Cartoon – Following the Invisible Hand
Tag Archives: Free Market Healthcare
Is M&A the Cure for a Failing Health Care System?
https://hbr.org/2017/12/is-ma-the-cure-for-a-failing-health-care-system
The U.S. health care system is begging for disruption. It costs way too much ($3.3 trillion last year) and delivers too little value. Hundreds of millions of Germans, French, English, Scandinavians, Dutch, Danish, Swiss, Canadians, New Zealanders, and Australians get comparable or better health services for half of what we pay. For most Americans, care is not only expensive but is also fragmented, inconvenient, and physically inaccessible, especially to the sickest and frailest among us.
It should come as no surprise, then, that when titans of our private, for-profit health care sector — like Aetna, CVS, UnitedHealth Group (UHG), and DaVita — strike out in new directions, stakeholders react with fascination and excitement. Could this be it? Is free-market magic finally bringing Amazon-style convenience, quality, and efficiency to health care? Are old-guard institutions, like hospitals and nursing homes, on the verge of extinction?
The answer, frustratingly, is that it depends. It depends above all on the results. To be the change that many desire, these new mergers and acquisitions, and the others that will likely follow, must produce a higher-quality product for consumers (and satisfy physicians and other health professionals) at an affordable price. The details are crucial, and the details in health care — as our political leaders have recently learned — are complicated.
Even a high level look at two apparently similar deals suggests the importance of getting under the hoods of these arrangements. Both CVS’s planned $69 billion acquisition of Aetna and UnitedHealth’s $4.9 billion deal to buy DaVita Medical Group, bring together a very large national insurer and a large provider of health care services. Combining an insurance function with a delivery system has ample precedent in health care. Some of the nation’s most innovative, high-performing non-profit health care organizations use this formula. These include the Kaiser Health Plans, Intermountain Healthcare in Utah and Idaho, the Geisinger System in Pennsylvania, the Henry Ford Health System in Detroit, and HealthPartners in Minnesota and Wisconsin, among others.
The reason this formula works is that when care-delivery systems also act as insurers, they assume financial responsibility for the care they provide. This tends to focus doctors, nurses, and other health professionals on the value of what they do — finding the most cost-effective approach to managing their patients’ problems. The result can be a culture of economy and quality that is very hard to replicate in the prevailing fee-for-service environment, where health professionals get rewarded for the volume rather than the value of services.
So the big question is whether these bold new combinations of insurer and provider can generate promising partnerships similar to a Kaiser or an Intermountain, or find some other equally powerful formula for disruption. The answer is far from certain, and the uncertainties differ for the two mergers.
In the CVS-Aetna case, the care provider, a pharmaceutical retailer and pharmaceutical benefit manager, provides a very limited set of health services: drugs, drug purchasing, and selected, basic, routinized primary care at more than 1,100 local Minute Clinics located in communities around the United States. To become a Geisinger or an Intermountain equivalent, Aetna-CVS would have to acquire — or develop — seamless relationships with legions of primary care and specialty physicians and hospitals. It would have to turn its stores into medical clinics, with exam rooms, diagnostic laboratories, and x-ray suites. And it would have to install and link electronic health records with other providers in its communities. Having done all this, CVS would have to excel at the very challenging task of managing physicians and other health professionals — something that daily confounds even the most experienced, long-time, care-delivery systems. The challenge would be unprecedented, the expense considerable, and the outcome uncertain.
The CVS-Aetna partnership seems likely, instead, to set off in a very different, and intriguing, direction: offering an augmented suite of preventive and population health services for high-cost chronically-ill patients through its convenient, community-based outlets. CVS staff will serve as local case managers and coordinators for patients who might otherwise skip needed preventive services, have trouble getting to their primary care physicians’ offices, or just need help taking their medicines. The hope is that this will reduce patients’ use of more expensive emergency, hospital, and specialty services, thereby reducing Aetna’s bills and making its product more competitive. Aetna would incent its clients to use CVS services by exempting these from the normal deductibles and copays that most insurers charge, thus incidentally, increasing CVS’s business more generally. This strategy could attract customers to both CVS and Aetna, add health care value, and even drive up profits.
But uncertainties remain. In addition to those I’ve mentioned, one of the biggest challenges will be coordinating with traditional care providers, both primary care and specialists. Seamless teamwork is critical to effective care of complex, high-cost patients. And by adding another player to our already-fragmented health care system, the CVS-Aetna project could actually undermine coordination of services. And while better care for complex patients is clearly part of the solution to our cost and quality problems, it may not be the systemic disruption that some are hoping for.
The UnitedHealth-DaVita deal, in contrast, seems more likely at first glance to accomplish the insurer-provider partnership that has characterized Kaiser-style organizations in the past. The DaVita Medical group employs 2,000 primary care and specialist physicians in nearly 300 medical clinics, 35 urgent-care centers, and six outpatient surgery centers in six states. Among the group’s divisions is the formerly independent HealthCare Partners, which, as this Commonwealth Fund case study makes clear, has a long history of accepting and managing financial risk, using advanced information systems, and promoting quality-improvement programs.
That said, no one should underestimate the challenge of growing the UnitedHealth acquisition of dispersed physician groups into a national system capable of disrupting our floundering health system. Health care is a very local affair, and the organizations providing it tend to be creatures of their localities and histories. It can take generations for a provider-insurer partnership to develop a culture of trust, collaboration, and value orientation that has made existing examples of these combinations so uniquely effective. If the new entity seeks to grow, it will find that recruiting and training physicians who can leave the fee-for-service mentality behind is a challenge, as is finding leadership that can gain and keep health professionals’ trust. Kaiser has failed in several attempts to spread to new locations. And though UnitedHealth’s Optum division, which will run the partnership, has some limited experience managing selected specialty health services, making this new enterprise work could prove daunting.
Even if the Aetna-CVS and UnitedHealth-DaVita ventures contain the seeds of transformative health system change, it will take time for those seeds to germinate. But Wall Street is not a patient audience. The involved companies will face short-term pressure to prove the profitability of the new arrangements. From this standpoint, it does not bode well that DaVita was anxious to sell its medical groups because they were not performing financially.
The excitement about these two bold new health care arrangements says as much about the desperation with our current health care systems as it does about the promise of the mergers themselves. They may have compelling short-term business value to shareholders — though that, too, remains to be proven. As fundamental health care disrupters, however, they face challenging and uncertain futures.
There’s No ‘Free Market’ Solution to Health Care
http://otherwords.org/theres-no-free-market-solution-to-health-care/
A fully privatized system can never adequately provision the nation.
The Republicans have big plans for health care in this country: to eliminate coverage for millions of Americans while delivering a big tax cut to the rich.
As someone who stands to benefit from that tax cut, let me just say: I don’t need it, and I don’t want it. No tax cut is worth excluding millions of Americans from the health services they need.
Any new health care legislation should be focused on providing the best available health services for all Americans, not deliberately putting them out of reach. And yet, this is exactly what the twin monstrosities that came out of the House and Senate would have done.
According to the Congressional Budget Office, the House bill would’ve left 23 million Americans uncovered by 2026. The Senate version was only a shade better, leaving 22 million people out. Those bills were nonstarters with the public — the party was forced to pull them, along with any immediate plans to repeal the Affordable Care Act (aka Obamacare).
This Republican-majority Congress has shown their cards: They favor less coverage for workers and the elderly and lower taxes for the wealthy.
Republicans in both chambers claim they’re doing this to support “freedom” and “choice” for the American people. They say the “free market” is the only way to provide Americans with access to affordable health care. They claim deregulation will help drive down health costs.
Well, for starters, so-called “free markets” are unicorns — fanciful creatures with magical powers that don’t exist in the real world. All markets are designed; they don’t emerge spontaneously from nature. We form, structure, regulate, and enforce markets through policy and institutions which reflect private and public interests.
When it comes to health care, we’re talking about something closer to a “natural monopoly” like electricity, not an industry like autos or breakfast cereals. Everyone needs basic medical services on a regular basis, and we need to make sure the same quality is available to everyone — even in hard to reach or low-income areas.
This will always require some form of direct government funding of services, especially with respect to primary care. Failing to do so means we’re not serious about the goal of quality care for all Americans.
This doesn’t necessarily mean an entirely government-run system — there’s plenty of room for private medical practices and businesses to provide the spectrum of services we need. But it does mean some degree of public funding is essential.
A fully privatized system can never adequately provision the nation. Rural communities don’t have adequate medical facilities and staff. Underdeveloped urban communities suffer from the same lack of basic resources, and their residents often don’t have the ability or time to travel to other locations.
Republican leaders claim they want affordable access to quality health care for all Americans, but all of their proposals have focused on lowering taxes on businesses and the rich, regardless of the very real cost in terms of human life.
It’s a false choice, and the effects will be cruel.
A healthy nation is a prosperous nation. This is primarily a challenge of real resources and the distribution of those resources, not of money. Congress can and should authorize any necessary funding to achieve the stated public goal simply by appropriating the funds.
This includes designing a system that will ensure there are enough facilities, doctors, nurses, specialists, transportation systems, and all the other elements of quality care in close proximity to all who need it — at any level of need and ability to pay.
Members of the House and Senate were put there by the voters and have an obligation to fight for and protect all of their constituents, not just the ones wealthy enough to bankroll their campaigns.
Who’s driving health care law – a free market or insurance companies?
Does this make economic sense?
Republicans may be too timid or lack the votes to advance structural reform. And they may feel it necessary to prop up insurance companies struggling with the costs of insuring high-risk patients. That’s a fair calculation.
But are they ready to create a health care system that aids every group except the working poor? The wealthy will have their health care and their tax cuts. The middle classes will continue to enjoy expensive, generous insurance that’s indirectly funded through the tax code. And insurance companies will accept whatever assistance the government provides – from tax cuts to coverage penalty periods – to continue increasing their authority over the medical system.
That’s an arrangement that leaves out the very groups that are most desperate for health care reform: lower-income families and the working poor.
Why the ‘free market’ for drugs doesn’t work and what we can do about it
The United States faces a major problem with prescription drug prices. Even as the prices of most goods and services have barely budged in recent years, the cost of drugs has surged.
During the presidential campaign, both Hillary Clinton and Donald Trump cited the high cost of prescription drugs as an issue that needed to be addressed. Most recently, the president-elect took direct aim at the pharmaceutical industry, saying it’s “getting away with murder” and arguing “new bidding procedures” are necessary to lower drug prices.
Trump didn’t get into specifics about what that would mean, but the most often suggested way to lower drug prices has been to expand the ability of major government buyers, such as Medicare, to negotiate prices.
While such negotiations could result in lower prices, we believe, based on our experience as economists and public policy experts, an alternative using public utility pricing would work better and ensure the discovery and distribution of important new medications.
‘Medically necessary’
The recent drug price data are indeed frightening.
In 2015 spending on prescription drugs rose by 8.5 percent to US$309.5 billion, compared with a rise of just 1.1 percent for consumer goods and services. Spending for specialty drugs increased by an even heftier 15 percent, on average. Individual examples that made big headlines, such as Turing Pharmaceuticals raising the price of Daraprim (a lifesaving drug for people with weakened immune systems) from $13.50 to $750 a tablet, are even more extreme.
In a competitive market, prices of a product are forced down to their costs plus a fair profit. Drug companies, on the other hand, can get away with raising prices without losing customers because the demand for certain medications is insensitive to their cost. If a drug will save your life, you’ll probably pay whatever the cost, if you can.
The problem may soon get worse. Last May, Washington state’s Medicaid program was ordered to provide the hepatitis C drugs Sovaldi and Harvoni after a court ruled they were “medically necessary.” The Washington State Health Care Authority had previously provided Harvoni – which costs $94,500 for an eight-week course of treatment – and Sovaldi – $84,000 for 12 weeks – to only the sickest patients.
Since then, other participants in Medicaid and private insurance plans have filed similar suits. Some states, including Florida, Massachusetts and New York, have already altered their Medicaid programs to pay for such life-preserving expensive drugs.
If “medically necessary” rulings become more common, producers of these drugs will have no need to worry that higher prices will reduce sales. They will be able to charge whatever they want and increase revenue and profit without hurting unit sales because insurance providers will need to make such drugs available to their policy holders.
A proposed solution
So what can be done to fix the problem?
Allowing more government agencies to negotiate prices is one option. While this has lowered the prices paid by the Veterans Administration, it may not be the best way to go in a market like the one for many innovative new specialty drugs in which consumers have no good substitutes to choose from.
Economists have shown that negotiated outcomes are not always the most efficient ones. As an example, if the government were to push drug producers too hard in negotiations, the public could get a great deal on prices in the short term but that could end up discouraging the development and testing of new drugs, which would hurt everyone in the long run.
A better approach is to start with a public utilities method, which is frequently used when there is a natural monopoly in production, such as for water or power. In these cases, state and local governments typically allow a company to have a monopoly over the market but also establish regulatory commissions to determine “fair” prices. Such prices take into account current costs, the need for investment in production facilities and the need to earn a rate of return on capital invested.
A wrinkle with drug developers is that they can incur substantial costs in their quest for new medications, including dead-end ideas and extensive testing. A 2014 report put the cost to develop a new drug at $2.6 billion, while others put it at around half that.
Under our proposal, an independent federal panel consisting of scientists, medical professionals, public health experts and economists – perhaps working as part of the FDA approval process and called on when the price of a drug is above a specific threshold – would determine the maximum price a government buyer such as Medicare or Medicaid could pay for a new drug. It could also do the same for existing treatments – for example, it could have turned down Turing’s huge Daraprim price hike.
A key element of this idea is that the panel would develop methods to identify and set maximum prices for existing and prospective drugs that cure a serious illness, improve the quality of life, limit contagion or otherwise provide large benefits to society. These procedures would need to make sure that producers of these important new drugs are sufficiently rewarded for those costly efforts.
A defensible drug-pricing system
Tough negotiations can help lower how much the government has to pay for its purchases, yet they’re not always the optimal way to achieve intended long-term results. With drugs, we definitely need to lower prices but we also need to ensure drug companies can “win” as well to avoid compromising their ability to develop lifesaving medicines.
While economists generally oppose government intervention in a “free market,” the current situation cries out for change. It is time to establish a defensible system for pricing drugs, one that both protects the public from price-gouging and encourages the development of new drugs.
Mr. Trump, Here’s Some Health Policy Advice — From a Physician
http://www.medpagetoday.com/Blogs/KevinMD/57318?xid=fb_o_
Free-market healthcare won’t last long in modern society, says Saurabh Jha, MD
HENRY KOTULA 