By PAUL LEVY
Here is one of my occasional updates on theMassachusetts scene, for people looking for hints as to the kind of issues that might arise nationally as health care reform is implemented.
I have written several times about the ongoing saga between the state administration and the health care insurers in the state concerning premiums for small businesses and individuals. Over the last several weeks, several insurers have reached settlements with the Division of Insurance. At least one has not and has prevailed at the appeals board because the rates forced upon it by the state were not actuarially sound. Where settlements have been was reached, they were not based on actuarial principles: They was based on a desire to get past this impasse and provide some stability to customers.
Here’s a quote from one company official:
Blue Cross spokesman Jay McQuaide said the organization agreed to accept “less-than-adequate rates’’ — which he said are too low to cover its costs — to resolve the uncertainty for customers.
The disturbing aspect that remains is a lack of understanding by some state officials of the issue. There appears to be a presumption that hospitals and doctors are somehow taking advantage of the situation to raise their costs. But that is at variance with what hospitals are actually doing and facing.
Here, for example, we see one hospital facing huge losses and another one laying off staff in the face of financial pressures.
There are sophisticated observers of the scene, however, who continue to offer thoughtful views. Here is an op-ed in today’s Boston Globe by Robert Pozen entitled “A bitter health care pill.” An excerpt:
[T]he perfect is often the enemy of the good in health care. Instead of taking a decade to move from fee-for-service to a capitation system, the state should implement two relatively significant cost-saving measures: Reduce the number of mandatory coverage items and charge higher co-payments for using the highest-cost providers.
Paul Levy is the President and CEO of Beth Israel Deconess Medical Center in Boston. Paul recently became the focus of much media attention when he decided to publish infection rates at his hospital, despite the fact that underMassachusetts law he is not yet required to do so. For the past three years he has blogged about his experiences in an online journal, Running a Hospital, one of the few blogs we know of maintained by a senior hospital executive.
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MA health care reform has been a disaster for my family. My wife and I are fined about $2400 each year by the state of Massachusetts for not buying health insurance. I’m almost 60, been layoff, and jobs are hard to find. We live basically off our savings and investments and always paid our own medical costs; but, since receiving the fines our family budget is now out of balance, I‘ve had to reduced my insulin shots to save money; this will eventually lead to organ failure. The state is literally killing me with there fine. I’m being fined for being responsible and paying my own medical bills. If the fines continue and get bigger we plan on moving out of the state when I retire to save money; my pension will follow me and the state will loose out on our income tax revenue. Being fined for living? Being fined for not buying a financial product? I love the people of MA but hate its insensitive no-it-all politicians.
“I think the problem is that they face too many disadvantages.”
Well of course they do Barry. Most of it environment, poor role models and little resources. If you think vouchers are the solution would those vouchers be able to be used for the suburban schools, and if so how would they get to those schools – busing maybe? You can also research Wake county schools to see if a “tipping point” was a problem or if test scores was also a problem. Resources is not the problem, allocation of resources is. As far as bussing is concerned it attempted to address decades of segregation and expose white kids to black kids they had never been exposed to. Don’t blame the black kids, blame the bigoted white population for creating the problem.
“So it’s the poor kids fault that the suburb schools they moved to became terrible?”
Peter – I don’t think “fault” is the right word in this context. I think the problem is that they face too many disadvantages. I’ll bet that if you took the teaching staff from a high performing suburban school and transferred them en masse to an inner city school, the students’ achievement probably wouldn’t come close to matching that of those in the upper middle class suburban school.
Why is that? The upper middle class kid probably has college educated parents who can help with homework or, if need be, hire and pay for a tutor. The student probably has his/her own room and a quiet place to study. There’s plenty of food in the house. There are probably books, computers, access to summer camps and enrichment programs. You get the picture. The inner city kid probably lives in a crowded household likely headed by an uneducated single mother. There may not be enough food let alone money to pay for a tutor. The environment in both the household and the surrounding neighborhood may be chaotic and dysfunctional.
While busing might benefit a handful of inner city kids if they also get plenty of extra help like tutoring, trying to bus too many of them to a given suburban school will probably hit a tipping point that causes the quality of education to decline for all students. Short of the massive help that the Tuhey family of Memphis made available to Michael Orr, as depicted in the movie, “The Blind Side,” the achievement gap will probably never be closed because it would be prohibitively expensive to provide the necessary resources.
That all said, there is plenty that can be done to help kids from low income families via charter schools, vouchers, paying good teachers more and firing bad ones. Tenure should be abolished at the elementary and secondary school level and we should be able to pay a premium for scarce skills like math and science teachers who have lucrative private sector non-teaching work alternatives available to them. Sorry, but busing isn’t the answer nor is separate but equal.
Nate, you can research Wake county schools and test scores yourself. The issue was not test scores, or bad schools for those opposed to busing, it was just the inconvenience of it and the lack of any social solidarity, and of course ideology .
“so instead of the really poor kids having a terrible school and not learning anything both the poor and middle class had terrible schools.”
Separate but equal? So it’s the poor kids fault that the suburb schools they moved to became terrible? See that’s the reason nothing’s done about inner city schools, because they’re “not our schools” they’re the poor kids schools. Same goes for healthcare, I got my company/Medicare paid healthcare so why should I care about someone else’s healthcare, or lack of it.
“The mixing was working well and made sure we didn’t have economic segregation,”
Please define worked well and back it up with some proof. My high school in Vegas also did bussing, so instead of the really poor kids having a terrible school and not learning anything both the poor and middle class had terrible schools. My senior year they buuilt a new school for the rich kids and they moved out. Bussing doesn’t improve outcomes it just lowers them to an equal level. Kids that could have excelled or done average at least instead also get a poor education, ya equility!
“I wouldn’t be surprised to find the educational opportunites at most prisons are better then most inner city schools.’
Well then let’s ask the folks in the suburbs if we can bus the inner city kids to their safe, well supplied, lots of food, great teachers schools. What do you think the answer would be – HELL NO? Here in Wake County there has been a school diversity program for many years where poor(er) kids were bused to more economically advantaged schools and visa/vera. The mixing was working well and made sure we didn’t have economic segregation, but new Republican school board members were elected by their better off constituents that made a board heavy for getting rid of the diversity program. I won’t excuse the voters who did not vote, but you see what happens when mostly minority (black) kids get to also get a great education – the better off parents don’t want their kids to have the association.
Pragmatic Pappu, I’m afraid you mistake hitting a branch on the way down as stopping your fall. Let me assure you that you are not only still falling but are picking up speed. All the new debt, ignoring BK law for political gain, 26 billion annual payoffs to Unions, you are closer to splattering on the bottom then you ever have been. If anything you swerved to avoid a pothole and drove off the side of the road.
“if others can get the same outcome at half the cost we pay, then the right capitalistic response cannot be to spend even more.”
I’m all for going that route, lets start by eliminating minimum wage, Medicaid, Medicare, SS, and public education. All of hwich can be delivered more efficently outside of government.
Barry I think telling an American they can’t buy the cadilliac insurance policy they want is slightly different then communist job creation. If I want to waste my money on uneeded medical test that is better then wasting it on a chineese made TV for my bathroom, from a GDP economics perspective.
Consumption of healthcare is already a personal decision, companies don’t make their employees spend poorly. Joe citizen is already getting what he wants and to date he has wanted excess healthcare more then fixing his home or hiring a hot maid from south america.
“But maybe we can build more prisons with the savings and send our kids there instead. Why isn’t healthcare looking at it’s budgets the same way education is?”
Do a little homework Peter, most inner city schools are prisons just not as safe. Or well feed or with as many entertainment options. I wouldn’t be surprised to find the educational opportunites at most prisons are better then most inner city schools.
Nate,
What a difference a year makes – not sure if you had any comprehension of the cliff we had teetered to the edge of. That we did not fall off the cliff does not mean the cliff was not real, or that it would not have been catastrophic had we indeed veered off the edge. The bailouts helped prevent us from getting off the edge. So, instead of being angry at being saved from falling off, you might be better of directing your anger at how we got to the edge in the first place.
Also, the fundamental tenet of capitalism is efficiency – if others can get the same outcome at half the cost we pay, then the right capitalistic response cannot be to spend even more.
Peter and Nate,
If people needed fewer healthcare services because they were able to stay healthier longer, if doctors ordered fewer unnecessary tests, and necessary healthcare were directed to the most cost-effective providers, society would be better off even if there were fewer jobs in the healthcare sector. The same is true if there were less fraud, less futile care at the end of life and less defensive medicine. By the same token, if Defense Secretary Gates is successful in canceling weapons systems that the Pentagon doesn’t want and redirects the savings, at least in part, to modernization programs that it does want, the country would be better of even there are layoffs among the people who were building the cancelled programs.
If we have more money in our paychecks because healthcare costs are lowered and/or if companies can lower prices or improve service because their healthcare costs declined, we are better off. Savings can be redirected to areas that provide more utility for people whether it’s remodeling their house, upgrading their car, taking a vacation or hiring someone to cut their grass, clean their house or watch their kids. If you think about what middle class and upper middle class people spend their money on now vs. 30 or 40 years ago, much more of it is for personal services which either save them time, give them pleasure or both vs. manufactured products like cars, appliances and furniture. In the public sector, money not needed for healthcare could be redirected to improving infrastructure, funding vouchers for inner city kids to escape failing schools or any number of other worthwhile priorities.
Before the Soviet Union collapsed, Eastern Europe was full of state owned facilities that employed thousands of people but produced little of value. My employer bought such a facility (steel mill) that employed about 8,000 people while a modern facility in the U.S. would need about 200 people to produce the same quantity of steel. We agreed not to lay people of but we don’t have to replace people who retire, die or quit. While I feel badly for people who are currently unemployed, jobs per se don’t necessarily translate to wealth creation or improvements in our standard of living. If they did, all we would need to do would be to put unemployed unskilled people to work raking leaves or digging ditches.
“Washington being as broke as it is to be honest I rather see HC spening hit 20% right now then go down.”
Sure, if you make your living from healthcare. I bet those who make their living from healthcare fraud would like that % to go higher as well.
“Education doesn’t need another penny, have you seen the inflation in educaiton compared to HC?”
Well if your state is anything like the rest you’ll notice cutbacks in education, layoffs, and program cuts. It’s equivalent to eating your seed corn. But maybe we can build more prisons with the savings and send our kids there instead. Why isn’t healthcare looking at it’s budgets the same way education is?
“outside the hookers and eating out very little gets returned to the middle and lower
classes,”
How about unemployment insurance payments, housing assistance, food stamps, military wages (certainly not mostly paid to college grads), highway taxes, education support, and yes Medicaid and Medicare. And where do you think all that “support” eventually ends up; landlords, banks, food stores, construction companies, hospitals, Porsche owning specialists, medical device makers, research. I’m not justifying it all, or the amounts, but to think that we’re all not connected to government programs is just blind. Here in NC there was a threat of cuts to military bases, the state legislature launched a massive PR campaign and lobbying to prevent this, and won. You think that was patriotism, and not pure and simple economics?
“Paolo do you think reserach returns anything close to healthcare?”
I think it actually returns much more. We wouldn’t be the world’s superpower if we hadn’t been the country that invented the telephone, the transistor, the computer, the Internet, the atom bomb, and more modern technology than the rest of the world combined. Some of if it eventually leaks overseas, but we are still world leader in high tech (this is especially true in medical devices). Without our Googles and Intels and Microsofts and Apples, our standard of living would be much lower.
I agree that there is currently a lot of waste in our education system. However, there are still tens of millions of citizens with inadequate education and skills. A dollar spent to educate/train them, not only stays in the US, but it makes the country as a whole wealther.
if a 3% reduction in HC spending meant even a 1% reduction in debt I would jump all over that in a heart beat. I have no reason to beleive and I don’t think histoiry as ever shown a time where washington would take even a penny of every dollar saved and reduce debt. I don’t think a single penny of our current HC spending either comes from debt maintenance, repayment, or forebearance.
Washington being as broke as it is to be honest I rather see HC spening hit 20% right now then go down. If our debt was higher and they had less money to spend maybe the AIG bailout never would have happened, I forgot the numbers from easlier this week but a large chuck of that went to France and Germany and the rest went to other Wall Street firms. HC consumption has a much broaded and domestic positive impact then Wall Streetl, outside the hookers and eating out very little gets returned to the middle and lower classes, not to insinutate hookers are middle or low class.
I would love to see HC spending increase to the point we had to stop funding the UN.
Education doesn’t need another penny, have you seen the inflation in educaiton compared to HC?
In regards to the 3% of GDP as exports I think your forgetting the scale in regards to each extra expendable dollar. The first $x is going to housing, car, utilities etc. After those are paid for then you start buying imported goods. As your excess capital increases a higher percentage of those dollars go to exports then your total income.
Paolo do you think reserach returns anything close to healthcare? We do a great job of the reserach but the return goes to other countries, see solar cells, lasers, LCDs, or any of the other hot technologies discovered here but profits are made overseas. We do a terrible job of capitalizing on our research. Educaiton is money pit. Defence if spent on wages yes, buying fighter jets from EADS no.
“What does Duke do to justify its tax exemption?”
I guess the same way BCBS justifies it’s exemption.
“Market-theory economics doesn’t work very well with health care.”
Agreed.
Nate, being happy with the economic contribution high healthcare spending produces is like being happy with the economic contribution vandalism produces. The broken window theory. And if you’re happy forcing people to spend on domestic healthcare as opposed to foreign products, why aren’t you happy with forcing people to spend on domestic taxes, which are spent in here as well?
Clarification: on a government level, lower health spending is in the first case about incurring less future debt, which is more or less equivalent to paying off old debt in the same amount.
The recurrence of the 3% figure in different contexts is unfortunate. Hopefully it doesn’t make the argument harder to follow.
Nate,
To really answer that would require a bigger treatment than I can do in a blog comment. But some things to consider:
1. We are a massively indebted society on a personal and governmental level. To the extent that the savings is used to pay down debt (through mechanisms too numerous to mention, but you can imagine several pretty quickly if you try) then this debt is less of a drag on the economy. I assume you believe that less debt (on the order of up to 3% of GDP, at least) will help our economy. Or do you believe debt doesn’t matter?
2. To the extent the money doesn’t go to pay down debt, it’s certainly true that some fraction will go to imports and thus leave our economy. Doing a quick search, it looks like the US GDP was 14 trillion in 2009 and our net trade deficit was $380 billion. That’s less than 3% of GDP, so less than 3% of the money conserved will go abroad, the rest will stay here to help the economy further. I did that calculation quickly so I welcome double-checking.
“Depending on the elacticity factor you use 3% increase in healthcare spending might actually increase GDP more then if that 3% had been spent on TVs and cheap chinese junk.”
True, but what’s the point of a higher GDP if the additional goods and services produced are useless? If we spent 90% of our income on health care, it’s true that our GDP (and employment) would be much higher, but our lifestyles would be horrible as we would be mostly producing something with no utility.
An unnecessary dollar spent on health care is simply pure waste. There are more productive uses of the 3%, like education, research, or even defense. All of these have high levels of domestic retention.
“If we achieve 12-14% of GDP it would free up enormous resources of human and economic capital for more productive uses.”
jd which other expenditures even come close to the level of domestic retnetion healthcare does? If you free up 5% of GDP by reducing healthcare spending I guarantee you the majority will be spent on imported goods.
Depending on the elacticity factor you use 3% increase in healthcare spending might actually increase GDP more then if that 3% had been spent on TVs and cheap chinese junk.
what are these more productive uses?
Peter and Barry–agreed in part. I can’t imagine that the state of NC stands for such an arrangement–but politics never made much sense. What does Duke do to justify its tax exemption? Barry–I see your point, but am one who feels like the traditional supply/demand and pricing theories don’t really hold much water in healthcare. Perhaps for certain non-emergent services like your example which one could clearly “bid”–but not for the routine care nor the emergencies. Strictly tiered networks with significant incentives for subscribers to use the least expensive could work, but are not likely to happen because the organizations with the highest prices have the most political clout (and often own or control their lower-cost competitors). Market-theory economics doesn’t work very well with health care. Poor HSA adoption suports this, and even those low rates would be less if the loophole allowing savings for non-health uses was eliminated. To move this beast we need to marshal some market forces, but need significant policy changes as well. It would help if some of the pilots being proposed succeed in showing that outcomes can really improve at lower rates of cost. Fee-for-service does not serve our system well, and must be replaced with a system that provides incentives to conserve resources, not provide an ever-increasing supply of services.
“But everyone forgets that the local hospital is taking all comers”
botetourt, in part you are right. But not all hospitals take all comers. In my state Duke transfers the uninsured to UNC (the state hosptial), if not directly, indirectly by charging such an outragious fee for cash pay services that the uninsured need to go to the lessor of two evils. My quoted cash fee for cataract surgery at UNC was $7500 per eye, the fee at Duke was $15000 per. I had it done in a Canadian hospital ($CAD) by the eye doc who did my original radial karatotomy for $1700 per eye. The hospital charges were $34 lab fee, $1357 per eye hospital fee and $200 per eye for anesthesiologist. My total bill for both eyes in CAD was $6548. Those hospitals truly do take all comers.
“The prices are high because the costs are high. And in many markets (like MA) the costs are high because the hospitals do not operate any where near their capacity.”
If that’s the case, which it is, then more hospitals need to downsize or close. Moreover, the Massachusetts AG’s investigation showed that some hospitals and large physician groups are paid as much as 60% more than others in the market for the same work even though their quality is no better and sometimes it’s worse. There is no way that can be sustained nor should it be. With better price and quality transparency tools and tiered in network insurance products, it won’t be.
It may be absolutely true that an MRI, or a knee replacement, or whatever may be less expensive at an independent center than it is at your local community hospital. But everyone forgets that the local hospital is taking all comers, is providing inpatient care that loses tons of money (docs are not out there building pneumonia hospitals), and is probably lucky to eke out a 2-3% operating margin. The prices are high because the costs are high. And in many markets (like MA) the costs are high because the hospitals do not operate any where near their capacity. Inpatient services comprise an ever-decreasing portion of the net revenue, and outpatient diagnostics and surgery support everything else. In this kind of environment, we should not be spending 15-20% of the healthcare dollar on the financing mechanism–i.e. insurance, with all the administrative duplication, , marketing, and other costs which they represent. I am not absolving hospitals at all–many operate very inefficiently and are loathe to eliminate losing services. But there is no quick fix, and for you learned bloggers to be complaining about the cost of lab or MRI in a hospital vs. some other free-standing environment is really not productive, and shows a lack of understanding of the depth of these issues. We continue to have too many hospitals, too much duplication of medical assets, which I suspect is rarely a problem in Switzerland or any other country touted to be spending a more appropriate percentage of its GDP on healthcare. By the way, this is what competition really gets you in healthcare–more sites of service, all of which will churn the volume needed to keep themselves afloat in a fee-for-service world. You need to talk about the policy alternatives which will achieve your goal rather than griping about MRI prices in differing settings.
ciphertext, why did you narrowly limit the options? At least a #4 would be government payor with regulation where you freely choose your hospital, surgeon, specialist, PCP, or drug store, and most prices are government controlled/regulated/negotiated.
As for the “prevailing winds” of govenment limiting choices, talk to rural communities here about how much choice they have with the private sector.
“hospitals are where the costs are.”
Peter – I’m with you 1,000 percent on this one. A friend from Ohio needs to get a brain MRI twice a year. When she gets it done at Ohio State’s hospital based clinic, insurance was billed $2,915 and paid $2,625. At her local independent, non-hospital owned imaging center, insurance was billed $1,900 but they accepted $660 as full payment from insurance. Amazingly, for people paying out of their own pocket, the charge is only $600 and for any MRI at that, not just the one she needed! I had the same test last December in NYC, also at an independent clinic. Insurance was billed $1,800 but the clinic accepted $475 as full payment of which my share was 20% or $95. Go figure.
To jd’s point about medical prices in the U.S. vs. other countries, in the August, 2010 issue of Health Affairs, there is a lengthy interview with Thomas Zeltner about the Swiss healthcare system. He was their health minister for 19 years. He agrees that high medical prices in the U.S. account for much of the difference in costs between the U.S., Switzerland and other European countries. In Switzerland, there are 84 insurance companies in a country of 7.8 million people though the top six control 80% of the market. They negotiate prices with providers as a group so every insurer pays the same prices to all providers in a given canton. Patients who live in high cost cantons pay higher prices for the same insurance coverage than those who live in lower cost cantons.
That all said, I think there is a lot we can do to reduce wasteful utilization of healthcare services including fewer mandated benefits, differential co-pays or tiering among in network providers, a serious attack on fraud, litigation reform to reduce defensive medicine, and a more sensible approach to end of life care such as the model already being used by the Gunderson Clinic in La Crosse, WI as discussed by Atul Gawande in his recent New Yorker magazine article. Robust, user friendly price and quality transparency tools would also help both patients and referring doctors to identify the most cost-effective providers so business can be shifted in their direction and away from high cost providers whose high prices are a function of their local or regional market power and not superior quality.
In the absence of competition you have two real options (three technically, but two are quite similar):MonopolyOligopoly (similar in many respects to Monopoly)Supplied via government.None of those options sound particularly appealing to me. You can either go to one company for all your health care needs because you have no alternatives (meaning your stuck with what they provide, when they provide it, and how they provide id); you can select from a relative few companies; or you are subject to the whims of the prevailing winds in government.
“Blue Cross spokesman Jay McQuaide said the organization agreed to accept “less-than-adequate rates’’ — which he said are too low to cover its costs — to resolve the uncertainty for customers.”
Do those “adaquate” rates include the millions spent to bonus execs?
“But Patrick administration officials acknowledge that they need to do more to keep rates from going up in the future.
“This is a long haul in terms of getting health care costs under control,’’ said Barbara Anthony, undersecretary for the state’s Office of Consumer Affairs and Business Regulation.”
“There appears to be a presumption that hospitals and doctors are somehow taking advantage of the situation to raise their costs.”
Paul, hospitals are where the costs are. We’re not in a cost crisis because of PCPs. I think there is an institutional mindset in hospitals that they deserve the high rates and grand empires and that administrative PHDs bring us better healthcare. My last blood work done through a hospital (PCP associated) was $275 for what I could have gotten from an unassociated PCP direct with the test lab for $50. Justify that!
Saw an interesting brief piece on NECN last night about an inidvidual who cannot afford premium or fine. He is going to court to sue for a waiver (of his obligation). Apparently this has been grated to 20 people to date.
Thank you for posting such a nice information…health care industry rising rapidly…! It makes revolution…!
Like you, I am an interested party in how this plays out. Unlike you, I will emphasize that we will never, ever get our costs to a level remotely like they have in Europe without cutting the cost of delivering care on a per unit/service basis. We will never get the numbers to add up by pointing to utilization or quality alone.
Right now we stand at 17% of GDP getting sucked into health care. Europe and other developed nations have about 10%, for quality that is as good on the whole and access that is as good (better when you consider the uninsured). Studies that look at international cost comparisons come to the conclusion that it’s the prices, not the utilization that is the main culprit.
If we achieve 12-14% of GDP it would free up enormous resources of human and economic capital for more productive uses. Most of that, to the tune of roughly 3% of GDP, will come from lower revenues for providers, pharma and devices.
That means layoffs, major changes to the business model, and a leaner, lower frills environment. But tweaks to mandatory coverage requirements and higher copays for higher cost providers will not get us very far.
The article cited says the mandatory coverage increased cost by $300 million in MA. I’m going to guess health care in Massachusetts is around $20 billion a year. That means even if you eliminate all the special MA coverage mandates you’ll save less than 2% of costs. 2% of 17% is 0.03%. This does not look like a top-tier opportunity for savings to me.
Selectively higher copays probably will have a slightly larger affect on total cost. They have done some good for pharma. I suspect they will be less successful here than pharma. Right now, a significant chunk of people are willing to deliberately go outside the network and pay coinsurance rather than copay, while some others don’t mean to go out of network but it happens to them anyway because they aren’t informed in a timely fashion. We really need to change that. No one should ever be surprised that a doc they thought was in-network at a hospital turns out to be out-of-network…and if they are surprised, they shouldn’t have to pay the difference if they were never told.
But more to the point: the process is going to be painful no matter what. Insurers are going to have to get squeezed and then squeeze providers in turn. The best thing that government can do when capping premium increases is to do it in a reasonable way that gives enough time to re-calibrate contracts and re-set the medical costs so that the insurer stays actuarially healthy. It doesn’t help at all if the state or feds insist on keeping the premium flat and then get in the way with regulations or rhetoric when insurers take the measures necessary to achieve this and keep medical costs flat to match.