tag:blogger.com,1999:blog-50905197983432568442024-03-05T04:05:53.948-05:00Compassionate EconomicsClear thinking about tough problems, but with compassion for the least fortunate among us.Anonymoushttp://www.blogger.com/profile/16508822019622004205noreply@blogger.comBlogger17125tag:blogger.com,1999:blog-5090519798343256844.post-26964859665565827442013-08-06T15:12:00.000-04:002013-08-06T15:12:58.380-04:00Compassionate, Efficient Health ReformThe following was drafted quite a few months ago, and had its genesis in a list of recommendations for improving the health care system that David Dranove solicited from a number of academics for an <a href="http://www.hmpi.org/pdf/HMPI%20-%20Dranove,%20Health%20System.pdf" target="_blank">issue of Health Management, Policy and Innovation</a>. I've dawdled in finishing and polishing it up, but seeing the <a href="http://www.aei.org/files/2013/08/02/-best-of-both-worlds-uniting-universal-coverage-and-personal-choice-in-health-care_105214167938.pdf" target="_blank">stimulating reform proposal</a> posted today by Jay Bhattacharya, Amitabh Chandra, Mike Chernew, Dana Goldman, Anupam Jena, Darius Lakdawalla, Anup Malani and Tom Philipson motivated me to return and finish it; so here it is finally.<br />
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<!--StartFragment-->
<br />
<div class="MsoNormal">
<b>Introduction<o:p></o:p></b></div>
<div class="MsoNormal">
<b><br /></b></div>
<div class="MsoNormal">
One can hardly say that there’s been too little discussion
of health reform recently. However, much of the discussion is focused on the
ACA and its details. That’s fine, but we’ve gotten very far away from thinking
about overarching principles that we think should guide the design of a health
system, and what that implies for what it would look like.<a href="http://www.blogger.com/blogger.g?blogID=5090519798343256844#_ftn1" name="_ftnref1" title=""><span class="MsoFootnoteReference"><!--[if !supportFootnotes]--><span class="MsoFootnoteReference"><span style="font-family: Calibri; font-size: 11.0pt; line-height: 115%; mso-ansi-language: EN-US; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Arial; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;">[1]</span></span><!--[endif]--></span></a>
What follows are some thoughts on what such a health reform might look like. They
are informed by my read of the research evidence, and my observations of the
U.S. health care system over a long period of time, but should be understood as
representing only my personal opinions.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
This is not intended as a criticism of the ACA. While the
ACA certainly isn’t perfect, in my opinion we’re better off as a country with
it than without it. However, there will be modifications to the ACA and other
changes to the health system as we move forward, so having a framework to
structure our thinking will be useful as we consider these inevitable changes.<o:p></o:p></div>
<div class="MsoNormal">
<b><br /></b></div>
<div class="MsoNormal">
<b>Guiding Principles<o:p></o:p></b></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
What I propose below is guided by the following. First,
economic efficiency is a goal. This simply means avoiding waste, i.e, trying to
generate the maximum benefits net of costs. The second goal is that no American
is exposed to excessive risk to their health or finances due to medical
expenses. Last, the overarching design principle is to create basic ground
rules for the system and then let the system run, avoiding heavy handed
regulation or micro management. The key objective of these ground rules is to
give participants the right incentives insofar as possible, while achieving
insurance objectives. With that in mind, compassionate, efficient health reform
would do the following.<o:p></o:p></div>
<div class="MsoNormal">
<b><br /></b></div>
<div class="MsoNormal">
<b>Health Insurance
Reform<o:p></o:p></b></div>
<div class="MsoListParagraphCxSpFirst" style="mso-list: l0 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span></div>
<div class="MsoListParagraphCxSpFirst" style="mso-list: l0 level1 lfo1; text-indent: -.25in;">
<!--[endif]--><i> First, eliminate the tax exclusion of
employer sponsored health insurance.</i> The exclusion of employer sponsored
health insurance from income taxation distorts the demand for insurance. This
leads to people with employer sponsored health insurance holding excessive
coverage, which drives up medical spending and thus insurance premiums.
Ironically, not taxing health insurance ends up making both health care and
health insurance less affordable. Eliminating the tax exclusion of employer
sponsored health insurance will eliminate a major distortion in health
insurance, health care, and labor markets. It can generate substantial tax
revenues (it’s estimated that the value of the state and federal income tax
exclusion for 2009 was $260 billion<a href="http://www.blogger.com/blogger.g?blogID=5090519798343256844#_ftn2" name="_ftnref2" title=""><span class="MsoFootnoteReference"><!--[if !supportFootnotes]--><span class="MsoFootnoteReference"><span style="font-family: Calibri; font-size: 11.0pt; line-height: 115%; mso-ansi-language: EN-US; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Arial; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;">[2]</span></span><!--[endif]--></span></a>),
while potentially allowing for lower income tax rates. It’s also worth pointing
out that the subsidy is biggest for those who face the highest marginal tax
rates, i.e., it’s regressive.<o:p></o:p></div>
<div class="MsoListParagraphCxSpFirst" style="mso-list: l0 level1 lfo1; text-indent: -.25in;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span><!--[endif]--><i>Second,</i>
<i>automatically enroll every U.S. citizen in a standard, basic health
insurance plan</i>. Everyone will be enrolled – there will be universal
coverage. Individuals will be randomly assigned to insurance companies, who
will be required to cover them. Individuals can opt out of this initial
assignment into a different plan, so long as that plan offers at least the
standard, basic coverage (it can be more generous, but not less). <o:p></o:p></div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo1; text-indent: -.25in;">
<br /></div>
<div class="MsoListParagraphCxSpLast" style="mso-list: l0 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span><!--[endif]--><i>Third, the
plan will provide protection against medical expenses that are catastrophic for
the individual or household, given their finances. </i>The function of the plan
is to provide insurance against large expenses associated with treating
episodes of ill health. It will therefore have a high deductible, and fairly
high coinsurance or co-pays, but will have a stop-loss to prevent financial
ruin. Preventive care that’s been shown to be effective can be “carved out” and
have lower cost-sharing. Cost-sharing features will be on a sliding scale
according to income, so individuals only face risk that they can reasonably
bear. Low-income individuals will have lower deductibles, coinsurance or
co-pays and stop-losses than will high-income individuals. In addition, premiums
will be subsidized on a sliding scale according to income, so insurance is
affordable for everyone. Insurer premiums will be risk-adjusted, and there will
be a high-risk pool. No denials of coverage or coverage rescissions will be
allowed. Under this plan ultimately Medicare and Medicaid will be phased out so
that everyone will obtain coverage as indicated above.<o:p></o:p></div>
<div class="MsoNormal">
<b><br /></b></div>
<div class="MsoNormal">
<b>Financing<o:p></o:p></b></div>
<div class="MsoListParagraph" style="mso-list: l1 level1 lfo2; text-indent: -.25in;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span></div>
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<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span><!--[endif]-->The government subsidies for insurance coverage above
will be entirely financed via a dedicated consumption (sales or value added)
tax, e.g., a la Fuchs and Shoven<a href="http://www.blogger.com/blogger.g?blogID=5090519798343256844#_ftn3" name="_ftnref3" title=""><span class="MsoFootnoteReference"><!--[if !supportFootnotes]--><span class="MsoFootnoteReference"><span style="font-family: Calibri; font-size: 11.0pt; line-height: 115%; mso-ansi-language: EN-US; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Arial; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;">[3]</span></span><!--[endif]--></span></a>,
with as few loopholes as possible. All government funding must only be from
this source – no other sources of revenues may be applied. This way the cost
and financing of government spending on health care will be as clear and
transparent as possible. All other funds will be privately financed.<o:p></o:p></div>
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<b><br /></b></div>
<div class="MsoNormal">
<b>Supply Side Reform<o:p></o:p></b></div>
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<br /></div>
<div class="MsoNormal">
The main goal of reforms here is enable competition, and to
eliminate barriers to entry to providing health services. Lack of competition
leads to poor service, poor quality, and high prices, and impedes innovation
(especially organizational innovation).<a href="http://www.blogger.com/blogger.g?blogID=5090519798343256844#_ftn4" name="_ftnref4" title=""><span class="MsoFootnoteReference"><!--[if !supportFootnotes]--><span class="MsoFootnoteReference"><span style="font-family: Calibri; font-size: 11.0pt; line-height: 115%; mso-ansi-language: EN-US; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Arial; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;">[4]</span></span><!--[endif]--></span></a><o:p></o:p></div>
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<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span></div>
<div class="MsoListParagraphCxSpFirst" style="mso-list: l1 level1 lfo2; text-indent: -.25in;">
<!--[endif]--><i> First,
strongly enforce the antitrust laws in health care. </i>There has been a great
deal of consolidation in health care markets in recent years, especially in
hospital and insurance markets, but also in physician markets and between the
different kinds of market participants (e.g., insurers-hospitals,
hospitals-physicians, etc.). Consolidation has resulted if few, if any
documented benefits, and has harmed competition and led to increased prices,
reduced quality, and impeded the emergence of new, innovative forms of health
care delivery.<i> </i>Antitrust enforcement
can help solve problems in specific markets. It can also have a deterrent
effect on those considering anticompetitive actions. <i><o:p></o:p></i></div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l1 level1 lfo2; text-indent: -.25in;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span></div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l1 level1 lfo2; text-indent: -.25in;">
<!--[endif]--><i> Second,
ease barriers on new forms of health care organizations entering the market,
such as retail clinics, freestanding surgery centers, specialty hospitals,
telemedicine, etc. </i>In contrast with much of the rest of the U.S. economy,
the health care industry has been rigid and unresponsive. New organizational
forms that are responsive to patients’ needs are long overdue. <i><o:p></o:p></i></div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l1 level1 lfo2; text-indent: -.25in;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span></div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l1 level1 lfo2; text-indent: -.25in;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span><!--[endif]--><i>Third, free
up entry into the medical profession.</i> Twice as many people apply to medical
school as get accepted, and this has been true for many years. Quite a few more
applicants can be accepted without diminishing the quality of medical students.
Therefore, artificial barriers to creating new medical schools or expanding the
number of slots in existing medical schools need to be eliminated. There has
been some recent progress in this domain.<a href="http://www.blogger.com/blogger.g?blogID=5090519798343256844#_ftn5" name="_ftnref5" title=""><span class="MsoFootnoteReference"><!--[if !supportFootnotes]--><span class="MsoFootnoteReference"><span style="font-family: Calibri; font-size: 11.0pt; line-height: 115%; mso-ansi-language: EN-US; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Arial; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;">[5]</span></span><!--[endif]--></span></a><o:p></o:p></div>
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<div class="MsoListParagraphCxSpMiddle" style="mso-list: l1 level1 lfo2; text-indent: -.25in;">
<!--[endif]--><i> Fourth, free
up entry into specialties.</i> Specialty societies have a great deal of
influence on residency training. This creates crazy distortions such as
dermatology being the hardest specialty to enter, while primary care
specialties have excess training capacity. Artificial barriers to entry into
residency training programs should be eliminated.<o:p></o:p></div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l1 level1 lfo2; text-indent: -.25in;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span></div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l1 level1 lfo2; text-indent: -.25in;">
<!--[endif]--><i> Fifth, reduce
or eliminate public subsidies to medical education.</i> These only add to the
crazy quilt of distortions in this area. With twice as many applicants as
accepted students, there is clearly excess demand for medical education. Public
subsidies are not only unnecessary, they overwhelmingly go to children from
upper middle class or upper class families. Certainly medical training should
receive no more in subsidies than training in science or engineering.<o:p></o:p></div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l1 level1 lfo2; text-indent: -.25in;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span></div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l1 level1 lfo2; text-indent: -.25in;">
<!--[endif]--><i> Sixth, allow
non-physician medical personnel, such as nurses, nurse practitioners,
psychologists, pharmacists, etc. much greater freedom to treat patients
independent of physicians.</i> Nurse practitioners and pharmacists (for
example) are highly trained medical professionals who can do more than they are
currently allowed due to restrictions on scope of practice in many states. Not
only can these practitioners substitute for physicians in some cases, they can
complement them and thereby enhance productivity.<i><o:p></o:p></i></div>
<div class="MsoListParagraphCxSpLast" style="mso-list: l1 level1 lfo2; text-indent: -.25in;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span></div>
<div class="MsoListParagraphCxSpLast" style="mso-list: l1 level1 lfo2; text-indent: -.25in;">
<!--[endif]--><i> Seventh,
regulate health insurers nationally, rather than on a state-by-state basis. </i>Insurers
currently must operate separate risk pools in every state in which they operate
and are regulated differently in every state. This is clearly inefficient.
Insurers should be allowed to pool risk nationally and should face one set of nationally
agreed upon rules and regulations. This will require a national regulatory body
to replace state regulatory agencies.<i><o:p></o:p></i></div>
<div class="MsoNormal">
<b><br /></b></div>
<div class="MsoNormal">
<b>Conclusion<o:p></o:p></b></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
These ground rules are intended to provide a general
framework for the health care system. They are deliberately intended to be
general, not specific, in particular so there are incentives for innovative and
efficient new arrangements and so such arrangements can spontaneously emerge. While
I believe these are sensible changes that would move our health care system in the
right direction, there are and will be alternative proposals that are worthy of
consideration as paths towards a more efficient, compassionate health care
system. <o:p></o:p></div>
<div>
<!--[if !supportFootnotes]--><br clear="all" />
<hr align="left" size="1" width="33%" />
<!--[endif]-->
<br />
<div id="ftn1">
<div class="MsoFootnoteText">
<a href="http://www.blogger.com/blogger.g?blogID=5090519798343256844#_ftnref1" name="_ftn1" title=""><span class="MsoFootnoteReference"><!--[if !supportFootnotes]--><span class="MsoFootnoteReference"><span style="font-family: Calibri; font-size: 10.0pt; line-height: 115%; mso-ansi-language: EN-US; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Arial; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;">[1]</span></span><!--[endif]--></span></a> There have been some
excellent discussions at a high level, some of which overlap with what I
propose here. E.g., Antos, J. Pauly, M.V. and G. Wilensky. (2012) “Bending the
Cost Curve through Market-Based Incentives.” New England Journal of Medicine.
367(10): 954-958. <a href="http://www.nejm.org/doi/full/10.1056/NEJMsb1207996">http://www.nejm.org/doi/full/10.1056/NEJMsb1207996</a>;
Emanuel, E. et al. (2012) “A Systemic Approach to Containing Health Care
Spending.” New England Journal of Medicine. 367(10): 949-954. <a href="http://www.nejm.org/doi/full/10.1056/NEJMsb120590">http://www.nejm.org/doi/full/10.1056/NEJMsb120590</a>;
Kotlikoff, L. “The Healthcare Fix: Universal Insurance for All Americans.” (2007)
Cambridge, MA: MIT Press; Goldhill, D. “The Health Benefits that Cut Your Pay.”
New York Times,February 16, 2013. <a href="http://www.nytimes.com/2013/02/17/opinion/sunday/the-health-benefits-that-cut-your-pay.html">http://www.nytimes.com/2013/02/17/opinion/sunday/the-health-benefits-that-cut-your-pay.html</a>;
Christensen, C., Flier, J. and Vijayaraghavan, V. “The Coming Failure of
Accountable Care.” The Wall Street Journal, February 18, 2013; Bhattacharya,
J., Chandra, A., Chernew, M., Goldman, D., Jena, A., Lakdawalla, D., Malani,
A., and T. Philipson (2013). “Best of Both Worlds: Uniting Universal Coverage
and Personal Choice in Health Care,” Washington, DC: American Enterprise
Institute, <a href="http://www.aei.org/files/2013/08/02/-best-of-both-worlds-uniting-universal-coverage-and-personal-choice-in-health-care_105214167938.pdf">http://www.aei.org/files/2013/08/02/-best-of-both-worlds-uniting-universal-coverage-and-personal-choice-in-health-care_105214167938.pdf</a>.<o:p></o:p></div>
</div>
<div id="ftn2">
<div class="MsoFootnoteText">
<a href="http://www.blogger.com/blogger.g?blogID=5090519798343256844#_ftnref2" name="_ftn2" title=""><span class="MsoFootnoteReference"><!--[if !supportFootnotes]--><span class="MsoFootnoteReference"><span style="font-family: Calibri; font-size: 10.0pt; line-height: 115%; mso-ansi-language: EN-US; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Arial; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;">[2]</span></span><!--[endif]--></span></a> Gruber, J. (2010) The Tax
Exclusion for Employer-Sponsored Health Insurance,” National Bureau of Economic
Research, Working Paper 15766, http://www.nber.org/papers/w15766.<o:p></o:p></div>
</div>
<div id="ftn3">
<div class="MsoFootnoteText">
<a href="http://www.blogger.com/blogger.g?blogID=5090519798343256844#_ftnref3" name="_ftn3" title=""><span class="MsoFootnoteReference"><!--[if !supportFootnotes]--><span class="MsoFootnoteReference"><span style="font-family: Calibri; font-size: 10.0pt; line-height: 115%; mso-ansi-language: EN-US; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Arial; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;">[3]</span></span><!--[endif]--></span></a> Fuchs, V.R. and J.B.
Shoven (2010). “The Dedicated VAT Solution, SIEPR Policy Brief, <a href="http://siepr.stanford.edu/www.stanford.edu/group/siepr/cgi-bin/siepr/?q=system/files/shared/pubs/papers/briefs/PolicyBrief08_2010v2.pdf">http://siepr.stanford.edu/www.stanford.edu/group/siepr/cgi-bin/siepr/?q=system/files/shared/pubs/papers/briefs/PolicyBrief08_2010v2.pdf</a>.
<o:p></o:p></div>
</div>
<div id="ftn4">
<div class="MsoFootnoteText">
<a href="http://www.blogger.com/blogger.g?blogID=5090519798343256844#_ftnref4" name="_ftn4" title=""><span class="MsoFootnoteReference"><!--[if !supportFootnotes]--><span class="MsoFootnoteReference"><span style="font-family: Calibri; font-size: 10.0pt; line-height: 115%; mso-ansi-language: EN-US; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Arial; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;">[4]</span></span><!--[endif]--></span></a> E.g., Gaynor, M. and Town,
R.J. (2012). “The Impact of Hospital Consolidation – Update,” The Synthesis
Project, Policy Brief No. 9, Princeton, NJ: The Robert Wood Johnson Foundation,
<a href="http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2012/rwjf73261">http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2012/rwjf73261</a>;
Richman, B.D., Mitchell, W. and Schulman, K.A. (2013). “Organizational
Innovation in Health Care,” <i>Health
Management, Policy and Innovation</i>, 1(3): 36-44, <a href="http://www.hmpi.org/pdf/HMPI%20-%20Richman,%20Mitchell,%20Schulman,%20Organizational%20Innovation%20in%20Healthcare.pdf">http://www.hmpi.org/pdf/HMPI%20-%20Richman,%20Mitchell,%20Schulman,%20Organizational%20Innovation%20in%20Healthcare.pdf</a>
<o:p></o:p></div>
</div>
<div id="ftn5">
<div class="MsoFootnoteText">
<a href="http://www.blogger.com/blogger.g?blogID=5090519798343256844#_ftnref5" name="_ftn5" title=""><span class="MsoFootnoteReference"><!--[if !supportFootnotes]--><span class="MsoFootnoteReference"><span style="font-family: Calibri; font-size: 10.0pt; line-height: 115%; mso-ansi-language: EN-US; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Arial; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;">[5]</span></span><!--[endif]--></span></a> See <a href="https://members.aamc.org/eweb/upload/12-237%20EnrollmSurvey2013.pdf">https://members.aamc.org/eweb/upload/12-237%20EnrollmSurvey2013.pdf</a> <o:p></o:p></div>
</div>
</div>
<!--EndFragment-->Anonymoushttp://www.blogger.com/profile/16508822019622004205noreply@blogger.com7tag:blogger.com,1999:blog-5090519798343256844.post-15198136395748887242013-03-31T14:15:00.003-04:002013-03-31T14:15:42.308-04:00Pittsburgh's Health Care Market -- It's a Pretty Ugly MessThe Pittsburgh Post-Gazette has an <a href="http://www.post-gazette.com/stories/business/news/upmc-vs-highmark-policy-experts-say-nows-the-time-to-end-the-warfare-681583/" target="_blank">article</a> on the UPMC (hospital system) and Highmark (health insurer) situation in which I and a number of others express opinions. Bottom line -- bilateral monopoly is ugly, and the losers are consumers.Anonymoushttp://www.blogger.com/profile/16508822019622004205noreply@blogger.com24tag:blogger.com,1999:blog-5090519798343256844.post-75397132325472627802013-03-07T12:27:00.000-05:002013-03-07T12:46:03.746-05:00Can Health Care Transparency Make a Difference?There's been a lot of discussion of transparency in health care recently, e.g., a <a href="http://www.usatoday.com/story/opinion/2013/03/05/health-care-pricing-transparency-insurance-providers/1966045/" target="_blank">USA Today op-ed</a> and a <a href="http://www.usatoday.com/story/opinion/2013/03/05/health-care-price-transparency-center-for-studying-health-system-change/1966039/" target="_blank">counterpoint by Paul Ginsburg</a>. The appeal of transparency is obvious. As movingly documented by <a href="http://healthland.time.com/2013/02/20/bitter-pill-why-medical-bills-are-killing-us/" target="_blank">Steven Brill in Time</a>, prices are high and often differ quite substantially, even across close by providers. However, we don't know the prices for the health care that we consume, and it's extremely difficult to find out what these things cost (e.g.,<a href="http://archinte.jamanetwork.com/article.aspx?articleid=1569848#AuthorInformation" target="_blank"> this recent study in JAMA</a>). <br />
<br />
While the appeal of transparency is obvious, it's important to realize that buying health care is not like buying milk at the grocery store. A key factor is health insurance. Health insurance is very important -- people need to be insured against the catastrophic expenses that can occur with serious illness. Thus people with high health care expenses won't be exposed to most of those expenses (and shouldn't) and therefore will have no reason to respond to information about health care prices. <br />
<br />
Further, the distribution of health care expenses among the population is very uneven. Fortunately severe illness is relatively rare. What that means is that most of us will have quite low health care expenses in a given year, while a very small number of people will unfortunately be very sick and have very high health care expenses. The figure below illustrates this. It shows the distribution of health care spending in the US population for 2009 (source: <a href="http://www.nihcm.org/images/stories/DataBrief3_Final.pdf" target="_blank">data brief by the National Institute of Health Care Management</a>). While this is a few years old, the distribution has remained essentially unchanged over a long period of time. The first thing to notice is that the vast majority of spending is accounted for by a small fraction of the population. The top 5 percent of spenders account for about half of all health care spending, and the top 50 percent account for almost 97 percent of spending. <br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg8lcZx32DLvbKaAX8kc_nDP9qwZm2Juu8tnVfEV03FXgpIl7fU9BnywfjUI94RA1JIaKzCFcHbSoeTutWCV7HRohiSrKt1iGul4RZWoo6A8dKE9N1pF6a7oOT7A3g-OeVX7nPWz9xWgV0/s1600/NIHCM_Spending_Distribution_2009.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="252" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg8lcZx32DLvbKaAX8kc_nDP9qwZm2Juu8tnVfEV03FXgpIl7fU9BnywfjUI94RA1JIaKzCFcHbSoeTutWCV7HRohiSrKt1iGul4RZWoo6A8dKE9N1pF6a7oOT7A3g-OeVX7nPWz9xWgV0/s400/NIHCM_Spending_Distribution_2009.jpg" width="400" /></a></div>
What this means is that most of the spending on health care in the US is accounted for by people with very high expenses. Further, many (but not all) of these people have expenses so high that they are well beyond the cost sharing features of any health insurance plan, even a high deductible plan that features extensive consumer cost sharing.<br />
<br />
Using the <a href="http://meps.ahrq.gov/mepsweb/data_stats/meps_query.jsp" target="_blank">query tool for the Medical Expenditure Panel Survey</a>, I found the expenditure levels associated with various percentiles of the 2010 spending distribution. Individuals in the 90th percentile of the spending distribution, who account for almost two-thirds of all health spending, have spending levels of $9,512.76 and higher. These people are almost certainly going to be beyond the cost sharing limits of their health insurance plans. As a consequence, two-thirds of health care spending is unlikely to be responsive to transparency efforts.<br />
<br />
Since these people are beyond the cost sharing features of their plans, they have no incentive to pay attention to the costs of care, either in total or cost differences across providers. In addition, people who are spending this much money on health care are unfortunately likely to be quite sick. The demand for care of people who are very ill tends not to be very responsive to prices. <br />
<br />
Does this mean that there's no point to transparency efforts? No. Forty nine (.999...) percent of the spending is accounted for by people who spend (just under) $814.86 or less. For these people, cost sharing can make a difference -- large, but conventional, deductibles (e.g., $1,000, $500) would be relevant to many of these people. However, for transparency efforts to work, price information has to be presented to people in a way they can understand and use -- the total cost to them of obtaining care, as opposed to the individual components. Further, there have to be alternative providers. Many health care markets have become <a href="https://www.dropbox.com/s/ul0so3fkllqsc4g/Gaynor_Consolidation_Statement_1.pdf" target="_blank">extremely consolidated</a>. If there are no good alternatives, then transparency efforts will be of little practical use. <br />
<br />
In addition, transparency with regard to the quality of care is both important and valuable to all, regardless of spending level. Providing accurate and informative measures of the quality of care is challenging, but a lot of progress has been made and there are ongoing efforts in this area.<br />
<br />
Last, there's some concern that by making prices public transparency efforts will facilitate collusion by providers. If so, this could unintentionally make things worse by reducing rather than increasing competition and leading to higher, rather than lower, prices. There's evidence that this has happened in other industries (e.g., cement), however I don't think it's terribly likely in health care (although not impossible). Even with transparency efforts, health insurers will play a major role as buyers of health care. Insurers' ability to direct large numbers of patients means that providers have large incentives to make deals to obtain those patients. Creating and maintaining collusion becomes difficult under these circumstances. <br />
<br />
In sum, trying to achieve greater transparency in health care is a worthwhile effort, but it has to involve usable measures of both price and quality. Further, it's unrealistic to expect consumer shopping alone, and hence transparency efforts, to drive the health care market. Transparency is but one ingredient --- much more is required. Anonymoushttp://www.blogger.com/profile/16508822019622004205noreply@blogger.com885tag:blogger.com,1999:blog-5090519798343256844.post-84093506589165597542013-02-27T14:52:00.000-05:002013-02-27T14:52:54.748-05:00Are Price Controls the Answer? Netherlands Edition<span style="font-size: small;">This post is co-authored with <a href="http://nl.linkedin.com/pub/misja-mikkers/4/b92/413" target="_blank">Misja Mikkers</a>, who is Director of Strategy and Legal Affairs<span style="color: #333333;"> at the Netherlands Healthcare Authority and is affiliated with Tilburg
University, the Netherlands and Copenhagen Business School, Denmark.</span></span><br />
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In a previous post one of us (Gaynor) examined some evidence
on whether price controls are effective in slowing the rate of growth of health
care spending, and how they compare with competition in private markets. In
this post we examine some evidence from the Netherlands that may bear on the
matter. In the previous post a data point from the Netherlands was shown as
part of an international comparison, but it’s worthwhile to examine the Netherlands experience a bit
further. The Netherlands is particularly interesting because they have employed
rate setting in health care and subsequently deregulated much of their health
sector to allow prices to be market determined. The question of whether the end
of rate setting and the introduction of competition raised or lowered health
care costs and prices in the Netherlands is hotly debated.</div>
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The <a href="http://healthland.time.com/2013/02/20/bitter-pill-why-medical-bills-are-killing-us/">article
by Steven Brill in Time</a> also led also to a lot of discussion in the
Netherlands. Rob Wijnberg (former editor of the important Dutch Newspaper
NRC-next) tweeted, “brilliant article about the reasons why competition in
health care doesn’t work" (<a href="https://twitter.com/robwijnberg">https://twitter.com/robwijnberg</a>,
Feb 26, translation M. Mikkers). </div>
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Health reform in the Netherlands has been gradual and has
had a number of different elements. Initially competition in health insurance
was introduced (with an individual mandate), while maintaining rate setting for
providers. A partial and gradual deregulation of provider prices followed. For
hospitals some services have been deregulated (this is called the B Segment)
and some services remain under price controls (the A Segment). The proportion
of services in the deregulated B Segment has increased over time. In 2005 8% of
hospital services were in the B-segment. This percentage then increased to 20%
and 30% in 2008 and 2009 respectively. In 2012 virtually all elective care (70%
of hospital services) was in the B segment.</div>
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<![endif]-->source: <a href="http://www.nza.nl/104107/105773/354532/Marktscan_Medisch_specialistische_zorg_2011.pdf" target="_blank">Market Scan Hospital Market 2011</a>, Netherlands Healthcare Authority [in Dutch]) shows the percentage change in hospital prices over time in the price
controlled A Segment and deregulated B Segment. As can be seen, growth in the
deregulated segment, where prices are market determined, is substantially lower
from about 2006-2007 onwards. In fact, from about 2008-2009 to 2010-2011 prices
were falling in the deregulated segment while they were still growing in the
price controlled segment. This doesn’t necessarily mean that competition
controls prices and rate setting does not (lots of other things could be going
on), but neither do we see what we’d expect if rate setting was doing a
superior job of controlling prices.</div>
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<![endif]--><a href="http://statline.cbs.nl/StatWeb/publication/?DM=SLNL&PA=71914ned&D1=2,26&D2=3-9,11-13&STB=G1,T&VW=T" target="_blank">source</a>: CBS [Dutch Central Bureau of Statistics]<span style="font-family: "Calibri","sans-serif"; font-size: 11.0pt; line-height: 115%; mso-ansi-language: EN-US; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Arial; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;"> </span>)<span class="MsoFootnoteReference"><span style="mso-special-character: footnote;"><span class="MsoFootnoteReference"><span style="font-family: "Calibri","sans-serif"; font-size: 11.0pt; line-height: 115%; mso-ansi-language: EN-US; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Arial; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;"> </span></span></span></span>shows the growth rate in hospital spending in the Netherlands in the period
before rate deregulation (2001-2005) and after deregulation began (2006-2011).
The average annual growth rates between the two periods are virtually
indistinguishable. Again, this isn’t scientific proof that rate setting doesn’t
control costs (either in general or in the Netherlands), but there’s no slam
dunk for rate setting in the patterns that we observe. We may be able to see
more interesting patterns in the future. By 2014 and 2015 virtually all prices
for elective care will have been deregulated and all parties in the market will
be fully exposed to the consequences of their (price) negotiations. <span style="mso-spacerun: yes;"> </span></div>
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In sum, the Netherlands is a good place to look for the
effects of rate setting versus markets on prices and spending, since they have
employed both. A quick look at some descriptive statistics doesn’t yield any
slam dunks for rate setting. If anything, shifting to markets may have substantially
reduced price growth. However, careful study will be required in order to draw
firmer conclusions. Last, while we believe that there are lessons for the US
from experiences in other countries (and vice versa), we do have to be cautious
in making strong inferences across very different health care systems and
societies.</div>
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<a href="http://www.blogger.com/blogger.g?blogID=5090519798343256844#_ftnref1" name="_ftn1" style="mso-footnote-id: ftn1;" title=""><span class="MsoFootnoteReference"><span style="mso-special-character: footnote;"><span class="MsoFootnoteReference"><span style="font-family: "Calibri","sans-serif"; font-size: 10.0pt; line-height: 115%; mso-ansi-language: EN-US; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Arial; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;"></span></span></span></span></a><span lang="EN-GB" style="mso-ansi-language: EN-GB;"></span></div>
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Anonymoushttp://www.blogger.com/profile/16508822019622004205noreply@blogger.com114tag:blogger.com,1999:blog-5090519798343256844.post-137331971030861612013-02-25T19:30:00.002-05:002013-02-26T14:19:32.444-05:00The Promises and Pitfalls of Pay for PerformanceThere's been a great deal of discussion about health care payment reform. Prominent in this discussion is "Pay for Performance" (P4P). The idea is simple -- rather than pay providers based on volume of care (fee-for-service) or number of patients (capitation), tie their payment to a measure(s) of performance. There has been substantial concern about the quality of care delivered to patients, so pay for performance appears to make a lot of sense. Don't we want to reward providers for good performance? Shouldn't this encourage them to provide high quality care? <br />
<br />
Unfortunately, this is not as straightforward as it might appear. While the idea of pay for performance is very appealing and intuitive, there are some major pitfalls in implementation. First, let's consider what we want to accomplish. We want to set up a system for paying providers that aligns their incentives with what's best for patients, taking into account the benefits and the costs of treatment. In practice P4P systems are set up by payers to align providers' incentives with their objectives. One question that emerges immediately is whether the payer's objectives are the right ones. If payers do not have the best interest of patients at heart a perfectly designed and effective P4P scheme may work extremely well, but may not be to the benefit of patients. This may be true regardless of whether the payer is public or private.<br />
<br />
Aside from the issue of the payer's motivation, there are a number of design issues that are critical for the effectiveness of P4P. This is truly a situation where "the devil is in the details."<br />
<br />
A number of issues revolve around how performance is measured. First, "you get what you pay for." Providers will respond to the incentive, but this may come at the cost of less of those things which are not measured and therefore not rewarded. For example, this means that aspects of quality that are hard to measure may suffer. If P4P is at the individual provider level, then informal consults or other aspects of being a "team player" may decline. Second, if the performance measure can be manipulated, then P4P may actually generate perverse incentives. For example, suppose performance is measured by patient outcomes incompletely adjusted for patient severity (as is certainly the case). Then providers may attempt to see only patients who are easy to treat and avoid difficult cases. Third, if the performance measure isn't very accurate then chance will play a large role in measured performance. In this case, provider effort won't play a large role in determining payment, so providers will have little incentive to try hard. In addition, rewards can be perceived as unfair -- some providers who aren't so good will receive rewards and some good doctors won't. How accurate the performance measure is depends (among other things) on the size of a provider's practice. A larger practice with a larger patient population will have more statistically reliable measures of the performance metric. Unfortunately, statistical reliability may be hard to achieve in practice. An article by <a href="http://jama.jamanetwork.com/article.aspx?articleid=185033" target="_blank">Nyweide et al</a>. finds that <span class="Abstract 0" id="scm6MainContent_rptSections_lblSection_0">"Relatively
few primary care physician practices are large enough to reliably
measure 10% relative differences in common measures of quality and cost
performance among fee-for-service Medicare patients." </span><br />
<br />
The figure below illustrates the problem with chance and fairness. (Note: This figure and the one below are borrowed from <a href="http://www.hcp.med.harvard.edu/people/hcp_core_faculty/thomas_mcguire" target="_blank">Tom McGuire</a>. His original presentation at the Third International Jerusalem Conference on Health Policy, which I highly recommend, is <a href="http://www.powershow.com/view1/f95b1-ODQyM/Thomas_G_McGuire_powerpoint_ppt_presentation" target="_blank">here</a>.) The "bell curve" to the left represents the performance distribution of "not so good" doctors. Some do better than others on the performance measure just by pure chance. The curve to the right represents the performance distribution of "good doctors." They clearly do better as a group than the "not so good" doctors, but purely by chance some of them will do worse than the "not so good" group. Given a target, a proportion A of the good doctors will end up falling below the target and not getting rewarded. Similarly, a proportion B of the not so good doctors will end up being rewarded. First, if the proportion of good doctors who will fall below the target just by chance is high enough, even good doctors won't bother trying. Second, given that a large proportion (in this example) of good doctors will not be rewarded and some not so good ones will, the system is likely to be perceived as unfair. <br />
<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhLYroQD7AdGYynD4W4iyVoROIgX0XjWVZGfkA1v9U6vgAWtCOXw8YfeWGDBmkeg_AeYj6FRi78tk1GyfvTvp-Vr-FAUwC63_m7oXUL5kt9n_tFF_D8Z1mkh0bYXZlU-887aZF26jIAlfc/s1600/P4P_fairness.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="202" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhLYroQD7AdGYynD4W4iyVoROIgX0XjWVZGfkA1v9U6vgAWtCOXw8YfeWGDBmkeg_AeYj6FRi78tk1GyfvTvp-Vr-FAUwC63_m7oXUL5kt9n_tFF_D8Z1mkh0bYXZlU-887aZF26jIAlfc/s400/P4P_fairness.jpg" width="400" /></a></div>
<br />
<br />
Another important factor is the amount of money at stake. If the amount at risk isn't large enough then it won't get providers' attention -- the incentive will be too weak (<a href="http://www.hsph.harvard.edu/ashish-jha/" target="_blank">Ashish Jha</a> has a nice blog post on this, and some other aspects of P4P, <a href="http://blogs.sph.harvard.edu/ashish-jha/getting-pay-for-performance-right/" target="_blank">here</a>). On the other hand, if the amount at risk is too high, then providers can be placed in the position of bearing too much risk -- a bad event can put their practice under water. This is not only undesirable for providers, it can have undesired consequences -- providers will have strong incentives to avoid difficult patients or to "teach to the test," i.e., distort treatment decisions to ensure meeting measured performance goals. In addition, payers that impose a large amount of risk on providers will have to pay more to have them see their patients and take on that risk.<br />
<br />
One way to mitigate accuracy problems in performance measures and risk is to use P4P for groups of providers instead of individuals. Performance measures for groups will have better <a href="http://jama.jamanetwork.com/article.aspx?articleid=185033." target="_blank">statistical properties</a> than for individuals and groups of providers can <a href="http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0CDIQFjAA&url=http%3A%2F%2Fwww.researchgate.net%2Fpublication%2F24048924_Moral_Hazard_and_Risk_Spreading_in_Partnerships%2Ffile%2F9fcfd50e614de16871.pdf&ei=MPcrUfvTLMq70QGkvIDgBw&usg=AFQjCNFXa9xGs69uDOi_lAOadp5m7fN5sg&sig2=XLU-EAGMA6y-q5_auJsMeg&bvm=bv.42768644,d.dmQ&cad=rja" target="_blank">spread risk</a> (pdf). Unfortunately, there's no free lunch. Using P4P for groups weakens individual incentives -- the well known "free rider problem." The larger the number of providers in the group, the <a href="http://www.hsrp.pitt.edu/seminar_docs/Gaynor_JPE_04.pdf" target="_blank">weaker is the incentive for individuals</a> (pdf). The weakening effect on incentives can be substantial. <br />
<br />
Third, most P4P programs use targets -- there's a measured performance goal and payments depend on reaching that target. Using targets in P4P presents a number of issues. First, how well P4P will work, or if at all, depends critically on where the target is set. Set the target too high and no one will be able to reach it, so no one will try. Set the target too low and everyone will be able to reach it, so no one will have to try. As a consequence, P4P schemes which use targets are very fragile -- how well they will work depends critically on where the target is set. This requires a lot of information on the part of the payer to get this right, especially because where the target should be set will change over time and also across providers. How much providers differ in their responsiveness or abilities to reach the target is also critical. <br />
<br />
For example, consider the figure below. Each angled line represents a different provider, e.g. a primary care physician. The horizontal axis is each provider's immunization rate for their patients and the vertical axis is their marginal cost of improving the immunization rates for their patient populations. The lines slope up, indicating that the cost of getting more patients immunized increases with the immunization rate -- it's pretty easy to get the first patients immunized, they're aware and compliant, but getting the last few patients immunized can be difficult. A fixed target for immunization is set, e.g., 75%, and providers receive a performance payment if they are at or over the target. Now consider four different providers. Provider A is so far below the target that she will never reach it no matter how hard she works, so P4P gives her no incentive for performance. Provider D is so far beyond the target that she will reach it no matter what she does. She also has no incentive for performance. It's only Providers C and D who have any incentive to respond to this P4P scheme -- the rest of the providers will ignore it.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjvz-yv_s81GliadDXES9oqWd-QCb-AuH65y_Y0CvWvLOC2iaemVKeHDmzaFCR0bQ_fTJ6E6CsRPGvyM-Z9adqHVT_eYUl3GwEJi2UIBcxrDtz-7VbcVe7ihyNAa7Wk5VlqkjuZzRYsclA/s1600/Target_Incentives.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="197" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjvz-yv_s81GliadDXES9oqWd-QCb-AuH65y_Y0CvWvLOC2iaemVKeHDmzaFCR0bQ_fTJ6E6CsRPGvyM-Z9adqHVT_eYUl3GwEJi2UIBcxrDtz-7VbcVe7ihyNAa7Wk5VlqkjuZzRYsclA/s400/Target_Incentives.jpg" width="400" /></a></div>
Last, P4P with a target can be wasteful. In the figure above, only Providers B and C respond to the incentive. Nonetheless, they plus Provider D and all of the providers to the right of Provider D will earn a reward, even though only B and C responded to the P4P incentive. This is clearly wasteful.The effect of P4P is small relative to the cost. The extent to which this is true depends on how much providers differ, and where the target is set. For example, in the figure above if all providers were like B or C, then P4P using the target in the figure would work quite well. If the target were set substantially above or below B or C, however, then P4P would likely fail. <br />
<br />
In sum, incentives matter, but the problems with P4P are substantial enough that simply using high powered pay for performance schemes may not be a practical or desirable way to try to improve quality or lower costs. Pay for performance has potential, but it has to be used carefully to avoid its pitfalls. It's important to realize that addressing health care quality and costs requires multiple tools and provider pay is merely one of them. Anonymoushttp://www.blogger.com/profile/16508822019622004205noreply@blogger.com1tag:blogger.com,1999:blog-5090519798343256844.post-38176104813924876782013-02-24T19:56:00.001-05:002013-06-04T09:55:10.032-04:00Are Price Controls the Answer?A recent article in Time magazine by Steven Brill, <a href="http://healthland.time.com/2013/02/20/bitter-pill-why-medical-bills-are-killing-us/" target="_blank">"Bitter Pill: Why Medical Bills Are Killing Us,"</a> is a brilliantly written expose of the excesses and outrages of health care pricing. In reaction to the story, some have suggested the price controls are the appropriate (or the only) way to rectify the situation. A recent story in the Washington Post's Wonkblog, <a href="http://www.washingtonpost.com/blogs/wonkblog/wp/2013/02/23/steven-brills-26000-word-health-care-story-in-one-sentence/" target="_blank">"Steven Brill’s 26,000-word health-care story, in one sentence,"</a> suggests that US health care costs and cost growth are so high because we do not use rate setting, i.e., price controls.<br />
<br />
In fact, I think it's not easy to establish whether that is indeed the case. We don't get to use randomized controlled trials for health policies or systems, so it's difficult to figure out how effective a policy like rate setting is. Let me start with some simple examinations of patterns in data to see if something jumps out that strongly supports (or contradicts) the assertion that price controls reduce health care costs. <br />
<br />
Starting at the most aggregate level, we can compare the growth rates of spending across countries
that use price controls for health care with those that don't. The figure
below shows the growth rates of health spending for OECD countries from
2000-2009. The US is the main country with a substantial part of its health sector
not subject to price controls. Spending by the privately insured in the
US is about 50% of the total, so about one-half of our health spending
is not subject to price controls. The Netherlands deregulated prices in their hospital sector starting at 10% in 2005 and moving to 34% in 2009, and also for many physician practices, although it's not clear whether the 2000-2009 growth rate reflects any effects. <br />
<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj7Kp_6zIVc52r3b1cTzK8wnhE8xmY55yztAq7B96PvYqoh0nxBsmFpyLAkNndqa_mS9pVmTfXcIB8Ta_mdSltFulnJUc5UXEEiDAN9Qb-C2V7vBMLtDqsp6irm2PXKvruKXvdCd5tiIJE/s1600/OECD+growth+rates.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj7Kp_6zIVc52r3b1cTzK8wnhE8xmY55yztAq7B96PvYqoh0nxBsmFpyLAkNndqa_mS9pVmTfXcIB8Ta_mdSltFulnJUc5UXEEiDAN9Qb-C2V7vBMLtDqsp6irm2PXKvruKXvdCd5tiIJE/s400/OECD+growth+rates.jpg" width="327" /></a></div>
<br />
There does not appear to be a revealing pattern here -- there are some countries that use rate
setting, such as Australia, France, Israel, and Italy that have lower growth rates than the US, and some
such as Canada, Finland, and the UK that have higher growth rates. The US is below the OECD average, whereas Finland is above, as is The Netherlands. While I wouldn't put much weight on anything we see in cross-country differences (there are way too many differences across countries besides price controls), nonetheless nothing striking emerges from these numbers.<br />
<br />
Another possible source of information on the effect of price
controls on spending is the Medicare program. Medicare fixes the prices
it pays doctors and hospitals, so it controls prices. The figure below
shows per enrollee growth rates for personal health care expenditures
from 1970-2011, as calculated by CMS for services covered both by
Medicare and by private insurance (Source <a href="http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/tables.pdf" target="_blank">here</a>, Table 21). <br />
<br />
<br />
<br />
While
examining this figure is clearly not a scientific test (there are many other things undoubtedly driving growth rates of spending), nonetheless, if
we see Medicare growth rates consistently lower than private growth
rates that would lend at least some preliminary support for the notion that rate setting
controls costs. As can be seen, sometimes Medicare spending per
enrollee grows faster than private spending, and sometimes the opposite.
In particular, Medicare spending slowed dramatically in the mid-1980s
after the introduction of the Prospective Payment System for hospitals.
Private spending growth fell below Medicare in the early to mid-1990s,
most likely due to managed care. More recently Medicare spending has
grown more slowly than private spending. Over the entire period the average Medicare growth rate is 8.02%, while private is 9.34%. The patterns here are mixed, but the long run average growth rate for Medicare is lower. <br />
<br />
The US does have quite a bit of experience with price controls for medical care at the state level, so we can look at evidence on the effectiveness of these programs. Many states used all-payer rate regulation for hospitals during the 1970s and 1980s. The evidence from these state hospital rate regulation programs indicates a mixed pattern of success. The setup and administration of the program played a large role in whether they were effective. Nonetheless, there is evidence that fi nds that mandatory rate regulation program in a number of states did reduce the rate of growth of hospital expenses (by a little more than 1%). I provide a few references <a href="http://www.andrew.cmu.edu/user/mgaynor/Assets/Gaynor_Consolidation_Statement_1.pdf" target="_blank">here</a>, for those who are interested. While a 1% reduction in spending growth rates isn't very dramatic, if
such an effect occurred and was sustained over time it would lead to a
substantial decrease in spending over time.This is probably the most relevant evidence, since if rate setting were to be revived it would almost certainly happen at the state level. <br />
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<a href="http://www.blogger.com/blogger.g?blogID=5090519798343256844" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img alt="" border="0" height="384" 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style="cursor: move;" width="640" /></a><a href="http://www.blogger.com/blogger.g?blogID=5090519798343256844" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><a href="http://www.blogger.com/blogger.g?blogID=5090519798343256844" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><a href="http://www.blogger.com/blogger.g?blogID=5090519798343256844" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><a href="http://www.blogger.com/blogger.g?blogID=5090519798343256844" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a>This effect of rate-setting pales, however, compared to the estimates of the impact of managed care from a prominent study, <a href="http://www.economics.harvard.edu/files/faculty/13_How%20Does%20Managed%20Care%20Do%20It.pdf" target="_blank">"How Does Managed Care Do It?,"</a> which found 30-40% lower expenditures (not growth rates) due to managed care in Massachusetts in the mid 1990s. Another prominent study, <a href="http://www.jstor.org/discover/10.2307/725439?uid=3739864&uid=2129&uid=2&uid=70&uid=4&uid=3739256&sid=21101859099737" target="_blank">"Price and Concentration in Hospital Markets: The Switch from Patient-Driven to Payer-Driven Competition,"</a> finds that hospital markups fell substantially in California in the 1980s, primarily due to the growth of managed care.<br />
<br />
So what do we conclude? My answer is that we don't know what the impact of rate setting (price controls) would be on health care spending in the US. It's possible that rate setting could prevent some of the most egregious practices recorded in the Brill article, but that depends on what's enacted and how it's enforced. Whether rate setting would substantially slow the rate of growth of health care spending isn't clear. Further, the question that must be asked is what is the alternative? There's evidence to suggest that robust price competition, such as we had with managed care during the 1990s, can perform very well in controlling costs. Unfortunately there has been a tremendous amount of <a href="http://www.andrew.cmu.edu/user/mgaynor/Assets/Gaynor_Consolidation_Statement_1.pdf" target="_blank">consolidation in health care markets since the 1990s, raising serious challenges to competition</a>. Whether the US decides to go with competition or with regulation, we have some serious work to do to make the system we choose work effectively. <br />
<br />
<br />
<br />Anonymoushttp://www.blogger.com/profile/16508822019622004205noreply@blogger.com8tag:blogger.com,1999:blog-5090519798343256844.post-48920081844942845722013-01-18T09:54:00.000-05:002013-01-18T09:58:09.470-05:00Health Insurers Should Not Become Too Big to Care<!--[if gte mso 9]><xml>
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<div class="MsoNormal" style="font-family: Arial,Helvetica,sans-serif; line-height: 14.4pt; margin: 1.5pt 0in;">
<span style="font-size: small;">This post is co-authored with
<a href="http://nl.linkedin.com/pub/rein-halbersma/4/2b/621" target="_blank"><b>Rein Halbersma</b></a> and <a href="http://nl.linkedin.com/pub/katalin-katona/7/979/157" target="_blank"><b>Katalin Katona</b></a>, who <span style="color: #333333;">are economic
policy advisors at the Netherlands Healthcare Authority and affiliated with Tilburg
University, the Netherlands.</span><span style="color: grey;"></span></span></div>
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<span style="font-size: small;"><span style="background: none repeat scroll 0% 0% white;">A recent Economix blog article in the New York Times (<a href="http://economix.blogs.nytimes.com/2012/11/23/health-insurance-exchanges-may-be-too-small-to-succeed/" target="_blank">“Health Insurance Exchanges MayBe Too Small to Succeed”</a>)<sup></sup>, raises the concern that encouraging competition in health
insurance exchanges could lead to health insurers that are too small to
succeed. I</span>t is clear that the bargaining leverage of insurers, which is determined
by their size and the presence of alternative insurers, lowers provider prices,
and that high provider prices are a serious problem. However, there are several
important arguments against letting health insurance markets gravitate towards
higher levels of concentration.<span style="background: none repeat scroll 0% 0% white;"></span></span></div>
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<br /></div>
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<span style="font-size: small;"><span style="background: none repeat scroll 0% 0% white;">First, allowing insurer market power only makes a bad problem worse. <span class="apple-converted-space">Insurer market power often has the political
repercussion of leading to a cry for even more “countervailing power” by
lobbying health care providers. The end result of such a process can be the
worst possible outcome for consumers: market power for both providers and
insurers. This process occurred in the U.S. during the 1990s in what was called
the “Managed Care Backlash”, and the phenomenon has also occurred in other
countries with private health insurers, such as the Netherlands.</span></span></span></div>
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<span style="font-size: small;"><span style="background: none repeat scroll 0% 0% white;">Second, if providers have too much market power, that problem is best dealt
with directly. Encouraging insurer market power is not an efficient policy for
dealing with antitrust issues in provider markets. Provider market power is
best dealt with through vigorous antitrust enforcement. The Federal Trade Commission
and the Antitrust Division of the Department
of Justice have renewed their
efforts in this area in recent years.</span></span></div>
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<span style="font-size: small;"><span style="background: none repeat scroll 0% 0% white;">Third, allowing insurer concentration can lead to too much insurer
market power and substantially higher premiums. The economic reasoning is that
insurer market power limits the incentives to pass on to consumers the
discounts they obtain via their buyer power. In extreme cases of insurer
monopoly power, the generated savings on provider prices can be more than
offset by dramatically higher premiums.</span></span></div>
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<span style="font-size: small;"><span style="background: none repeat scroll 0% 0% white;">Fourth, the consequences of too much insurer market power are worse than
the consequences of too little. Once insurers have obtained market power, the
situation is typically irreversible. Small insurers may always decide to merge
–subject to antitrust control-, but “unscrambling the eggs”<span class="apple-converted-space"> is impossible in practice.</span></span></span></div>
<div class="MsoNormal" style="color: black; font-family: Arial,Helvetica,sans-serif;">
<br /></div>
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<span style="background: white; color: #333333; font-family: "Georgia","serif"; font-size: 10.5pt; mso-ansi-language: EN-US;"><span style="font-family: Arial,Helvetica,sans-serif; font-size: small;"><span style="color: black;">As the New York Times article rightly points out, one may worry whether some health insurers
are too small to succeed against powerful providers. And excessively high
prices set by powerful health care providers are a serious problem for health
policy. However, when it comes to passing on provider discounts to consumers, we
should also ask whether allowing insurer market power simply makes them too big
to care.</span></span><a href="http://www.blogger.com/blogger.g?blogID=5090519798343256844" name="_GoBack"></a></span></div>
Anonymoushttp://www.blogger.com/profile/16508822019622004205noreply@blogger.com1tag:blogger.com,1999:blog-5090519798343256844.post-34610942429694874912013-01-18T09:36:00.002-05:002013-01-18T09:36:17.891-05:00Health Care Competition Saves LivesEvidence has been mounting on the impacts of health care competition on the quality of care. The vast majority of these studies look at hospital competition and use mortality risk as a measure of the quality of care. Two recent studies I've done with colleagues analyze the impact of reforms in the English NHS designed to promote competition among hospitals.<br />
<br />
In one study, <a href="https://sites.google.com/site/rodrigomorenoserra/" target="_blank">Rodrigo Moreno-Serra</a>, <a href="http://www3.imperial.ac.uk/people/c.propper" target="_blank">Carol Propper</a> and I examine the impact of these reforms on mortality for heart attack patients and overall mortality. We find that mortality declined substantially more after the reforms for hospitals facing more potential competition than for those that did not. Specifically, we estimate that the reforms led to a 0.3% drop in the mortality rate for heart attack victims, saving nearly 1,000 lives per year. A recent <a href="http://www.voxeu.org/article/healthcare-competition-saves-lives" target="_blank">article in Vox</a> (an online <a href="http://www.voxeu.org/pages/about-vox" target="_blank">economic policy journal</a>) summarizes the results. <br />
<br />
In a followup study, <a href="http://www3.imperial.ac.uk/people/c.propper" target="_blank">Carol Propper</a>, <a href="http://faculty-gsb.stanford.edu/seiler/" target="_blank">Stephan Seiler</a> and I analyze the impact of the NHS reforms on patient choice of hospitals for heart bypass surgery (CABG). This is summarized in a recent <a href="http://www.voxeu.org/article/free-choose" target="_blank">Vox article</a>. We find that NHS patients are much more responsive to quality differences across hospitals (measured as risk-adjusted mortality rates) after the reforms. As a consequence, hospitals are driven to be responsive to patients and compete on the basis of the quality of care. We find that the reform reduced mortality for bypass surgery patients by 3%, via patients choosing better quality hospitals.<br />
<br />
While there is still a lot of work to do to better understand the nature of competition in health care markets and impacts on quality, these two studies do add to a growing body of evidence on the topic. The weight of the evidence, in my opinion, is showing that health care competition saves lives. For more general overviews on the evidence, see a recent <a href="http://www.rwjf.org/en/research-publications/find-rwjf-research/2012/06/the-impact-of-hospital-consolidation.html" target="_blank">synthesis piece on hospital consolidation</a> that <a href="https://hcmg.wharton.upenn.edu/profile/1665/" target="_blank">Robert Town</a> and I wrote for the Robert Wood Johnson Foundation, an <a href="http://www.rwjf.org/en/research-publications/find-rwjf-research/2006/02/how-has-hospital-consolidation-affected-the-price-and-quality-of.html" target="_blank">earlier synthesis piece</a> by Town and <a href="http://www.terry.uga.edu/directory/profile/wbvogt/" target="_blank">William B. Vogt</a>, a chapter that Town and I wrote for the <a href="http://www.sciencedirect.com/science/article/pii/B9780444535924000098" target="_blank">Handbook of Health Economics</a> , and a recent survey piece on <a href="http://www.york.ac.uk/media/che/documents/papers/researchpapers/CHERP80_hospital_quality_competition_fixedprices.pdf" target="_blank">hospital competition under fixed prices</a> by <a href="http://www.york.ac.uk/che/staff/research/hugh-gravelle/#profile" target="_blank">Hugh Gravelle</a>, <a href="http://www.york.ac.uk/che/staff/research/rita-santos/" target="_blank">Rita Santos</a>, <a href="http://www.york.ac.uk/che/staff/research/luigi-siciliani/" target="_blank">Luigi Siciliani</a>, and <a href="http://www.bris.ac.uk/social-community-medicine/people/rosalind-goudie/index.html" target="_blank">Rosalind Goudie</a>. Anonymoushttp://www.blogger.com/profile/16508822019622004205noreply@blogger.com3tag:blogger.com,1999:blog-5090519798343256844.post-80465649102113397012012-11-11T16:50:00.001-05:002012-11-11T17:04:26.645-05:00Nothing Focuses the Mind Like a Fiscal CliffThe Federal government is facing a self imposed deadline to reduce the budget deficit or face a mandated combination of large tax increases or budget cuts. Everyone agrees that allowing the mandated cuts to occur could cause serious harm to the economy, so the White House and Congress will have to come to some agreement (soon) to avoid driving the economy off the fiscal cliff.<br />
<br />
The process of confronting this problem provides an opportunity to reform the U.S. tax code. No one likes our current income tax system -- there are a bewildering array of deductions, exclusions, and loopholes. This not only makes it hard for people to complete their income tax forms, it leads to serious distortions in incentives -- costing our economy billions of dollars.<br />
<br />
A straightforward solution is to simply eliminate all exclusions, deductions, and loopholes. Under this reformed tax code all income will be taxed -- period. Both earned (wages and salaries) and unearned (capital gains) income will be taxed at the same rate. Higher incomes will be taxed at higher rates. This will be a truly progressive income tax because individuals with high incomes won't be able to avoid taxes via the shelters and loopholes that are present in the current tax system. Further, resources will flow to their highest valued use, rather than those that allow the avoidance of taxes.<br />
<br />
Pursuing this option will mean eliminating some tax exclusions and deductions that are popular -- the mortgage interest deduction and the tax exclusion of employer sponsored health insurance benefits for example. But not taxing these inefficiently distorts incentives and also means that income tax rates have to be higher. For example, it's estimated that these two features of the tax code alone will cost the Federal government over $1 trillion in foregone tax revenues over the next five years. Further, since the value of these features of the tax code rises with an individual's tax rate, they are regressive. High income individuals derive more benefit from these (since they avoid more tax) than do lower income individuals.<br />
<br />
As a practical matter, it's unlikely that we'll actually eliminate all exclusions and deductions from the tax code. It may be desirable to retain some, such as deductions for charitable donations (although even that can be debated), and we'd likely gradually phase out those features to be eliminated. Of course, pursuing tax reform doesn't eliminate the need to address spending, but it can help. It's also important to point out that there still may be a need to increase tax rates, even if serious tax reform is undertaken.<br />
<br />
I am not being particularly original or innovative in calling for this kind of tax reform. Many economists, politicians, and others have proposed this kind of tax code simplification over the years. What I do think is that our current set of fiscal challenges, not just the looming fiscal cliff, may finally provide our politicians with the stimulus they need to pursue meaningful tax reform.<br />
<br />
While moving from our current system to a simplified tax code would be a big change, I think it's a change that most people would welcome. The current system is widely perceived as arbitrary, byzantine, and unfair. A tax code where all income is taxed would be simpler, more efficient, and fairer. The looming fiscal cliff provides our government with an opportunity for real tax reform -- one they shouldn't pass up.Anonymoushttp://www.blogger.com/profile/16508822019622004205noreply@blogger.com1tag:blogger.com,1999:blog-5090519798343256844.post-49933886398239572362012-10-05T17:03:00.001-04:002012-10-05T17:07:22.719-04:00Is The 716 Billionth Cut The Deepest?One of the primary items of contention in Wednesday night's Presidential debate was the $716 billion in cuts to Medicare through the Accountable Care Act (ACA). Mitt Romney claimed that this would harm Medicare beneficiaries, while Barack Obama claimed just the opposite, that this would help them. Let's consider these claims.<br />
<br />
First Romney's claim. First, let's be clear that there are no payment cuts to doctors included, so there should be no impact of the cuts on physician supply of services. It is possible that if Medicare spending exceeds the target growth rate that the Independent Payment Advisory Board (see nice explanation of the <a href="http://www.kff.org/medicare/upload/8150.pdf" target="_blank">IPAB</a>) could recommend payment cuts to physicians as part of its recommendations to reduce cost growth, but that is not mandated. <br />
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The main cuts are payment cuts to Medicare Advantage (MA) plans and cuts in the rate of increase to hospitals and a few other providers. It is possible that cuts in payment rates to MA plans will lead to some of those plans leaving the market. A recent paper by Austin Frakt, Steve Pizer and Roger Feldman finds large impacts of payment cuts on plan participation in MA (<a href="http://blog.academyhealth.org/the-effects-of-market-structure-and-payment-rate-on-the-entry-of-private-health-plans-into-the-medicare-market/" target="_blank">blog post </a>by Austin Frakt on the findings, with link to the paper). Medicare beneficiaries who lose their MA plans could simply enroll in traditional Medicare or in another MA plan (if available), so they won't lose coverage entirely or access to services. Studies have shown, however, that beneficiaries in MA plans prefer them to traditional Medicare, so they would suffer a loss from having to switch. In a separate paper, Frakt, Pizer, and Feldman estimate that what beneficiaries lose due to the exit of their MA plan is more than outweighed by the savings from reduced MA payments (<a href="http://theincidentaleconomist.com/medicare-advantage-cuts-once-more-with-feeling/" target="_blank">blog post </a>on this with link to paper). <br />
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There are two main questions regarding the impacts of reductions in the growth of hospital payments. Will hospitals reduce their supply of services to Medicare beneficiaries, and will they reduce the quality of care they provide? The first question is basically about the elasticity of supply -- how responsive are hospitals to changes in Medicare reimbursements? There is surprisingly little direct evidence (so far as I'm aware) on how hospitals' supply of services to Medicare beneficiaries responds to Medicare payment levels. There is a lot of research evidence on hospitals' response to the introduction of the Prospective Payment System (PPS) in 1983, which did have impacts on payment levels. The evidence there seems to be that the PPS payment changes did affect intensity of care, but not volume. More recent work on changes in Medicare reimbursements for different DRGs also finds no volume response (but upcoding: <a href="http://www.jstor.org/stable/4132763" target="_blank">"How Do Hospitals Respond to Price Changes?"Leemore S. Dafny, The American Economic Review , Vol. 95, No. 5, Dec., 2005, pp. 1525-1547</a>). Deductively, we know that Medicare beneficiaries make up a large part of hospital patients. Therefore it's unlikely that hospitals could replace them with more remunerative patients or activities, even if they want to. As a consequence, it does not appear likely that hospitals respond to Medicare payment cuts by seeing fewer Medicare patients. <br />
<br />
There is evidence, however, that hospitals do respond to Medicare payment reductions by reducing the intensity of care they provide to Medicare patients. David Cutler ("Empirical Evidence on Hospital Delivery under Prospective Payment," unpublished Paper, 1990) finds reductions in the intensity of treatment by hospitals in response to reimbursement reductions due to PPS. <a href="http://www.nber.org/papers/w16859" target="_blank">Vivian Wu and Yu-Chu Shen (2011)</a> find evidence that hospitals that experienced large cuts in Medicare payment rates had increased mortality rates for heart attack patients relative to hospitals that had smaller cuts. <br />
<br />
So it's possible that hospitals could respond to the reduced growth in their Medicare payment rates mandated by the ACA by cutting back on things that end up harming the quality of care. It is important to realize, however, that the <a href="http://www.politico.com/news/stories/0912/81828.html?hp=l10" target="_blank">ACA also introduces quality incentives into Medicare payments for hospitals</a>. These are based on clinical quality measures and patient surveys, and penalties for readmissions. As a consequence, it's not clear that slower increases in payments will end up leading to lower quality.<br />
<br />
So, it's far from clear that Mitt Romney's claim that the ACA's reductions in Medicare payments will harm Medicare beneficiaries is correct. There is some evidence that points in this direction, but my personal opinion is that it's unlikely.<br />
<br />
What about Barack Obama's claim that the Medicare payment cuts will help beneficiaries by keeping Medicare solvent? It extends the solvency of Medicare from 2016 to 2024. There has been some controversy about the impacts on Medicare spending and the Federal budget. <a href="http://mercatus.org/publication/fiscal-consequences-affordable-care-act" target="_blank">Charles Blahous</a> has claimed that extending the solvency of Medicare actually ends up increasing the government's spending and increases deficits. He assumes that benefits would be cut when the Medicare trust fund is exhausted (the law is that it can't spend more than comes in) and there would be no Medicare deficits. Therefore the Medicare savings from the ACA aren't really savings -- they wouldn't have been spent anyway.<br />
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<a href="http://thehealthcareblog.com/blog/2012/04/18/washington-stuck-fighting-wrong-health-care-battle/" target="_blank">Peter Orszag</a> says this isn't correct -- roughly speaking, the government would have continued to pay for Medicare absent the ACA, so that's not the right basis for comparison and there are true savings. <a href="http://www.forbes.com/sites/jeffreybrown/2012/04/18/making-sense-of-the-war-of-words-over-the-cost-of-obamacare/" target="_blank">Jeff Brown</a> does yeoman's work trying to sort out the controversy. These views lead to very different conclusions about the impacts of the ACA on Medicare and the federal deficit. My own view is that Peter Orszag is right. I seriously doubt if the government would carry out the benefit cuts that would be required.<br />
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Obama's claim about the solvency of Medicare is correct. The implications for spending and deficits are subject to some (very wonky!) debate, but I think the most likely scenario is one in which these are true savings.<br />
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<br />Anonymoushttp://www.blogger.com/profile/16508822019622004205noreply@blogger.com4tag:blogger.com,1999:blog-5090519798343256844.post-28777561128044507232012-09-25T15:47:00.000-04:002012-09-25T15:47:05.731-04:00We're Better Off with the ACAIn order to be completely aboveboard, I want to be clear that I support the ACA. In my opinion, we're better off with it than without it. Extending health insurance coverage to over 30 million Americans will be a major improvement for the US. That doesn't mean I think it's perfect or that I like every aspect of the ACA (I seriously doubt if anyone does), or that I don't seem problems or issues with some aspects of it. I do, and it's not how I would have done it (more on this in a post to follow). But I feel that it's a major accomplishment finally passing a health reform bill and substantially reducing the ranks of the uninsured. Imperfect as it is, that's progress, and I'll take it.Anonymoushttp://www.blogger.com/profile/16508822019622004205noreply@blogger.com10tag:blogger.com,1999:blog-5090519798343256844.post-67496533950319219302012-09-25T08:36:00.001-04:002012-09-25T08:36:05.808-04:00Have We Bent the Cost Curve? Not So Fast<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgIJwLo_GLUgIIDM0UAWr1QXjw2p5pv_p1lcSoRpR6JN-mEuH3dvEXkiPPGtkRwHGlQHbfmVZ5D6hkJxNcvZNQ0V1jAf08kEBFWQZgUesM5jyTGiO4CFRzpZCnqksjgS-pKAmQfqAA9ic8/s1600/hcci_2011_graphic.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="285" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgIJwLo_GLUgIIDM0UAWr1QXjw2p5pv_p1lcSoRpR6JN-mEuH3dvEXkiPPGtkRwHGlQHbfmVZ5D6hkJxNcvZNQ0V1jAf08kEBFWQZgUesM5jyTGiO4CFRzpZCnqksjgS-pKAmQfqAA9ic8/s320/hcci_2011_graphic.jpg" width="320" /></a></div>
The Health Care Cost Institute issued a new <a href="http://www.healthcostinstitute.org/2011report" target="_blank">report</a> today that shows the rate of growth of (private) health care
spending trending up again after a couple of years of slower growth.
This casts some doubt on contentions that the slower growth we've seen
is due to cost control efforts finally taking hold. Obviously it's too
soon to know for sure, but this reversal in trend is disturbing.<br />
<br />
What's
driving the increase? Prices are the answer, as previously. We don't
know what's behind the increase in prices, but there are a number of
possible candidates, including increased consolidation and exercise of
market power by providers, overall price increases in the economy, and
the ACA 80/20 rule. Provider consolidation has been increasing, and we know that this leads to substantially higher prices. The 80/20 rule specifies that health insurers can allocate no more than 20% of their total expenses to administration; the rest has to go to medical care for beneficiaries. Obviously the intent is to moderate administrative expenses, but this regulation can be complied with either by controlling administrative spending or increasing spending on medical care. It's possible that an unintended consequence of this rule has been to drive up health care spending, although I need to be clear that this is just speculation at this point. Some careful research is necessary in order to
determine what the major factors are driving these price increases.<br />
<br />
Another
important finding in this report is that spending on children's health
care (age 18 and under) rose faster than for any other age group. This
continues a trend that was discovered in the 2010 HCCI report. This
indicates that this is not simply a one time phenomenon, but rather an
ongoing trend. Obviously this is cause for concern and we need to dig in to determine what's behind this. Anonymoushttp://www.blogger.com/profile/16508822019622004205noreply@blogger.com10tag:blogger.com,1999:blog-5090519798343256844.post-9516089817477128352012-09-19T23:21:00.001-04:002012-09-19T23:21:51.523-04:00Everything You Need to Know About a Doctor Shortage, Medical School Debt, and Physician Payment in a Few Easy NumbersThere has been a lot of discussion recently about an impending doctor shortage, the large amounts of debt medical students are saddled with, and whether physician reimbursements (Medicare specifically) are sufficiently high. These issues all basically revolve around whether medicine remains an attractive occupation. While it's certainly possible to subject this question to extensive empirical analysis, a few simple numbers tell the story.<br />
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First, more than twice as many people apply to medical school as are admitted. In 2011, 43,919 people applied to US medical schools, and 19,230 were accepted and matriculated -- a ratio of nearly 2.3 applicants for every person admitted (who subsequently attended). This ratio has varied over time, but the long run average is greater than two. Don't just believe me -- the Association of American Medical Colleges -- the medical school trade association, publishes these <a href="https://www.aamc.org/download/153708/data/charts1982to2012.pdf" target="_blank">statistics</a>. <br />
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The fact that so many people want to become physicians (and so few do) over a long period of time is prima facie evidence that medicine is an attractive occupation. If medical school debt is so crushing, or Medicare physician reimbursements so penurious, then why do so many people desperately try to get admitted to US medical schools? <br />
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Second, physicians from other countries want to come to the US, not the other way around. Currently approximately <a href="http://www.ama-assn.org/ama1/pub/upload/mm/18/img-workforce-paper.pdf" target="_blank">26% of physicians practicing in the US were trained in other countries</a>. Some of those people of course are US citizens, but the majority are (originally) foreign nationals. There is very little flow in the other direction.<br />
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Clearly medicine remains a very attractive occupation. That's not to say that we couldn't face problems when the Accountable Care Act extends health insurance coverage to over 30 million Americans, thereby expanding the demand for medical services. But any such shortage (if it occurs) will largely be due to restrictions on entry into the profession, not because medicine has become financially unattractive.<br />
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<br />Anonymoushttp://www.blogger.com/profile/16508822019622004205noreply@blogger.com43tag:blogger.com,1999:blog-5090519798343256844.post-1509827121747304662012-09-19T11:28:00.002-04:002012-09-19T11:28:27.420-04:00Video Interviews on Health Care Reform from Aspen<a href="http://www.genconnect.com/" target="_blank">GenConnect<span id="goog_1348185227"></span><span id="goog_1348185228"></span></a> just posted a couple of <a href="http://www.genconnect.com/health/health-care-reform-what-it-means-for-the-economy-video/" target="_blank">brief video interviews</a> they did with me in Aspen, Colorado this summer. One is on health care reform, the other is on information in health care markets. Take a look!Anonymoushttp://www.blogger.com/profile/16508822019622004205noreply@blogger.com11tag:blogger.com,1999:blog-5090519798343256844.post-56270164585429906172012-09-09T15:38:00.000-04:002012-09-09T15:39:40.003-04:00Why Are There No Economists in Heaven?Because there's no scarcity! Cute. <a href="http://t.co/Rp37L3zR" target="_blank">Column by Jessica Irvine</a> in the Sydney Morning Herald. If you like this, she has a collection of her columns in <a href="http://www.amazon.com/Zombies-Bananas-Why-There-Econo/dp/1742379974/ref=sr_1_1?s=books&ie=UTF8&qid=1347219320&sr=1-1&keywords=zombies+bananas" target="_blank">book form</a>.Anonymoushttp://www.blogger.com/profile/16508822019622004205noreply@blogger.com29tag:blogger.com,1999:blog-5090519798343256844.post-17117753456352149522012-09-07T16:47:00.003-04:002012-09-07T16:47:36.678-04:00"Obama" Talks Yiddish!OK, <a href="http://www.youtube.com/watch?v=bf_YDwdDucU" target="_blank">this video</a> has nothing to do with economics, health policy, or even compassion, but I find it just too funny not to post. It's hilarious if you talk Yiddish, but (I think) pretty darn funny even if you don't. The guy has Obama's mannerisms down pat. Anonymoushttp://www.blogger.com/profile/16508822019622004205noreply@blogger.com31tag:blogger.com,1999:blog-5090519798343256844.post-36614910581678977362012-09-07T11:51:00.002-04:002012-09-07T16:19:38.014-04:00The Health Care Industry Is Really Messed UpThe Institute of Medicine just issued a new report entitled <a href="http://www.iom.edu/Reports/2012/Best-Care-at-Lower-Cost-The-Path-to-Continuously-Learning-Health-Care-in-America.aspx" target="_blank">"<span style="font-size: small;">Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.</span>"</a> The conclusions of the report are nicely summarized in this <a href="http://www.iom.edu/Reports/2012/Best-Care-at-Lower-Cost-The-Path-to-Continuously-Learning-Health-Care-in-America/Infographic.aspx" target="_blank">graphic</a>. In short, what they say is that the health care industry should simply do what every other industry in America does, and has been doing, for years -- emphasize customer service, provide high quality, be efficient, be safe, have workers cooperate and communicate, and innovate in order to improve in all of these areas.<br />
<br />
Really? Shouldn't all of this be totally obvious? The fact that (apparently) it's necessary to point these things out epitomizes for me what's wrong with US health care. In what other industry would businesses be closed when customers most need them (how many pediatrician offices are open nights and weekends)? In what other industry would receptionists ask for payment before greeting you or asking any other questions about what you're there for? In what other industry would customers be kept waiting for long periods of time until it's convenient for the business to serve them? What other industries actively resist the adoption of technologies that would improve the quality of the product and reduce costs (can you say health information technology)? How many customers would a bank, McDonald's, even an airline, have if they behaved this way?<br />
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The health care industry is inefficient and very reified. There are many causes behind this problem, but to my mind one of the key ones is lack of competition. Doctors, hospitals, etc. aren't efficient, and don't serve customers well because they don't have to. The reason for that is there aren't enough rivals competing aggressively enough to force them to innovate.<br />
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Health care providers have been given a free rein for many years. Perhaps the understanding (or hope) was that they'd provide high quality care for middle and upper income folks and charity care for low income people. If so, neither of those has happened to the extent it should if we are to tolerate the inefficiency, high costs, and low quality in the system. It's time for a change. More on that in future posts. Anonymoushttp://www.blogger.com/profile/16508822019622004205noreply@blogger.com103