively young company Voya Financial. Patterson mentioned that he has recently spent time visiting Silicon Valley and attending Fintech conferences.

Killian acknowledged that realizing a company’s vision of customer experience requires investment and pointed out that Principal is committed to making the right investments to accomplish this. He remarked “We have invested a lot in Lean Six Sigma. It’s amazing how much energy you can unlock through these processes.”

Joe Beneducci, chairman, president and CEO of Prosight Specialty Insurance, said, “Technology is a catalyst that affords us options.” Life insurance executives discussed their expectation that the analytics movement will affect carriers’ entire value chain. They also saw predictive analytics enable insurance carriers to be learning organizations.

West Hunt, vice president and chief data officer at Nationwide, discussed the capability of scaling human expertise through cognitive computing. At the same time, the rise of robo-advisers and their potential threat to the business was mentioned. Finally, the recent trend toward digital and what it means to the industry was raised. Technology was discussed all over the conference.

  1. Further opportunities to leverage technology were identified. Colleen Risk, senior analyst at Celent, mentioned the opportunity insurance carriers have of enhancing their websites to provide transaction capabilities for consumers, such as changing beneficiaries. Recent research by Celent showed that less than 25% of life insurance carriers are doing e-delivery of contracts. Other opportunities include: making data available throughout the company, producing strategies to sustain customer loyalty, developing a compelling message for life insurance and educating Millennial consumers.

I was happy to participate in the conference and felt energized by the discussion of new topics that position the industry to continue to thrive into the future.

What do you think? Post your comments below!

Innovation Spreads in U.S. State by State

Innovation can start simple. It does not always have to start with a big bang. We all know that doing anything in insurance across 50 states is often complex and expensive and a long process, but it is possible to begin with an idea around a new model, product, channel or line of business. Decide on which state(s) to start with, and then run with it. What a great way to launch and experience innovation.

This past year, we have seen new distribution models springing up on both coasts — auto in California and life in Massachusetts. Let your imagination take over, and you can envision innovation spreading across our industry… across every state in our nation… and beyond.

We have two great examples of East Coast and West Coast success stories. The West Coast example is Google Compare. Google is essentially acting as a partner for insurers — helping them become more customer-centric by taking distribution capabilities to where the customers are, on the platforms that customers are using. With a history of being very accurate at predicting what customers want, Google is bringing that strength to the insurance industry. Google Compare started with personal auto, for the state of California, and with only a few insurers — all with the goal to add more states, more lines and more insurer partners.

The East Coast reference to innovation in Massachusetts involves Haven Life. Haven Life is offering a totally-online customer service experience for buying term life insurance. In addition to ‘instantly’ quoting, Haven Life offers information and tools that help take the complexity and the complications out of the process of buying life insurance — making it a much quicker process and simpler decision for the customer.

The East/West examples demonstrate how creative thinking and novel approaches are delivering new, profitable and productive business models that will reshape tomorrow — by starting simple.

At SMA, we regularly track solution investment trends and the progress of maturing and emerging technology. There isn’t a day that goes by that I don’t see or hear about something exciting and inventive taking place in our industry. That wouldn’t have been true five years ago. This is a critical time for our industry — a time of great opportunities. It is a period when the possibilities are endless — thanks to a formidable combination of technology capabilities and changing customer expectations and behaviors.