Price Transparency: An Interactive Timeline

“Price transparency.” Search the term on google news and almost all of the hits deal with health care. In the less than four months since Steven Brill published his Time expose on hospital prices (which I commented on), health care price transparency has vaulted to the center of national health care debate.

Today, Mr. Brill is on Capitol Hill testifying at a Senate Finance Committee hearing on price transparency. Sounds like he had some pretty harsh words on Obamacare.

Given the growing momentum on the topic, I’ve thrown together an interactive timeline of key events that have happened in the last few weeks. (Really wish WordPress would allow me to embed flash.) Enjoy!

Sorry Steven Brill: These Aren’t the Costs You’re Looking For

Steven Brill made headlines last week when he published a 26,000-word, 11-page Time article on why health care costs are so high–the longest article by a single author in the history of Time magazine. It’s a fascinating read, one that’s filled with real life stories, making it both more engaging and palatable than, say, a 26,000-word economics thesis on the same topic. But for those who don’t want to wade through all 11 pages, here’s a summary of Mr. Brill’s argument:

  1. Health care costs are so high in the US because prices for health care are so high.
  2. Prices for health care are high because by law, we have allowed them to be high. A lack of universal price controls allows “nonprofit” hospitals, pharmaceutical companies, and device makers to charge ridiculous prices and reap in huge profits.
  3. His solutions:
    1. Tighten anti-trust laws so that hospitals can’t conglomerate and demand high prices from “helpless” insurance companies.
    2. Tax hospital profits at 75% and institute a tax surcharge on non-doctor hospital salaries that exceed $750,000.
    3. Outlaw the “chargemaster”, an internal price list that all hospitals keep which contain ridiculously high prices that seemingly have no basis, and are often only used as a starting point in negotiations.
    4. Institute medical malpractice reform to reduce defensive medicine (doctors prescribing too much for fear of being sued).

The article has already generated a multitude of responses, especially from the health care blogger community–ranging from ardent support (from “crooksandliars.com“) to scathing criticism (from Mitt Romney’s domestic policy director).

I’m certainly no health care expert, policy wonk, or Carnegie Mellon professor of economics. But given what I’ve heard through working with hospitals across the U.S. (many of whom pay us precisely because they’re worried they’ll go out of business in a few years), I thought I’d throw in my own two cents.

(I’ve tried to be as objective as possible and use data to support my assertions when I can. But given my job, it’s certainly possible that I’ve been slowly influenced to adopt an overly sympathetic view of hospitals…in which case I better watch myself.)

Real Stories, Real Hardships

First, I think the the most important thing to keep in mind as we engage in debate about the economics of the health care system, and whether the various root problems and solutions that Mr. Brill identifies are real, is that the seven lives Mr. Brill outlines in his article are very real. Emilia Gilbert, the 66-year-old school-bus driver who was put on a payment schedule of $20 a week for six years from one fall and ER trip. Alice D., who decided she can’t remarry because she can’t “risk the liability” of being stuck with over $170,000 in bills for her husband’s end-of-life cancer treatment. These seven stories represent the 48.6 million Americans who are uninsured (a number that will hopefully continue to drop as insurance expansion rolls out next year), people who are very much vulnerable to the excessive hospital prices that Mr. Brill outlines.

Brill’s Demonized Chargemaster is a Distraction

However, from a system perspective, I think the chargemaster that Mr. Brill repeatedly attacks is a distraction. The chargemaster is the internal list of prices that every hospital keeps for every procedure and supply item that the hospital uses. These are the prices that Mr. Brill incredulously highlights: $1200 for one hour of a nurse’s services; $1.50 for a single Tylenol tablet that you can buy a 100 of for $1.49 on Amazon.

They are indeed ridiculous, and often created without rhyme or reason. Thing is, they’re also rarely used:

  • The latest data (from 2009) shows that on average, 40.9% of hospital cases in the U.S. are paid for by Medicare. Medicare, which–as Mr. Brill describes–could give a rat’s *** (my words) about chargemaster prices and instead pays each hospital a set amount, about 90% of the actual costs of treating that patient (see graph below).
  • Another 17.2% are paid for by Medicaid, which vary on a state-by-state basis but are usually some percentage off of Medicare rates.
  • 30.5% are paid for by HMOs, PPOs, or other private insurance. According to Mr. Brill, these private payers negotiate rates that are 30-50% higher than Medicare rates (rather than negotiating downward from chargemaster rates).
payer to cost ratio

Here’s a handy graph showing how payments from Medicare, Medicaid, and commercial payers compare to the cost of treating a patient. Note that Medicare and Medicaid actually pay less than costs on average while commercial payers pay more–leading to the phenomenon of hospitals using profits from commercial payers to “cross subsidize” the costs of treating public payer patients. Source: Ginsburg PB. 2011. Reforming provider payment – The price side of the equation. N Engl J Med, 365:1268-1270.

  • Excluding workers comp and some other miscellaneous categories, this leaves “just” 4.9% that are true self-pay cases, where the uninsured is charged the full chargemaster price. HOWEVER, many hospitals offer payment subsidies, discount prices, or simply write off patients’ charges as uncollected “bad debt”. A 2008 analysis of actual payments received by hospitals in California showed that the median uninsured patient paid 1% less than Medicare rates and 28% less than commercial rates.

These numbers suggest that the individual stories Mr. Brill documents may be limited to a very small subset of the population. Indeed, the average self-pay payment rate rate was higher than the median (20% higher than Medicare and 14% less than commercial), indicating a rightward skew–a small number of uninsured patients are truly getting hit hard. However, the concern about these ridiculous prices, and the dangers that a subset of the uninsured face when they can’t get discounts, can be solved by a simple solution–one that doesn’t require outlawing the chargemaster as Mr. Brill recommends, which would arguably make hospital prices even less transparent (the “Treatment for Heart Attack: $100,000” bill, as Oren Cass posits). Rather, it’s a solution that Uwe Reinhardt suggested back in 2009: a national ceiling of 115% of Medicare rates for charges to the uninsured. Since hospitals are only collecting de facto payments of 1% less than Medicare rates from the median uninsured patient anyway, it’s not like it’s going to affect their bottom line. They would get to keep their (admittedly meaningless) chargemasters for negotiating purposes, patients could still see everything they’re being charged for (without having to pay the full amount), and those uninsured patients that are getting hit with true full prices today would be protected.

Are Hospitals Really That Profitable?

Apart from the chargemaster, Mr. Brill sees the primary culprit behind high health care costs as paradoxically profitable “nonprofit” hospitals that command high prices from “helpless” insurance companies and manipulate their “sympathetic nonprofit status” to reap in huge profits and dissuade lawmakers from doing anything about it. “That’s a 12.7% operating profit margin,” Mr. Brill writes of Stamford Hospital’s 2011 financials, “which would be the envy of shareholders of high-service business across other sectors of the economy.”

But is that really true? As of January 2013, the average operating margin of 6177 U.S. firms across most major sectors was 17.1%. The average for Medical Services was 10.1%–hardly enviable from a market perspective. In addition, as Mr. Brill himself notes, hospital inpatient care has an operating margin of only 2%. (Which does beg the question, why is hospital outpatient care so “wildly profitable”–and is this something that should be addressed? Perhaps more on this in a later post.)

I’m also somewhat dubious that the insurance companies Mr. Brill mentions are anything but helpless. Mr. Brill is right when he points out that hospital consolidation will increase their negotiating power against insurance companies. What he overlooks is the fact that insurance companies are consolidating too. Last July, WellPoint announced that it was buying Amerigroup. Six weeks later, Aetna announced it was buying Coventry. Which consolidation will “win out” on prices–hospitals or insurers–is unclear, but this 2011 study is enlightening: while consolidation of hospitals does appear to drive up prices, consolidation of insurers appears to have the opposite effect of driving down prices (by about 12% in the most consolidated markets), and that overall, “more concentrated health plan markets can counteract the price-increasing effects of concentrated hospital markets.”

On balance, excessively profitable hospitals may not be the major cause of excessive costs, as Mr. Brill believes. In fact, signs suggest that hospital profits are about to drop. Plans for the exchanges, which roll out next year, will likely pay hospitals lower than current commercial rates (10% lower, according to recent news from Texas; most providers fear more). Payment penalties and reforms from the Affordable Care Act, combined with movement by commercial payers toward paying for value, will only serve to further push down prices.

Barking Up the Wrong Tree

In 26,000 words, Steven Brill has painted a picture of soaring health care costs because profitable hospitals command high prices. Interestingly, Mr. Brill stops short of actually advocating for any type of price controls. The logical solutions–as Matthew Yglesias at Slate points out–would be to either (1) expand the price-setting Medicare program to cover the entire population, or (2) set health care prices nationally, as a number of European countries do. Aside from the fact that both solutions would be politically DOA, each one would either face substantial challenges or have unintended consequences.

However, given that full hospital prices only apply to less than 5% of cases, and that hospitals may not be as profitable as Mr. Brill suggests, trying to control hospital prices as a way to control health care costs may be barking up the wrong tree.

As Mitt Romney’s Domestic Policy Director points out (and as much as I hate to agree with Mitt’s anyone on anything), the true question may not be why health care prices are so high, but why the costs of providing that care are so high. As he writes:

“All of those enormous costs for treating a patient actually go to pay for things, not to line the pockets of scheming industrialists. But what? How much of a hospital’s expenditures are construction? Capital equipment? Doctors? Supplies? Management? Bureaucracy? And each of those things that it buys – an MRI machine, a pacemaker, a cancer injection – where does that money end up? How much of it goes to researchers? To the acquisition of start-ups that create new intellectual property? To TV advertisements? How much of a doctor’s income goes to the cost of her education? To her malpractice insurance?”

One more thing I would add: How much of the money we pour into health care is for services we don’t need? How much is going toward outcomes we don’t value? And most importantly, how can we get our health care system to start achieving ones that we do?

Doctor Knows Best? If Not, Who Does?

A few weeks ago, as I ate lunch with a few of my coworkers, we came upon the topic of our plans for the future.

“I’m planning on studying medicine,” I announce. That’s always been the plan coming in.

“Even after working here?” my coworker asked, alluding to the…less than flattering view of doctors one can get working in the hospital research industry.

And it’s true: sometimes it seems like doctors are the biggest obstacle to transforming the way we deliver care in this country. They fail to follow care standards. They screw up efforts to reduce supply costs. And as made famous by the landmark Dartmouth Atlas study, physicians’ discretionary decisions are a primary driver of the (presumably) unwarranted health care spending that drives up cost.

In response, the government has taken it upon itself to drive health care decision-making toward higher quality, more rational care. It’s enacted penalties for hospitals with excessive readmissions, designed a value-based purchasing program tying hospital payments to a growing number of quality indicators, and outlined 33 measures for health systems hoping hoping to achieve shared savings by forming Accountable Care Organizations.

It’s not hard to imagine these incentives filtering down to the ultimate decision-maker: the doctor. Indeed, last month the New York Times reported that the country’s largest public health care system, Health and Hospital Corporation, will begin tying their doctors’ raises to performance on quality measures. In fact, Medicare itself has even made plans to apply quality performance measures directly to physicians starting 2015, although it hasn’t quite figured out how it will do that yet.

Given the push to hold physicians more accountable for “doing the right thing”, a 2010 article from Dr. Jerome Groopman struck me as incredibly relevant. Dr. Groopman is a oncologist and staff writer for The New Yorker who has written about the intersection of medicine and behavioral economics. In this article, written when Obamacare was still making its way through a bitterly divided Congress, Dr. Groopman lays out two opposing views of how our government should influence doctors’ decisions:

  1. The first, based on concepts in behavioral economics (and supported by Dr. Groopman), argues for creating structures that “nudge” physicians toward making the best clinical decision without forcing them into making one.
  2. The second, supported by then OMB director Peter Orszag, believes that to truly change behavior, we need to combine the dissemination of clinical information with “aggressive promulgation of standards and changes in financial and other incentives.”

Three years later, it appears the second viewpoint has won out.

For those of us working in an industry geared toward helping hospitals respond to these incentives, it can be easy to see doctors as the obstacle to implementing widespread adherence to clinical protocols and moving the dial on these performance measures. However, sometimes I wonder if we need to slow down and think about whether it’s really as simple as getting doctors to do the right thing.

Last week, a new study reported (disconcertingly) that excessive hospital readmission rates–one of the measures CMS is already penalizing providers for–isn’t related to mortality at all. It’s not the only study that has questioned whether readmission rates are a good proxy for “good care”, and it makes you wonder how many of the other performance measures have conflicting evidence.

In theory, if we gathered enough clinical evidence and limited ourselves only to measures that have been shown to be strongly correlated with quality outcomes (assuming we can define them first), we could create care standards that we could then promulgate to physicians for adherence. But even for practices for which the clinical evidence is unequivocal on, it still might not be in our best interests to get all doctors to adhere to them. One emerging criticism of randomized controlled trials–the “gold standard” of clinical trials–is that they are based on highly controlled situations with 100% adherence to protocols and a subject sample from which non-ideal participants have been excluded. Real world medicine is rarely as clean. Yet when a health system creates clinical protocols for its physicians, or when CMS lays out performance measures for physicians across the country, we are essentially creating default options without considering the individual circumstances of each case. “Setting the default option that doctors will present to patients requires us to make value judgments,” writes Dr. Groopman. Given the uncertainly of health care, are we really ready to do that for huge swaths of the population?

The answer, I think, should certainly not be a return to the hands-off approach of fee-for-service. There’s enough evidence out there to show that significant care variation is unwarranted, and there are enough success stories of hospitals and health systems that have partnered with their doctors and achieved remarkable improvements in outcomes at reduced costs. But it should serve as a reminder to us that even if it sometimes feel like our health care problems would be solved if only doctors would consistently do the right thing, often times what “the right thing” is isn’t so clear.

Then again, maybe in the future, we’ll just have supercomputers like Watson tell us what to do.

(My List of) 2013 Health Care Trends to Watch

Welcome to 2013! Apologies for the long hiatus since last October; I got hit with crunch time at work, then the flu, and then went on a week-long road trip to the south.

Being super nerdy at the CDC.

Being super nerdy at the CDC.

However, with the project finished, the flu defeated, and myself filled with more fatty fried foods than I’d care to think about, I thought it would be appropriate to kick off 2013 with an overview of the biggest health care trends to watch for in the upcoming year. I know, every health news outlet is doing it–but for those who don’t subscribe to Modern Healthcare and Kaiser Health News, here is what I hope to be a pithy, reader-friendly list. Enjoy!

  1. The impending (?) roll out of health insurance exchanges. Mandated by the Affordable Care Act, state-wide exchanges are slated to begin enrollment this October. What is a health insurance exchange? Imagine Amazon.com, except for health plans, where individuals without health insurance (or whose companies drop their health insurance because the penalties aren’t high enough) can go to buy their own insurance. Want a living example? Visit the Massachusetts Health Connector site, which has been up and running since 2006. The Department of Health and Human Services conditionally approved 8 more states last Thursday, bringing the total to 19 plus DC. Key questions include how many employers will actually leave their employees to the exchanges (one survey suggests, none); how insurers will react to capture this new market segment; and perhaps most importantly, whether the fed can actually roll out well-functioning exchanges in the 25+ states that have opted for federal exchanges by the October deadline.
  2. More posturing and debate about Medicaid expansion. The ACA had initially required all states to expand eligibility of Medicaid to all adults under 65 at or below 133% of the federal poverty line (with the fed covering 90-100% of the cost). Thanks to a surprise Supreme Court ruling, that expansion is now optional. Check out this cool map I’m shameless posting from my company showing where the states stand on the expansion decision. More news stories come out every day, with Idaho’s governor rejecting expansion this Monday, New Mexico accepting expansion today, and Florida’s governor brandishing exorbitant costs of expansion–even when his own experts tell him the numbers are wrong.
  3. Possible Medicare overhauls? The fiscal cliff fiasco and the last-minute deal in Congress didn’t save us from disaster–it just created Fiscal Cliff 2.0 in February and March, during which automatic 2% spending cuts are scheduled to hit again unless Congress can strike another deal. The fact that we’ve already played the tax-increase card has some analysts predicting the end of Medicare and other entitlements, which will have to be cut to escape our deficit crisis. Not so, say others, who think that Medicare and Social Security are still too sacred to be touched. In any case, Pres. Obama has expressed a willingness to consider changes to Medicare to address its unsustainable cost to the government, and may even try to use it to find common ground with conservatives.
  4. Continued transition to “value-based payment”. For those unfamiliar with health care jargon, that basically means shifting from a world in which providers are paid for volume of services to one in which they are paid for based on the quality of care they provide (you think we’d have figured that out sooner, go figure). Much of this shift is being accelerated by various ACA programs. CMS kicked off its Value-Based Payment program last October (here’s a great overview by Kaiser Health News), which is already rewarding and penalizing hospitals (apparently those here in DC are doing the worst), and beginning this October will be adding patient mortality to the mix of incentive measures. CMS is also accelerating its Accountable Care Organization program, in which groups of providers can band together into systems that can be awarded savings for providing cost-effective, high-quality care. Starting with only 32 “pioneer” ACOs in December 2011, recent research indicates 328 ACOs as of November 2012, with CMS expected to announce the 2013 participants soon just announcing 106 new ACOs today (updated Jan. 10).
  5. …And due to the surging interest in ACOs and population health management, hospitals are responding with continued consolidation, building of physician networks, and partnering with post-acute and other providers. Scale is once again the name of the game. Expect a slew of anti-trust cases to follow.
  6. Finally, often under-reported by the mainstream media, expect further developments in health IT. Continuing growth of electronic health records, app-enabled consumer tech, and cybersecurity breaches, oh my! Take a look at some of the biggest trends here.