As Congress continues to work on a health-reform bill that may -- or may not -- include some kind of public option, health insurers continue to protest the creation of a government-run health plan. Dr. Donald R. Fischer, chief medical officer at Highmark Inc., recently discussed health reform and other issues with the Post-Gazette.

Dr. Fischer has been with Highmark, Pittsburgh's largest health insurer, since 2001, and has served as CMO and senior vice president for the last five years. He helped guide Highmark's pay-for-performance incentive program, which rewards physicians and hospitals for better health outcomes.

Q: Two of the main bills under consideration now by the House and Senate include a public insurance option. Why do insurers think that's such a bad idea?

A: "It's neither necessary nor advantageous to have a public option with reform. We think very clearly that health insurance market reform needs to happen …. Blue Cross-Blue Shield Association and others have noted the need for market reform for a number of years. [But] to build a whole new infrastructure to implement market reform isn't necessary. [A public plan would result in] massive migration from private plans to a public plans." A public plan, drawing money and customers away from private insurers, also would "decrease the opportunity for innovation that happens at private plans. … We don't want to lose that innovation by imploding the private insurance model."

Q: Would a public option be more palatable if reimbursement rates to providers weren't tied to Medicare rates, and instead were negotiated on the open market?

A: "The way they talk about lowering costs is by lowering [reimbursement] across the board for providers. … If you simply say we're going to pay you less across the board, that will cause trenchantly the cost of a provider's care to be less -- but we know from experience that utilization increases to make up for [what's lost] in unit price .… It's inconceivable that Medicare would set up a mechanism to [negotiate] separate rates with providers across the country."

Q: OK, what if the public option were tied to Medicare rates? Would that be easier?

A: "Medicare and Medicaid payment rates are substantially less than cost. … I am sure that growing the public option is not going to lead to more choice; it is going to lead to less choice. … You will see massive migration of people …. It will lead to the death of more private plans."

Q: As America gets older, more and more people have their health care paid for by the government. Already more than half of Americans who are insured have government insurance. Should providers be preparing for that, and how are insurers preparing for an increased government workload?

A: "We have a history of doing government work. We also have Medicare Advantage products. We also have a subsidiary, Gateway, that delivers a Medicaid product. We developed [an] SCHIP product. We've been very innovative [with our government products]."

Q: Democrats also want to eliminate insurers' ability to deny or limit coverage based on pre-existing health conditions. Is Highmark OK with that?

A: "That's not controversial at all … [but] we are the insurer of last resort. Anybody can come to us and get insurance. The problem is that's a very high-risk pool," and it's more expensive to cover those people. "We have to mandate coverage -- individual mandate, employer mandate. … Everybody gets in the pool," including young, healthy people who would otherwise opt out of coverage.

Q: Obesity underlies a number of other health problems -- diabetes, heart disease -- and adult obesity, as well as childhood obesity, is on the rise, costing the health system billions. How do we fight it? How can insurers help?

A: "It's going to be a multichannel initiative …. We believe strongly in wellness and prevention. [We have] product designs that incentivise people to do the right thing. … We've learned a lot about what works."

Q: What about on the government side? Does the government go too far when it tries to regulate what people eat and drink?

A: "At least there is an awareness in Washington. … [I am] a strong advocate of the idea that you would tax sweetened soft drinks. Similar to taxing cigarettes, why not do the same thing with this so-called soda tax?"

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