Health care spending
Like many health policy experts, I’ve closely followed and participated in the debate over the Affordable Care Act. I’ve spoken at town hall events, fielded questions from reporters, and discussed the ACA with students, friends, and colleagues.I have been asked a wide range of questions about the ACA, but I am always amazed by the one topic that almost never seems to come up: how the deeply indebted federal government will pay the roughly $200 billion annual cost of expanding coverage.
The inattention to the financing of the ACA by the public, the media, and even Republicans is a testament to the skill of its drafters. The benefits of the ACA are highly visible, the costs are concealed.
Consider the ACA’s treatment of Medicare hospital reimbursements. Reimbursements to hospitals increase from year to year based on the projected increase in hospitals’ labor and capital costs. The ACA reduces the rate of growth in payments by 0.1 percentage points per year plus an additional factor based on projected economy-wide productivity growth. It is possible that the application of these factors will result in a net reduction in payments, but, more likely, payments will not increase by as much as they would have in the absence of the law.
This provision, which will raise $64 billion in 2020, may result in the closure of some hospitals and reduce quality in those that remain open. However, these effects are uncertain and difficult to summarize in a soundbite.
Other financing provisions are only slightly less obtuse. About one quarter of Medicare beneficiaries are enrolled in private health plans, the so-called Medicare Advantage plans. The ACA will revamp the formula used to set payments to these plans for a savings of $19 billion in 2020. The ACA will reduce subsidies to so-called Disproportionate Share Hospitals (hospitals that serve a large number of low-income patients) for a 2020 savings of $9 billion.
Continue reading “Paying for the ACA: A Field Guide”
Filed Under: Economics, THCB
Tagged: David Howard, Economics, GOP Repeal, Health care spending, The Affordable Care Act
Oct 12, 2013
“We spend far more on health care than other peer countries yet have worse outcomes. Why is U.S. health care so expensive?” I’m sure you’ve encountered similar statements, maybe even expressed it yourself. It occurs often, including by knowledgeable people and health-related institutions. However, it’s a fallacy because it confuses health care with population health.
Health care is a proper subset of population health. For example, longevity is determined by more than just health care. Using a specific recent estimate (Appendix Exhibit A6 – gated), an average 20-year old U.S. white male who did not graduate high school will live 10.5 fewer years than a similar man with a college degree. That’s over ten years of life related to educational attainment. Sure, there are many reasons for the difference, and health care or the lack of it is only one of them.
Continue reading “Health Care Shibboleth”
Filed Under: OP-ED, THCB
Tagged: Art Kellermann, Costs, Frank de Libero, Health Affairs, Health care spending, health-care-is-health-fallacy, Institute of Medicine, Outcomes, Population Health, Tom Daschle
Mar 24, 2013
Conservatives love to apply “cost-benefit analysis” to government programs—except in health care. In fact, working with drug companies and warning of “death panels,” they slipped language into Obamacare banning cost-effectiveness research. Here’s how that happened, and why it can’t stand.
Why are you reading this when you could be doing jumping jacks?
And how come you’ve gone on to read this sentence when you could be having a colonoscopy?
You and I could be doing all sorts of things right now that we have reason to believe would improve our health and life expectancy. We could be working out at the gym, or waiting in a doctor’s office to have our bodies scanned and probed for tumors and polyps. We could be using this time to eat a steaming plate of broccoli, or attending a support group to help us overcome some unhealthy habit.
Yet you are not doing those things right now, and the chances are very strong that I am not either. Why not?
Continue reading “The Republican Case For Waste In Health Care”
Filed Under: OP-ED, THCB
Tagged: Comparative Effectiveness Research, Cost effectiveness research, Costs, Dartmouth Atlas Project, GOP, Health care spending, IOM, IPAB, Medicare, NEJM, PCORI, Phillip Longman, Politics, QALY, The Affordable Care Act
Mar 8, 2013
For the third year in a row, national health spending in 2011 grew less than 4 percent, according to the CMS Office of the Actuary. However, the report said modest rebounds in pharmaceutical spending and physician visits pointed toward an acceleration of costs in 2012 and beyond. CMS’s analysts make much of the cyclical character of health spending’s relationship to economic growth and also forecast a doubling of cost growth in 2014 to coincide with the implementation of health reform.
This non-economist respectfully disagrees and believes the pause could be more durable, even after 2014. Something deeper and more troublesome than the recession is at work here. As observed last year, the health spending curve actually bent downward a decade ago, four years before the economic crisis. Health cost growth has now spent three years at a pre-Medicare (indeed, a pre-Kennedy Administration) low.
More Than The Recession Is At Work
Hospital inpatient admissions have been flat for nine years, and down for the past two, despite compelling incentives for hospitals to admit more patients. Even hospital outpatient volumes flat-lined in 2010 and 2011, after, seemingly, decades of near double-digit growth. Physician office visits peaked eight years ago, in 2005, and fell 10 percent from 2009 to 2011 before a modest rebound late in 2011 — all this despite the irresistible power of fee-for-service incentives to induce demand.
The modest rebound in pharmaceutical spending (2.9 percent growth) in 2011 appears to have been a blip. IMS Health reports that US pharmaceutical sales actually shrank in 2012, for the first time in recorded history, and that generic drugs vaulted to the high 70s as a percent of prescriptions!
There is no question that the recession’s 7-million increase in the uninsured depressed cost growth. But the main reason health cost growth has been slowing for ten years is the steadily growing number of Americans — insured or otherwise — that cannot afford to use the health system. The cost of health care may have played an unscripted role in the 2008 economic collapse. A 2011 analysis published in Health Affairs found that after accounting for increased health premium contributions, out-of-pocket spending growth and general inflation, families had a princely $95 more a month to spend on non-health items in 2009 than a decade earlier. To maintain their living standards, families doubled their household debt in just five years (2003-2008), a debt load that proved unsustainable. When consumers began defaulting on their mortgages, credit cards and car loans, the resultant chain reaction brought down our financial markets, and nearly resulted in a depression.
By sucking up consumers’ income since 2008, the rising cost of health benefits has weighed heavily upon the recovery. According to the 2012 Milliman Cost Index, the cost of health coverage rose by 32.8 percent from 2008 to 2012, while family income did not grow at all in real terms. The total cost (employer and employee contributions plus OOP spending) of a standard PPO policy for a US family of four was $20,700, almost 42 percent of the US household median income in 2012.
Continue reading “The Gold Plated Health Care System: What the New Numbers Tell Us about the State of the Economy”
Filed Under: Economics, THCB, The Business of Health Care
Tagged: California, CMS, CMS Office of the Actuary, Costs, Health care spending, Health Insurance Exchanges, Jeff Goldsmith, Massachusetts, Medicaid Expansion, The Affordable Care Act, The States
Feb 2, 2013
Suppose I throw a rock through a store owner’s window. You admonish me for this act of vandalism. But I reply that I have actually done a good deed.
The store owner will now have to employ someone to haul the broken glass away and someone else, perhaps, to clean up afterward. Then, the order of a new glass pane will create work and wages for the glassmaker. Plus, someone will have to install it. In short, my act of vandalism created jobs and income for others.
The French economist, Frédéric Bastiat called this type of reasoning the “fallacy of the broken window.” All the resources employed to remove the broken glass and install a new pane, he said, could have been employed to produce something else. Now they will not be. So society is not better off from my act of vandalism. It is worse off — by one pane of glass.
But there is a new type of Keynesian (to be distinguished from Keynes himself) that rejects the economist’s answer. Wasteful spending can actually be good, they argue. If so, they will love what happens in health care.
By some estimates one of every three dollars spent on health care is unnecessary and therefore wasteful. ObamaCare’s “wellness exams” for Medicare enrollees — so touted during the last election — is an example. Millions of taxpayer dollars will be spent on this service, yet there is no known medical benefit. Similarly, ObamaCare is encouraging all manner of preventive care — by requiring no deductibles or copayments — which is not cost effective.
Continue reading “Could Wasteful Healthcare Spending Be Good for the Economy?”
Filed Under: Economics, OP-ED, THCB
Tagged: Economics, fallacy of the broken window, fiscal stimulus, Frederic Bastiat, Health care spending, Johannes Wieland, John Cochrane, John Goodman, Medicare wellness exams, Obamacare, Paul Krugman, Preventive care, The Affordable Care Act
Jan 31, 2013
Henry David Thoreau said, “There are a thousand hacking at the branches of evil to one who is striking at the root.”
We have hacked at healthcare costs for what seems like thousands of times, with very limited success. It is time to strike at the root. Rather than focus on reducing costs after preventable diseases have taken hold, it is time to focus attention on eliminating the disease.
Let us look at two specific examples.
1. The CDC (Center for Disease Control and Prevention) has estimated that the cost of smoking(estimated cost of smoking-related medical expenses and loss of productivity) exceeds $167 billion annually. The CDC has also estimated that 326 billion cigarettes (combustible tobacco, to be more precise) went up in smoke in 2011. In other words, every cigarette consumed costs the nation about 50 cents; every pack, $10.
Put another way, while the smoker paid approximately $5 a pack up front, there was also an additional $10 secret surcharge — the cost of which is born by all of us (such as taxpayers, anyone who buys health insurance, even private companies who suffer from lower productivity as a result). It is as if we are telling the smoker, “I know you can’t afford to pay $15 for a pack. So we will give you $10 so you can afford to smoke.” We are not this generous even with people who don’t have one square meal a day. We spent $78 billion on food stamps, with constant pressure to bring that down further even if some people will be left without food as a result.
Continue reading “Cigarettes Should Cost $25 a Pack”
Filed Under: Commentology, OP-ED, THCB
Tagged: Cancer, Diabetes, Earl C. Daum, Health care spending, President Obama, preventable diseases, smoking, smoking cessation, sugar consumption, Vijay Govindarajan
Nov 21, 2012
In last Sunday’s New York Times, Paul Krugman extolled the virtues of Medicaid. Here are some excerpts from this astonishing column:
“Medicaid has been more successful at controlling costs than any other major part of the nation’s health care system.”
“How does Medicaid achieve these lower costs? Partly by having much lower administrative costs than private insurers.”
“Medicaid is much more effective at bargaining with the medical-industrial complex.”
“Consider, for example, drug prices. Last year a government study compared the prices that Medicaid paid for brand-name drugs with those paid by Medicare Part D — also a government program, but one run through private insurance companies, and explicitly forbidden from using its power in the market to bargain for lower prices. The conclusion: Medicaid pays almost a third less on average?”
In the days since this column was published, I have spoken with many experts on Medicaid who are uniformly appalled by it. While I may not reach the same audience as the New York Times (at least not yet!), I feel compelled to set the record straight on Medicaid’s “successes.”
Continue reading “Setting the Record Straight on Medicaid’s “Success””
Filed Under: THCB
Tagged: David Dranove, Health care spending, Medicaid, Paul Krugman, Quality
Nov 5, 2012
Coming Soon, North Shore University Health Systems Medical Office Building.
For me, this is sad news. I am not saddened that North Shore University Health is opening yet another medical office building. It is where they are opening that gets me. They are taking over a two story building that used to house a Border’s Bookstore. My Border’s Bookstore. Sure, Border’s may have been a bit corporate, but this was still a great bookstore. They sold best sellers there, of course, but they also carried all the classics and lots of eccentric titles. Heck, they even briefly carried one of my own books! They had a vast selection of books about military history and an amazing travel section. My wife lost herself for hours in gardening and my sons ogled the aisles of mystery and fantasy novels. Border’s also had vast CD and DVD departments (with classical CDs and Criterion Collection movies) and the café sold a chocolate bundt cake that was out of this world. Maybe best of all, the building had an odd layout with lots of nooks and crannies and surprises around the corner. For a corporate bookstore, it oozed charm. Medical office buildings never ooze charm.
Continue reading “A Sign of the Times”
Filed Under: THCB, The Business of Health Care
Tagged: Borders, David Dranove, disposable income, Health care spending, North Shore University Health System, Northwestern Memorial Medical Group, The Great Recession
Oct 29, 2012
In 1932, the Committee on the Cost of Medical Care identified rising medical costs as a threat to the financial security of millions of Americans. In a series of studies that created the field of health services research, the Committee recommended several strategies for cost containment that reads like a blueprint for today’s cost containment efforts: prevention, price controls, capitation, elimination of unnecessary care, and integration. If it sounds like a précis of my previous two blogs – cut prices and cut quantities – it should. We have known for a long time that those are the only ways to cut spending. And yet here we are, 80 years later, facing a spending crisis that threatens to take down the entire economy.
In my lifetime, we have been subjected to a steady drumbeat of rising medical costs. There have been respites – for a couple of years after Medicare introduced DRGs and for about five years in the 1990s during the heyday of HMOs. While DRGs and HMOs shifted costs down, they did not seem to reverse underlying growth trends, although HMOs did not thrive for long enough to be certain.
Not for lack of trying have medical costs continued to increase. We promote prevention, regulate prices, capitate providers, and review utilization to eliminate wasteful spending. We have seen horizontal integration that led to market power and higher costs, and vertical integration that more often than not created unmanageable bureaucracies. Most of today’s proposals for cost containment can be encapsulated by two words: “Try harder.” The Affordable Care Act gives us free preventive care, stricter price controls, ACOs, and the Comparative Effectiveness Institute. We need radical change but all we get is creeping incrementalism. I will take creeping incrementalism over the do-nothing approach of the previous decade, if only because we could use another respite. But the ACA is no permanent fix.
Continue reading “The Way Out of the Wilderness”
Filed Under: Health Plans
Tagged: 2012 Election, David Dranove, Health care spending, Health Plans, HMOs, Innovation, Medicare, skin in the game, The Affordable Care Act
Aug 17, 2012
Health care had its own version of the LeBron James “Decision” last month with the Supreme Court upholding the critically important elements of the Affordable Care Act. Now that the uncertainty is behind us―at least until the November elections―health care leaders can continue preparing their organizations for the changes ahead.
Fixing the system requires reforms at the macro level. But it also takes a symphony of smaller actions happening in concert. As experience bears out, it is difficult to agree upon a collective action with so many competing interests in health care and the partisanship that has gripped politics. But there is a song that we can all agree upon, loud and in unison. Reduce the waste.
Nearly a third of our health care costs come from wasteful spending and inefficiencies that could be avoided. Left unchecked, this is a nail in the coffin of our system; but, if tackled, is a huge cost containing opportunity. By identifying waste in the delivery system and systematically reducing it, we could lower costs without resorting to budget cuts and fees that compromise the quality of care.
Continue reading “How Do We Bend the Cost Curve? Reduce the Waste.”
Filed Under: The Business of Health Care
Tagged: Health care spending, Health IT, NEHI, spending waste, The Affordable Care Act, Wendy Everett
Aug 17, 2012