Tag: hospitals

Obama’s Hospital Admission

My latest, at National Review Online:

Buried deep within President Obama’s $3.77 trillion budget is a tiny little proposal to increase Medicaid spending by $360 million. In a budget as large as this one, $360 million is scarcely worth mentioning. It amounts to less than one-hundredth of one percent of total outlays. But this 0.01 percent is worth mentioning, because it proves the president’s health-care law will not work…

With this proposal, President Obama has admitted that:

1. The PPACA is not likely to reduce uncompensated care in 2014…

2. The PPACA won’t reduce the deficit…

3. Hospitals can stop crying poverty…

4. States don’t need to expand Medicaid to protect hospitals.

The Washington Post reports that rescission of the DSH cuts “could make it a bit easier for states not to expand the Medicaid program. If they know the additional dollars are coming in, there’s a bit less worry about turning down the Medicaid expansion funds.” At the same time, the president has undercut expansion supporters by admitting that expanding Medicaid will not reduce uncompensated care.

The president’s budget shows that the brave state legislators who have been fighting the Medicaid expansion in states like Ohio and Florida were right all along — and it makes expansion supporters, like Governors Rick Scott (R., Fla.) and John Kasich (R., Ohio), look rather silly.

This relatively small spending item is a big admission that the president’s health-care law simply won’t work, and it should provide encouragement to state officials who are still resisting the massive increase in deficit spending, government bureaucracy, and health-care costs the PPACA embodies.

Read the whole thing.

Obama Admin. Repeats Discredited Cost-Shifting Claim in Federal Court

Defending ObamaCare in federal court yesterday, the Obama administration’s acting solicitor general, Neal K. Katyal, peddled the widely discredited claim that the uninsured increase your and my health insurance premiums by $1,000:

“When people self-finance their health care,” Katyal contended, “that raises the cost of health care overall by $43 billion a year, and that raises the average family’s premiums by $1,000 a year. That will price untold numbers of people out of the market.”

That estimate comes from two left-wing groups, Families USA and the Center for American Progress Action Fund.

When President Obama himself made this claim, FactCheck.org reported:

[Obama] said ”the average family pays a thousand dollars in extra premiums to pay for people going to the emergency room who don’t have health insurance.” That’s from a recent report by Families USA, a group that lobbies for expanded government coverage. But another study for the authoritative Kaiser Family Foundation thinks that figure is far too high.

Serendipitously, the same day that Kaytal was repeating this discredited claim in federal court, USA Today reported:

Jack Hadley, senior health services researcher at George Mason University in Fairfax, Va…has found that privately insured individuals don’t end up paying higher premiums to make up for the uninsured because hospitals that serve lower-income families don’t have a lot of patients with insurance. He said the government pays about 75% of those unpaid hospital bills either by direct payment or through a disproportionate payment of Medicaid. (emphasis added)

Why Hospital Price Quotes Are So Often Useless

A colleague forwarded me a letter his friend received from their local hospital.  The friend needs surgery.  His health insurance has a very high deductible, so he figured he would do some comparison shopping.  He asked the local hospital to quote him a price. Here’s how the hospital responded:

[This] hospital typically charges between $2,360.45 and $22,290.74 for this procedure or service.  This is an estimate only…

Our goal is to provide you with the most informed and accurate estimate of the cost of your treatment.  If circumstances result in a final bill that exceeds this estimate by more than 20%, we will work together with you to resolve the balance.

For surgical services, the price quote does not include any physicians’ charges.  The surgeon and/or anesthesiologist will bill you separately for his or her time.

That price range varies nine fold, or 11 fold if you count the additional 20 percent.  Translated from Hospitalese into English, the letter essentially said:

Our hospital faces so little competitive pressure, we’re just going to blow you off.

If you do have your surgery here, don’t even think about complaining about the bill unless it exceeds $27,000.

Or even then.

The hospital noted – correctly – that “people react in their own individual way to surgery.”   Those individuated reactions could easily lead to an 11-fold cost variation for the same procedure.  That information is useful to a hospital.  It is not useful to a patient who is trying to find the lowest-cost hospital.

One would expect hospitals (or ambulatory surgery centers) to find some way to cope with the uncertainty about costs and provide useful price information to patients.  For example, hospitals could offer the same flat price for each procedure; the flat price would cover the higher costs of patients who experience complications.  Or they could quote higher prices to patients who have risk factors associated with complications.  While they’re at it, they could also include the physicians’ charges.  In a competitive market, hospitals that didn’t do these things would lose customers to hospitals that do.

The problem is that most hospitals do not operate in a competitive market.  Many states pass regulations that block entry by new hospitals.  Government interventions from Medicare to the tax exclusion for employer-sponsored health insurance block the creation of health systems that face greater incentives to offer a single “package” price and to reduce the uncertainty associated with surgical complications.  Those same interventions also encourage excessive health insurance, which reduces the share of patients who pay out of pocket for surgeries in this price range.  That reduces the demand for useful price information.

Price transparency is not a problem for government, private insurance companies, or employers.  They control the money, so they get all the price information they demand.  If we want to give patients useful price information, we need to let patients control the money.

The Importance of Incentives

NPR reports on more doctors giving up private practices and going to work for hospitals. Hospitals think they can manage care better and get more patients, and doctors like being relieved of administrative headaches. But it isn’t a perfect solution. Reporter Jenny Gold notes one of the problems:

GOLD: This isn’t the first time hospitals have gone doctor shopping. In the 1990s, hospitals bought up as many practices as possible. Dr. Bill Jessee is the president of the Medical Group Management Association. He remembers the ’90s as something of a disaster.

Dr. BILL JESSEE (President, Medical Group Management Association): The first thing a lot of physicians did was took a vacation. And when they came back, they weren’t working as hard as they were before their practice was acquired.

Indeed. This is a standard insight of economics. People work harder when they have something to gain. There are real benefits to the division of labor, including corporations where salaried employees contribute to a joint product, but there are also risks that employees won’t work as hard when their compensation isn’t directly tied to their output. Managers and economists have searched for solutions to the “shirking” problem. In this case the hospitals are experimenting with bonus systems based on how many patients the doctors see. The problem is much more significant, of course, in government, which is far more restricted in its ability to use merit pay, bonuses, or other performance-related pay systems. Thus the widespread impression that government employees don’t work as hard as private-sector employees – and one reason that it’s a good idea to leave as many services as possible in the private sector.

The NPR story also reminded me of Malcolm Gladwell’s New Yorker article on Philo T. Farnsworth, the inventor of television. Gladwell dismisses the romantic notion of the lone inventor and says that Farnsworth would have been better off working for a big corporation, where other people would have worried about raising capital, fending off lawsuits, and all the little details of management and left Farnsworth free to invent:

Farnsworth was forced to work in a state of chronic insecurity. He never had enough money….he did not understand how to raise money or run a business or organize his life. All he really knew how to do was invent, which was something that, as a solo operator, he too seldom had time for.

This is the reason that so many of us work for big companies, of course: in a big company, there is always someone to do what we do not want to do or do not do well–someone to answer the phone, and set up our computer, and arrange our health insurance, and clean our office at night, and make sure the building is insured. In a famous 1937 essay, “The Nature of the Firm,” the economist Ronald Coase said that the reason we have corporations is to reduce the everyday transaction costs of doing business: a company puts an accountant on the staff so that if a staffer needs to check the books all he has to do is walk down the hall. It’s an obvious point, but one that is consistently overlooked, particularly by those who periodically rail, in the name of efficiency, against corporate bloat and superfluous middle managers. Yes, the middle manager does not always contribute directly to the bottom line. But he does contribute to those who contribute to the bottom line, and only an absurdly truncated account of human productivity–one that assumes real work to be somehow possible when phones are ringing, computers are crashing, and health insurance is expiring–does not see that secondary contribution as valuable….

Philo Farnsworth should have gone to work for RCA. He would still have been the father of television, and he might have died a happy man.

Obama’s Populism a Hoax: ObamaCare Is a Sop to Big PhRMA

From the invaluable Tim Carney:

The Obama team regularly dismisses opponents as industry lackeys. The Democratic National Committee blasted out e-mails this week warning that “for every member of Congress, there are eight anti-reform lobbyists swarming Capitol Hill” and “Congress is under attack from insurance lobbyists.”

But drug industry lobbyists, according to Politico, spent the weekend “huddled with Democratic staffers” who needed the drug lobby to “sign off” on proposals before moving ahead. Meanwhile, we learn that the drug lobby is buying millions of dollars of ads in 43 districts where a Democratic candidate stands to suffer for supporting the bill. The doctors’ lobby and the hospitals’ lobby are also on board with the Senate bill.

So the battle at this point is not reformers versus industry, as Obama would have you believe. Rather, it is a battle between most of the health care industry and the insurance companies.

(And the insurers are not opposed to the whole package. On the bill’s central planks — limits on price discrimination, outlawing exclusions for pre-existing conditions, a mandate that employers insure their workers and a mandate that everyone hold insurance — insurers are on board. They object mostly that the penalty is too small for violating the individual mandate.)

Read the whole thing.

Massachusetts Treasurer Blasts RomneyCare and, Equivalently, ObamaCare

Massachusetts state treasurer and recent Democrat Timothy Cahill has harsh words for the health plan foisted on his state and the identical plan that President Obama is trying to foist on the nation.  From The Boston Globe:

“If President Obama and the Democrats repeat the mistake of the health insurance reform here in Massachusetts on a national level, they will threaten to wipe out the American economy within four years,” Cahill said in a press conference in his office.

Echoing criticism leveled by congressional Republicans in recent weeks, Cahill said, “It is time for the president, the Democratic leadership, to go back to the drawing board and come up with a new plan that does not threaten to bankrupt this country.”

[T]he state’s health insurance law…Cahill said, “has nearly bankrupted the state.”

Cahill said the law is being sustained only with the help of federal aid, which he suggested that the Obama administration is funneling to Massachusetts to help the president make the case for a similar plan in Congress.

“The real problem is the sucking sound of money that has been going in to pay for this health care reform,” Cahill said. “And I would argue that we’re being propped up so that the federal government and the Obama administration can drive it through” Congress.

Commonwealth Connector, the independent state agency established to help residents find the health insurance, has “totally failed,” to create competition and connect people with affordable insurance, Cahill said, pointing out that 68 percent of the residents it serves receive subsidized care.

“We haven’t done anything about driving down costs,” Cahill said. “We haven’t helped small business. We haven’t changed the way we pay for health care and the way we deliver it.”…

Asked for solutions today, Cahill said he would seek to “level the playing field” between hospitals that charge different rates for similar procedures, seek to increase competition by allowing health insurance companies plans to sell plans across state lines, and would slash benefits mandated under state law.

For more on the Massachusetts health plan, see “The Massachusetts Health Plan: Much Pain, Little Gain.”

ObamaCare Threatens Innovation

That’s the conclusion of economist Glen Whitman and physician Raymond Raad, who write in Forbes:

Unfortunately, the health care bills moving through Congress could curtail medical innovation. Imposing price controls on drugs and treatments–or indirectly forcing their prices down by means of a “public option” or expanded public insurance programs–would reduce the incentive for innovators to develop new treatments.

Proposed reforms could also retard business model innovation–an area where innovation is weak. Congress has already used its control of Medicare to limit the growth of specialty hospitals. A nationally mandated insurance package would severely curtail innovation in payment methods and insurance products, which have the potential to improve the coordination and delivery of health care services.

The health care debate should address more than just covering the uninsured and controlling costs. When the U.S. generates medical innovations, the whole world benefits. That is a virtue of the American system that is not reflected in comparative life expectancy and mortality statistics.

The op-ed is based on the authors’ Cato Institute policy analysis, “Bending the Productivity Curve: Why America Leads the World in Medical Innovation.”