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Posted on Apr 26, 2019

Health plan leader recognized for turning system around: Column

By Don C. Brunell

Imagine sitting home and learning Fortune magazine just listed you among the world’s greatest leaders. That’s exactly what happened to Marilyn Bartlett, who led the effort to save Montana’s state employee health insurance plan from bankruptcy.
In April, Bartlett was ranked No. 16 on a list that featured global leaders including Bill and Melinda Gates, New Zealand Prime Minister Jacinda Ardern, Michael J. Fox and Apple’s Tim Cook.
“Our sixth annual leaders list is the home of the brave,” the Fortune article stated. “These thinkers, speakers, and doers make bold choices and take big risks — and move others to do the same.”
When Bartlett took over Montana’s employee health plan in 2014, the state spent $200 million a year to cover its 30,000 employees and their families. The plan’s losses were projected to top $50 million and state officials predicted it would go broke without radical changes. By the time she departed, the plan was on solid footing and the state was saving millions without cutting benefits to employees or raising their rates.
Bartlett came with some unique qualifications. She had just spent 13 years on the insurance industry side, first as a controller for a Montana’s Blue Cross Blue Shield plan, then as the chief financial officer for a company that administered benefits.
Montana, like many large employers, self-funds its plan. That means it pays the bills and hires an insurance company or other firm to process the claims. More than half of American workers are covered by self-funded plans. Today, many employers are starting to follow Bartlett’s blueprint, which starts with transparency.
As the boss in this arrangement, Bartlett assumed she would have access to detailed information about how much the plan, which was managed by Cigna, paid for procedures at each hospital. When Cigna told her the information was secret and not available, Bartlett demanded all of the information and began examining every detail of the contracts.
Her plan turned the payment system upside down. The state would set its own prices for the hospitals, insurers and drug companies based on rates set by Medicare as a reference point. Montana’s plan now pays hospitals a set percentage above the Medicare amount, a method known as “reference-based pricing,” making it impossible for the hospitals to arbitrarily raise their prices.
From the start, she knew she would have to tackle the staggering bills from the state’s hospitals, which made up the bulk of the plan’s expenses. It wouldn’t be popular because they also made up a significant chunk of hospitals’ profits, National Public Radio’s Marshall Allen reported last October.
Bartlett found a new pharmacy benefit manager that would not take any “spread” and would pass along all rebates in full. The immediate savings was $16 per prescription. “Spread” is the practice where a pharmacy benefit manager, for example, will tell an employer it cost $100 to fill a prescription that actually cost $60, allowing the pharmacy benefit manager to pocket the extra $40. The fine print in the contracts often allows it.
“Most importantly, Bartlett understood something the state officials didn’t: the side deals, kickbacks and lucrative clauses that industry players secretly build into medical costs. Everyone, she had observed, was profiting except the employers and workers paying the tab,” Allen reported.
In Bartlett’s view, employers should be pushing back against the industry and demanding that it justify its costs. They should ask for itemized bills to determine how prices are set. And they should read the fine print in their contracts to weed out secret deals that work against them.
That’s good advice for any purchaser whether it be government, business or nonprofit.

Don C. Brunell is a business analyst, writer and columnist. He retired as president of the Association of Washington Business, the state’s oldest and largest business organization, and lives in Vancouver. He can be contacted at theBrunells@msn.com.