American industry, remember, has a way of taking what's impossible in one generation and making it common in the next. It is true that PPO enrollment went up more than HMO enrollment, but remember that HMO enrollment, while it dropped 1 percent of total managed care, actually grew in gross numbers. In other words, PPOs grew at the expense of the fast-withering indemnity market. There may be a lot of discussion about direct contracting in various trade magazines, but the actual facts don't support it. It is also absolutely critical to remember that employers do not view managed care and health insurance the way physicians do.
Employers see health insurance as a benefits cost, albeit an important benefit.
There are a lot of employers who, deep down, blame physicians. I have spoken with experts from other companies that do benefits consulting, and many still firmly believe that someone needs to watch over expenses that physicians can run up. Some of the pioneers have quietly gone back to using health insurance companies and MCOs. Providers want plans to take on even more risk. To be sure, there are still plenty of HMOs that want to shift out risk, but far more are no longer comfortable with the idea.