Healthcare Triage: Hospital Competition Can Impact Your Health

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It turns out, hospital and health system consolidations can result in worse outcomes for patients. These mergers reduce competition, and it turns out that hospitals compete more often on quality than they do on prices. The result is that quality suffers in markets with less competition.



A review of health care costs: deck chairs and the Titanic, part 2

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This article is Part II of a two-part series on the cost of health care and its component parts. Part I explores the recent growth of health care costs in the United States as well as the utilization inputs in the cost equation. Part II breaks down the pricing component of cost, determined by market leverage and the cost of delivering services. 

The Titanic

This brings us to the second category of costs: the Titanic. Or, to use our equation here of THC = U x P, the Titanic I’m talking about is the pricing component of cost.

In other words, health care leaders should do everything they can to make sure that utilization is the right care at the right time in the right setting. This makes a meaningful difference in the quality of our health care system.

But, if we focus on health care utilization alone, the health care system is still going to sink under the weight of costs. Our efforts will still be deck chairs on the Titanic.

To keep our ship afloat, we have to address the pricing input of our cost equation.

Like our cost equation above, pricing also has a simple equation of two inputs that determine price. According to a seminal study out of Massachusetts, which has been reaffirmed in additional studies (and by the experience of many network relations vice presidents across America’s health plans), this equation is straightforward.

Pricing is determined by a combination of market leverage (ML) and service delivery costs (SDC), where market leverage is 75 percent of the pricing structure and the cost of delivering the service is 25 percent.

This is true for either the plan or the provider, depending on where market leverage exists. This equation looks like this: P = ML(.75) + SDC(.25).

If we put this together, the math equation would look like this: THC = U x (ML(.75) + SDC(.25)).

Here’s how the study put it:

Price variations are correlated to market leverage as measured by the relative market position of the hospital or provider group compared with other hospitals or provider groups within a geographic region or within a group of academic medical centers. 

While addressing the utilization component of the cost-growth problem is essential, any successful reform initiative must take into account the significant role of unit price in driving costs. Bending the cost curve will require tackling the growth in price and the market dynamics that perpetuate price inflation and lead to irrational price disparities.

But here is what the numbers say: between 2004 and 2017, adjusting for age and sex factors, 68 percent of the growth in overall national health care expenditures came from increases in medical prices. Only 32 percent of growth came from utilization of services.

In other words, pricing is more than twice as important as utilization in the growth of health care costs – costs that are increasing more rapidly than ever.



Put graphically, while we have two inputs into total health care costs or expenditures, it’s incorrect to think of them as weighted equally, as demonstrated in image 1 above. It’s more accurate to think of these two pieces weighted as shown in image 2. And, if we are honest about the role of market leverage in health care pricing, market leverage alone is more than half of the overall problem in health care costs – more than all of the service delivery costs and utilization combined.


Keeping the Titanic afloat

Let’s restate the challenge we face here in our trans-Atlantic metaphor. Cost is the biggest problem in health care today. Those costs are made up by pricing and utilization, where pricing is more than twice as impactful in cost growth as utilization, and where market leverage is three times more impactful to pricing than are service delivery costs.

In order to keep our health care system afloat, we must address costs. And to address costs, we must address pricing.  And to address pricing, we must address market leverage.

If we move every deck chair around, but fail to address the cost consequences of market leverage, our ship will sink.

In our capitalist economy, we view consolidated market leverage as a market failure. It’s why we have antitrust statutes and an active regulatory regime to manage and push back against consolidation. Where the market failure is in the area of a public good, the American political system has often regulated those consolidated markets like public utilities or quasi-public entities.

Think of energy and Enron, of railroads and BNSF, of telephones and Ma Bell.

As health care nears 20 percent of the US economy, and where even urban states like California suffer from a “staggering” concentration of market leverage among health care providers, the lesson for health care policymakers and senior health care executives is this: If you want to get your hands around cost, you’re going to have to address market leverage to do that. Everything else is just deck chairs.



Why the U.S. Spends So Much More Than Other Nations on Health Care

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The United States spends almost twice as much on health care, as a percentage of its economy, as other advanced industrialized countries — totaling $3.3 trillion, or 17.9 percent of gross domestic product in 2016.

But a few decades ago American health care spending was much closer to that of peer nations.

What happened?

A large part of the answer can be found in the title of a 2003 paper in Health Affairs by the Princeton University health economist Uwe Reinhardt: “It’s the prices, stupid.

The study, also written by Gerard Anderson, Peter Hussey and Varduhi Petrosyan, found that people in the United States typically use about the same amount of health care as people in other wealthy countries do, but pay a lot more for it.

Ashish Jha, a physician with the Harvard T.H. Chan School of Public Health and the director of the Harvard Global Health Institute, studies how health systems from various countries compare in terms of prices and health care use. “What was true in 2003 remains so today,” he said. “The U.S. just isn’t that different from other developed countries in how much health care we use. It is very different in how much we pay for it.”

A recent study in JAMA by scholars from the Institute for Health Metrics and Evaluation in Seattle and the U.C.L.A. David Geffen School of Medicine also points to prices as a likely culprit. Their study spanned 1996 to 2013 and analyzed U.S. personal health spending by the size of the population; its age; and the amount of disease present in it.

They also examined how much health care we use in terms of such things as doctor visits, days in the hospital and prescriptions. They looked at what happens during those visits and hospital stays (called care intensity), combined with the price of that care.

The researchers looked at the breakdown for 155 different health conditions separately. Since their data included only personal health care spending, it did not account for spending in the health sector not directly attributed to care of patients, like hospital construction and administrative costs connected to running Medicaid and Medicaid.

Over all, the researchers found that American personal health spending grew by about $930 billion between 1996 and 2013, from $1.2 trillion to $2.1 trillion (amounts adjusted for inflation). This was a huge increase, far outpacing overall economic growth. The health sector grew at a 4 percent annual rate, while the overall economy grew at a 2.4 percent rate.

You’d expect some growth in health care spending over this span from the increase in population size and the aging of the population. But that explains less than half of the spending growth. After accounting for those kinds of demographic factors, which we can do very little about, health spending still grew by about $574 billion from 1996 to 2013.

Did the increasing sickness in the American population explain much of the rest of the growth in spending? Nope. Measured by how much we spend, we’ve actually gotten a bit healthier. Change in health status was associated with a decrease in health spending — 2.4 percent — not an increase. A great deal of this decrease can be attributed to factors related to cardiovascular diseases, which were associated with about a 20 percent reduction in spending.

This could be a result of greater use of statins for cholesterol or reduced smoking rates, though the study didn’t point to specific causes. On the other hand, increases in diabetes and low back and neck pain were associated with spending growth, but not enough to offset the decrease from cardiovascular and other diseases.

Did we spend more time in the hospital? No, though we did have more doctor visits and used more prescription drugs. These tend to be less costly than hospital stays, so, on balance, changes in health care use were associated with a minor reduction (2.5 percent) in health care spending.

That leaves what happens during health care visits and hospital stays (care intensity) and the price of those services and procedures.

Did we do more for patients in each health visit or inpatient stay? Did we charge more? The JAMA study found that, together, these accounted for 63 percent of the increase in spending from 1996 to 2013. In other words, most of the explanation for American health spending growth — and why it has pulled away from health spending in other countries — is that more is done for patients during hospital stays and doctor visits, they’re charged more per service, or both.

Though the JAMA study could not separate care intensity and price, other research blames prices more. For example, one study found that the spending growth for treating patients between 2003 and 2007 is almost entirely because of a growth in prices, with little contribution from growth in the quantity of treatment services provided. Another study found that U.S. hospital prices are 60 percent higher than those in Europe. Other studiesalso point to prices as a major factor in American health care spending growth.

There are ways to combat high health care prices. One is an all-payer system, like that seen in Maryland. This regulates prices so that all insurers and public programs pay the same amount. A single-payer system could also regulate prices. If attempted nationally, or even in a state, either of these would be met with resistance from all those who directly benefit from high prices, including physicians, hospitals, pharmaceutical companies — and pretty much every other provider of health care in the United States.

Higher prices aren’t all bad for consumers. They probably lead to some increased innovation, which confers benefits to patients globally. Though it’s reasonable to push back on high health care prices, there may be a limit to how far we should.


Health Care Price Growth Plummets To Lowest Rate In Almost Two Years

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Fueled by health policy uncertainty and structural health sector changes, health care price growth in August rose by only 1.2% compared to a year earlier. This is the lowest health price growth rate recorded in almost 2 years, and just slightly above the all-time low, according to Altarum’s latest Health Sector Economic Indicators Briefs. Contributing to overall slow price growth is a historically low Medical Consumer Price Index growth rate, a possible signal of relief for health care consumers with substantial out-of-pocket expenditures.

Despite an upward revision to recent estimates, health spending growth in August 2017 was only a modest 4.3% higher than a year earlier. Per Charles Roehrig, founding director of Altarum’s Center for Sustainable Health Spending, this moderation in spending growth is in response to a leveling-off in insurance coverage.

Health care job growth also remained modest, with 22,500 new jobs added in September 2017, slightly less than the 2017 average of 25,000. “Slower growth in health care utilization is reflected in slower growth in health jobs, particularly in the hospital sector,” said Roehrig. “This relatively good news should be tempered by a serious look at whether even this moderate growth is sustainable in the longer term.”

Health Care Spending

In August, the health share of gross domestic project (GDP) fell to 18.0%, but spending at an annual rate was 4.3% higher than August 2016, exceeding $3.5 trillion. Spending growth in August 2017 increased in all major categories, led by home health care at 6.5%. Hospital spending continues to grow slowly, at a 2.3% rate.

Health Care Employment

Hospitals added 4,500 jobs and ambulatory care settings added an above-average 24,700 jobs in August, but these gains were offset by the loss of 6,700 jobs in nursing and residential care. Slow hospital job growth in 2017 is a primary force behind the health sector growing at about three-quarters the pace of 2015 and 2016.

Health Care Prices

The 12-month moving average of the Health Care Price Index (HCPI) fell to 1.8% growth after being at 1.9% for 6 straight months, dousing any expectations of a return to a 2.0% growth rate range in the near term. Year-over-year hospital price growth fell to from 1.5% to 1.3%, and physician and clinical services price growth fell one-tenth to 0.5%. Annual drug price growth fell to a 2.7% rate, its lowest reading since growing by 2.4% in December 2015.

Health Sector Trend Report, January 2017

Click to access Altarum%20RWJF%20Trend%20Report%20January%202017.pdf

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These reports, with funding from the Robert Wood Johnson Foundation, provide a monthly summary of key trends in health care spending, prices, utilization, and employment.

They are related to, but distinct from, the Center for Sustainable Health Spending Health Sector Economic Indicators.

The trend reports make direct use of the Quarterly Services Survey (QSS), the timeliest source of detailed, survey-based spending information for health care services, which account for more than 70% of national health spending.

Each quarter, when new QSS data are released (March, June, September, and December), we will publish an expanded version of this report with a more detailed analysis of health care services trends.

The regular monthly reports will supplement the most recent full quarterly analysis with new data on other aspects of health spending, health care prices and utilization, employment and early indications of the trends for the next quarter.

This report provides a monthly summary of key trends in U.S. health care spending, prices, utilization, and employment. The reports build on Altarum’s Health Sector Economic Indicators SM briefs (HSEI) and make direct use of the U.S. Census Bureau’s Quarterly Services Survey (QSS). When new QSS data are released (March, June, September, December), an expanded version of this report is published. Interim reports highlight noteworthy health sector trends and early indications of results for the next quarter. In this January 2017 report, spending estimates are available through November 2016, while prices and labor are available through December 2016.

Health Sector Economic Indicators – Price Brief

Click to access CSHS-Price-Brief_July_2016.pdf

Health care prices in May 2016 were 1.5% higher than in May 2015, the third consecutive month at this rate. The May 2016 12­month moving average was 1.2% for the fourth straight month. Year-over-year hospital price growth rose modestly to 1.0% from 0.8% in April. Physician and clinical services prices rose only 0.3% in May, down from 0.6% growth in April. Drug price growth fell to 3.3% from 4.0% in April.