Costs, Commitment and Locality: A Comparison of For-Profit and Not-for-Profit Health Plans
Authors:   Treo Solutions
Published: August 2011

Following on the heels of the first national study demonstrating differences in the community benefits provided by not-for-profit and for-profit health maintenance organizations (HMOs) (Schlesinger, Mitchell, and Gray 2003), this study of the New York state market shows significant differences in premiums, administrative overhead and commitment to safety net coverage between nonprofit and for-profit health plans. This study shows that for-profit health plans do act differently than not-for-profit plans in terms of performance, efficiency, and contribution to safety net programs. Moreover, it suggests that not-for-profit health insurers operating in a predominantly for-profit market act in many ways like for-profits.

The New York state insurance market provides an ideal study environment because one can compare a large number of policyholders and plans in both business models (for-profit and not-for-profit) that share an identical legislative and regulatory environment. New York has large populations being provided coverage under both models and no allowances had to be made for state-to-state political and/or legal differences. Specifically, this study shows that:

□ The downstate insurance market is predominantly for-profit, while the upstate market is almost entirely not-for-profit. The recent conversion of Empire Blue Cross Blue Shield to a for-profit model moves the downstate market further into the for-profit column, while the upstate region remains not-for-profit. □ Insurers in the upstate not-for-profit market are more administratively efficient than insurers in the downstate region. Compared to the downstate region, insurers in upstate New York spent 1.5% less of their operating revenues on administrative expenses. The additional 1.5% of spending on administrative expenses downstate totals $137,000,000. □ Upstate insurers spend significantly more of the revenues received on payments for medical care. Downstate insurers spent 80.4% of operating revenues on medical care. Upstate insurers spent 87.7% of operating revenue on medical care. If health care spending patterns downstate were similar to upstate, the additional 7.3% allocated to medical care would total $678,000,000. □ A lower level of investment in medical care in the downstate region translated into higher underwriting gains, which totaled 8.1% of operating revenue. Plans in the upstate region reported underwriting gains of only 2.3%. □ Not-for-profit insurers offer more cost effective (i.e., lower) premium options for consumers. In 2002, the upstate market had the lowest operating revenues (premiums) statewide, averaging $184 per member per month (pmpm); the not-for-profit plans downstate averaged $203 pmpm. Premiums in the for-profit segment of the downstate market averaged $221 pmpm in 2002. □ The not-for-profit upstate market has proved its viability, while maintaining commitments to New York safety net and Medicare programs. The not-for-profit upstate market experienced a $12 million loss in New York safety net programs in 2002, but generated $131 million in underwriting gains for all product lines combined. Furthermore, upstate revenue gains in 2002 exceeded 2001 results by $45 million. □ Not-for-profit HMOs, both upstate and downstate, participate in state-sponsored safety net programs to a far greater degree than the downstate for-profit managed care organizations. Within the plan group selected for this study, the not-for-profit plans supported 88% of the enrollment in New York state-sponsored programs, compared with for-profit plans' support of only 12% of safety net membership. □ Not-for-profit plans have also demonstrated a higher level of dedication to the Medicare Plus Choice product line than for-profit insurers downstate. In 2002, not-for-profit plans enrolled 73% of this population of 385,000 elderly statewide. Despite the favorable financial returns in the product line, for-profit insurers downstate enrolled only 105,000 Medicare risk members in 2002, or 27% of the statewide total.

The emergence in New York of health care insurance markets that are predominantly for-profit raises significant public policy issues, especially with reference to community benefits and services. Should the upstate health insurance environment change with the entrance of for-profit plans or conversion of existing plans to for-profit status, the upstate market is likely to look very similar to the downstate in that there will be diminished access to care for the at-risk population; premium costs will be higher and administrative costs will be higher. The health care insurance market upstate would become less attentive to the provision of public goods as insurers strive to maximize their economic advantages.