The Fallen Souffle Economy

It is increasingly clear that the United States’ economic troubles are far from over.

The stock market plunge that began in earnest last week reflects the market’s belief that we’re not going to recover fully from the recession that began in 2007. As a Wall Street Journal commentator said mid-Monday’s plunge:  “The market is pricing in a double dip recession”. In reality, the 2007 recession (caused initially by $150 a barrel oil) never really ended.

Past remedies for recession basically involved nearly free money and Keynesian pump priming to stimulate demand with either borrowed or freshly printed money. The most recent (bipartisan) stimulus effort, nearly a trillion worth of extended Bush tax cuts, unemployment extensions, payroll tax cuts, etc. which Congress and the Obama Administration negotiated in December, seems to have disappeared into thin air, producing a whopping 0.8% economic growth in the first half of 2011 and a July unemployment rate of 9.2%. This Economist analysis argues that the political system has exhausted its remedies for our economic problems.

Unfortunately, healthcare played a major, if unscripted role, in causing our economic crisis. Rising health premiums made a major contribution to the recession by depriving employers of cash flow, and employees of real earnings growth. The health benefits vampire sucked out every dime of spare employee comp, leaving most workers with no real growth in their paychecks for the decade. Consumers borrowed trillions of dollars to make up for this slack purchasing power, peaking at $14 trillion in consumer debt in mid 2006.  When families ran out of cash in late 2006, they began defaulting on their mortgages and car loans, and the financial crisis that brought down the bond market in 2008 caught fire.

As the Economist’s Buttonwood points out, the result of the cheap money/borrow and spend remedies to past recessions and foreign financial crises (the Mexican, Thai and Russian debt crises)  was a succession of  bubbles- Internet stocks, real estate, commodities (oil, gold, grains, etc.) and, sadly for those in our field, healthcare.  The real estate bubble was a doozy- and left us with nine million empty houses and condos, and millions of idle construction workers. Since real estate financed with cheap credit has traditionally been the engine that pulled us out of recession, it was clear from the moment the real estate bubble popped that this recession was going to be different–much longer and more painful.

Ironically, healthcare has been the healthiest part of the private economy the past three years, if by “healthy”, you mean adding jobs. The health sector has added a million net jobs since the beginning of 2007, while the rest of the economy lost, at the bottom of the trough, more than nine million jobs. Health care’s employment growth has taken place in the face of across the board slack demand for health services. All this job growth has taken place despite the fact that the health system itself is in recession.

Healthcare’s recession actually began in 2003, when the cost curve politicians like to pontificate about bent downward.  I believe demand for health services has slackened because almost half the country cannot afford to use the health system’s product, either because they lack health coverage, lack the cash to pay their copays if they are covered, or are on Medicaid, and face significant access challenges.

The healthcare bubble didn’t burst in a cataclysmic pop like real estate; rather, it sprang a slow leak. It continued behaving like a growth industry, however, pretty much up until last week. It’s like management didn’t get the memo. Nearly every indicator of demand for health services has turned negative in the past eighteen months after softening for several years:  hospital admissions, surgical volume, physician office visits, branded drug sales, etc. Even imaging volume is shrinking, for literally the first time since the technologies were invented.

People inside the health system know that a lot of demand for the health system’s product was either 1) medically unnecessary in the first place or 2) the product of correcting iatrogenic errors in treatment. In our imaging sector research, which led to The Sorcerer’s Apprentice: How Imaging is Reshaping Healthcare (with radiologist Bruce Hillman), we heard over and over again that perhaps as much as a third of imaging studies contributed nothing to medical outcomes.  Imaging demand was stimulated by malpractice butt-covering, self-referral (e.g. provider conflicts of interest) and, most of all, by wasteful Gregory House-style diagnostic workups.

Healthcare stocks have gotten clobbered in the most recent stock market debacle. HCA, the largest IPO since the 2008 stock market crash, had lost a staggering 40% of its IPO market value as of this last Monday. Long term care stocks have gotten crushed as Medicare prepares to cut payment for nursing home care.  Managed care stocks that depend on government payment (Medicaid or Medicare Advantage) have also taken it on the chin. Basically, anyone who has financed their healthcare businesses on borrowed (e.g. federal) money is going to endure a lot of shared deficit reduction pain, and an agonizing reappraisal of their operational efficiency.

It isn’t the end of the world. It’s just the end of an era–a drunken bender of cheap credit and heedless government and private borrowing and spending. Our economy will resume growing when we’ve “detoxed”–withdrawn from the cheap money cures and found “neutral buoyancy”–demand fueled by real income growth. We’ve taken down a trillion dollars in consumer credit already, either by paying it back or defaulting, in the past two years. It’s going to take another two or three trillion paid off to restore household cash flow, and return consumers to the market.

Healthcare providers, manufacturers and technology firms will have to play their parts -focused and thoughtful conservancy in the name of patients and the non-healthcare businesses whose health insurance contracts provide the industry’s free cash flow. What is needed is an extended period of single digit premium increases, and an end to cost shifting as we know it. Hospitals, ambulatory and long term care providers need to learn to run on regular gas. Providers need to manage their expenses and service intensity in such a way that they break even on Medicare payments, and avoid wasting resources in treating the Medicaid population.

Providers are going to learn from Virginia Mason, Thedacare and Denver Health how to run lean, and to make war on waste, both of time and resources. We won’t have a choice. The good news, longer term, is that demand for health services will eventually resume growing, buoyed by health reform (if it survives the coming deficit reduction jihad and political/judicial challenges) and by a lot of newly employed younger people. The health system is going to endure a period of austerity, one that could leave us on a healthier and more sustainable footing. There’s a lot of hard work to do.  . .

Jeff Goldsmith is president of Health Futures Inc. He is also the author of “The Long Baby Boom: An Optimistic Vision for a Graying Generation.” Health Futures Inc. specializes in corporate strategic planning and forecasting future health care trends.

4 replies »

  1. I have to partially agree with Dr. Vickstrom here. While I do not think the 30% fee cut will occur, I do think there is a concerted drive to get rid of primary care doctors. I don’t think this is driven by the President, as much as it is driven by influential academic research centers that are producing paper after paper about NPs and PAs being equally qualified to serve as the primary care provider. There was even a paper published last year, I believe, how primary care visits make no difference in diabetic outcomes.

    Of course the unintended consequence of rising costs due to having specialists treat patients is completely ignored, as are the equally voluminous suggestions that primary care (provided by doctors) reduces costs and improves health in other countries.

    I don’t understand the agenda here, and I don’t understand why we are trying to cut expenses where something useful is being accomplished for relatively little money.

  2. I think primary care will get hit with a 30% fee cut. Those of us in private practice will greatly decrease the medicare/medicaid pts they see, and those of us in non-profits will have to reduce appointment times to 5 min per patient per visit to break even. You forget that primary care/wellness/preventative is always the first to get the axe. So much for Obamacare. I think their ultimate goal is to get rid of physicians in primary care altogether.

    MD as Hell is right on the money [sic] of where they will go next, I think. A leaner, meaner medicare indeed.

  3. What my posting suggested is that this agonizing reappraisal of medical necessity has already begun in the under-65 population- e.g. the people with no cash and/or no insurance, which is why volumes for everything have softened.

    The elimination of truly unnecessary or low value care for the over 65 population was what the “death panels” controversy was really about- preventing an empirical evaluation of where we are simply squandering Medicare dollars that produce no change in the quality of someone’s life. There was a ton of money in ACA for comparative effectiveness, to build the empirical basis for reducing or eliminating low value care for the “elderly”. If you read the law, Congress was scared to death of actually using the data. That’s where running out of money will be very helpful- by forcing Congress’s hand. The “industry” will fight to keep the cash flowing for many of these things. Don’t hold your breath on the max cap for Medicare . . .

    Disability claims are soaring. It’s the new “unemployment”. Watch the claims really soar when Congress finally stops extending unemployment.
    This is a tough one. Watch the TV ads. This is an industry. . .

    Eliminating the free lunch stuff, like the scooters, which makes me furious whenever I see the ads, is something CMS is prepared to do, but needs a Congressional charter for. Again, there are a lot of clubs in the closet, but we need a genuine fiscal emergency.

    There will not be a 29% fee cut for Medicare, now or ever. What they’ll try to do more of is cut the high earners, which they are attempting to do to the radiologists and cardiologists. What they won’t do is redistribute enough to the primary care docs to avoid there being a terrible and more or less immediate (e.g. when the recession is over) access crisis for primary care.

  4. Great piece.

    You forgot the final paragraph. You know, the one where the patient is responsible for demanding services and will have to grow up and accept less and demand less.

    No more scooters.
    No more feeding tubes.
    No more cataract surgery for nursing home patients.
    No more dialysis for cocaine abusers.
    No more “treatment” for incorrigable substance abusers.
    No more disability for people with sham mental illness.

    I could go on.

    Basically there should be a lifetime max for medicare spending without falling into a special category of managed cases under compassionate care.

    Primary care is at cost with Medicare patients. Hit them with a 29% fee cut in January and they are paying to see Medicare patients. Not going to happen.