Code Red: Two Economists Examine the U.S. Healthcare System

October 3, 2014

The President’s Speech at Kellogg: When Fiction Becomes Fact

Filed under: Uncategorized — David Dranove and (from Oct. 11, 2013) Craig Garthwaite @ 9:57 am

Last Thursday was a watershed day for the Kellogg School of Management and Northwestern University.  For the first time in 60 years, a sitting President spoke at NU, as President Obama spoke before an audience packed largely with Kellogg students and faculty.  As this is election season, it was no surprise that he spoke at length on a variety of issues and defended the Democratic record.  We are not experts on every matter of public policy and therefore will not examine every aspect of the speech.  But we have more than passing knowledge of health policy, and the President did spend some time discussing the ACA. He also mentioned many times that he was simply giving the audience “the facts” and that they could not be disputed. Given this speech occurred at our University, we feel obligated to take a look at what he said and do some basic “fact” checking.

Here is the relevant excerpt from his speech:

“Today, we’ve seen a dramatic slowdown in the rising cost of health care. If your family gets your health care through your employer, premiums are rising at a rate tied for the lowest on record. What this means for the economy is staggering. If we hadn’t taken this on, and premiums had kept growing at the rate they did in the last decade, the average premium for family coverage today would be $1,800 higher than they are. That’s $1,800 you don’t have to pay out of our pocket or see vanish from your paycheck. That’s like a $1,800 tax cut. And because the insurance marketplaces we created encourage insurers to compete for your business, in many of the cities that have announced next year’s premiums, something important is happening – premiums are actually falling. One expert said it’s like ‘defying the law of physics.’ But we’re getting it done. That’s progress we can be proud of.”

There is no reasonable interpretation of this section other than the President is claiming that 100 percent of the recent slowdown in private sector health spending is attributable to the ACA.  Unfortunately, this claim does not stand up to basic scrutiny.  This issue has been extensively researched by both ourselves and a number of other economists. Conclusions drawn from studies of prior recessions suggest that the ACA could be responsible for more than half of the current slowdown in health spending.  More significantly, the most recent published work, which focused on differences across geographic areas during the most recent recession, suggests that the ACA is responsible for at most a small fraction of the slowdown in private health spending.  We happen to know a lot about this research because we (along with colleague Chris Ody) are the authors of the aforementioned study.   We blogged about it last month, and you can find the full study here, in the policy journal Health Affairs.  We have also shared this evidence with staff in several Federal agencies, so our findings are not unknown in DC.

We will be generous to the President and assume that these findings somehow did not make it onto his radar screen, or that of his speechwriters, or even more unlikely even his economic advisers.*  As a result, the President has, at best, grossly exaggerated the impact of the ACA when the best available evidence is that the ACA may not have had any impact at all!  We find it at least a little ironic that the President has (perhaps unknowingly) misrepresented the facts on a subject that was extensively researched by faculty at his host institution.

While we are on the subject of the accomplishments of the ACA, the President has in other venues reminded his audiences that the ACA has reduced the ranks of the uninsured by 10 million.  What he fails to mention is that a very large portion of those individuals (perhaps even a large majority) were simply added to the Medicaid rolls of various states. Considering that roughly half of the states chose to sit out the expansion, this is a remarkable figure.  While it is a good thing that we are able to provide these people with health coverage, the ACA was billed as a way to utilize the marketplace to expand private health insurance coverage by bringing some order to the individual marketplace. This is a policy goal that dates back to Stanford Professor Alain Enthoven’s 1978 Consumer Choice Health Plan, and was shared by President Clinton as well as many Republicans.  We may ultimately get to this point, but we certainly are not there today. Given this fact, why not call the ACA what it is – a massive expansion of the Medicaid entitlement, coupled with an as yet modest program to help some individuals find subsidized private health insurance?   We are rather partial to Professor Enthoven’s plan and hope the exchanges grow, but we are a long way from fulfilling his vision.  Let’s not pretend otherwise.

*We are reminded of an episode of the great British comedy, Yes Minister, where the Minister for Administrative Affairs Jim Hacker learns, to his chagrin, that he would have been better off politically if he had remained unaware of the facts.  Perhaps it is best for the President if he can continue, with conviction, to spin this tale about the ACA.

August 5, 2014

The slowdown in health care spending growth: It was (mainly) the economy

Filed under: Uncategorized — David Dranove and (from Oct. 11, 2013) Craig Garthwaite @ 9:46 am

We have all seen the doomsday predictions.  Health expenditures in the United States are a large and ever growing component of GDP.  Nothing can seem to stop this perpetual growth, and eventually these expenditures could account for over 20 percent of government spending and have ruinous effects on both state and federal budgets. This was part of the motivation for the 2009 Affordable Care Act (ACA).

But before the ACA was even drafted, something important was happening to the rate of growth medical spending – it was slowing!  From 2000 – 2007, health spending grew at 6.6 percent per year, well above inflation and a source of concern.  However, over the next four years this rate of growth slowed to an annual rate of “just” 3.3 percent.  We should note that even slower growth of a large number is a cause for concern.

The source of this slower growth has caused great debate.  Theories have ranged from a slower adoption and development of new costly technologies, to a number of blockbuster drugs coming off patent, to early effects of the ACA, and finally the effects of the “Great Recession.”

In a new study published in Health Affairs, we (along with our co-author Christopher Ody) examine the role of the economy in the slowdown in health spending.  In a research partnership with the newly established Health Care Cost Institute (HCCI) we obtained data on the health expenditures of a large sample of privately insured individuals.  We aggregate these data to the CBSA level and then examine how the effect of the 2008 economic downturn affects health spending in these areas.  We find that absent the recession, the rate of growth in health expenditures would have been 70 percent higher.  This is similar to some previous studies, and quite higher than others.

An advantage of our study over the existing literature is our ability to exploit regional variation during this downturn.  Previous efforts have primarily used evidence from past recessions on the relationship between aggregate economic activity and health spending to predict the role of the recession in the past few years.  However, there are many reasons to think that this recession might be different.  For example, it has been a longer and deeper recession than those in recent decades.  In addition, it was caused primarily by a shock to the financial system and results in large losses in housing wealth.  A second advantage of our study is that we examine individuals that retain private insurance. Therefore, our results show that the downturn in spending from the economy was not caused simply by individual losing employer provided health insurance.

Exploiting regional variation also allows us to control for other coterminous factors that might be affected health spending.  A fair question is what is the appropriate measure of economic activity in this setting?  The generally used measure in this literature is Gross Domestic Product (GDP).  For two reasons, this measure won’t work for our research question. The first is practical.  We don’t have good measures of this type of economic activity at the local (i.e. CBSA) level.  The second is more conceptual.  It is not clear that GDP reflects the economic conditions facing the average American.  This is particular true following the most recent recessions which have been marked by “jobless” recoveries where employment growth lags aggregate economic activity.

For these reasons, we measure the impact of the 2008 economic downturn using the change in the CBSAs employment-population ratio.  Looking just at the raw correlations, we find that every one percentage point decrease in the employment to population ratio resulted in a 0.84 percentage point decrease in medical spending in that CBSA.

While it is important to understand the past, the obvious question is: What does this mean for the future of health spending.  Our results suggest that if all other things remain equal, as the economy improves we should see a return to the previous rate of growth in health spending.  But are all things remaining equal?  Of course not!

First, we have implemented the ACA.  While we think it is naively optimistic to think this caused an immediate change in health spending in 2009, it is quite possible that in the future the incentives and programs created by this law could coordinate care in a way that leads to lower spending.  On the other hand, it is also fair to note that an increase in the number of insured individuals might actually raise health spending.  Just today, the Wall Street Journal reports large increases in utilization by the newly insured – including an increased used of the emergency room.  This utilization increase might offset the benefits of more coordination.

Second, one mechanism that likely drives a portion of our main results is a decrease in the generosity of cost-sharing for employer provided plans.  It is possible that this shift was greater in areas the suffered a larger macroeconomic shock as employers used less generous health insurance as a means of lowering compensation and absorbing the financial shock.  However, if this were the case it is quite possible that future employment negotiations may increase the cost sharing in these plans in the future.  Such a shift may take some time as these contracts are typically negotiated on at least at most an annual basis.  Therefore, we are not sure whether this will remain a permanent feature of the market.

Our results show that attempts to claim the slowdown in health spending primarily resulted from changes in government policy have little merit.  Importantly, we find this change among a group of insured individuals. This means that we are not simply finding that individuals losing insurance following job loss spend less on health services.  Instead, our results show that the depth and breadth of the downturn (and likely the decline in housing wealth) affected even the health spending of those who retained insurance.

However, it is also important to note that we find that among our sample of privately insured individuals approximately 30 percent of the decline in the growth in health spending resulted from factors other than the local economy. Given what we spend on health care services each year, this point is nothing to gloss over.  It is important to think carefully about what might or might not be in that 30 percent.  For example, this could result from factors such as a lower rate of technology adoption or the lack of new blockbuster drugs (though if this was the cause it seems like Sovaldi alone might end this channel).  But it also could be that economic trends that were not well correlated with the local economy, such as changes in the stock market, could explain a large portion of this effect.  Given this fact, we might want to keep our proverbial champagne on ice for even the 30 percent decline going forward.

July 29, 2014

Narrow Networks Redux

Filed under: Uncategorized — David Dranove and (from Oct. 11, 2013) Craig Garthwaite @ 10:44 am

The Affordable Care Act is premised, at least in part, on the notion that competition can be harnessed to reduce healthcare costs and improve quality. This explains why insurance in the individual market has not been nationalized. Instead, consumers go to an online exchange where they customers can easily (at least in theory) compare plans offered by different firms. Unleashing competitive forces should result in lower premiums for these plans. And why not? Over the past two decades, competition has been one of the few success stories in the U.S. health economy. For example, when competition intensified in the 1990s, healthcare costs moderated. When competition weakened in the wake of provider mergers and the backlash to the narrow networks that were essential to cost containment, healthcare costs rose.

When most people think about the benefits of competition, they tend to think about prices. Monopolies charge high prices; competitors charge low prices. There is nothing wrong with this perspective, but it misses a more fundamental point. In the long run, the greatest benefit of competition is that it has the potential to fuel innovation. This is as true, in theory, for health insurers as it is for telecommunications and consumer electronics. It hasn’t always been true in practice; for several decades after the IRS made employer-sponsored health insurance tax deductible, insurers tended to offer the same costly indemnity products. But consumers eventually demanded lower premiums, and insurers responded with managed care. After the backlash, insurers developed high deductible health plans and value based insurance design. Insurers are now moving towards reference pricing. These plans offer consumers reimbursement up to a pre-specified level for treatments that can be easily broken into a treatment episode such as hip replacements or MRIs. Patients have the choice of any provider, but they bear the cost of choosing a more expensive facility.

High deductibles and reference pricing are fine, but do not always work in practice. Chronically ill patients quickly exhaust their deductibles, and reference pricing does not work well for chronic diseases. In order to complement these tactics, some insurers are once again offering narrow network plans. We commented in earlier blog posts that the ACA would catalyze the return of these narrow networks and also warned that this might fuel another backlash. Unfortunately, a recent New York Times article shows, the backlash is well underway.

Make no mistake, restrictive networks are essential to cost containment. Through narrow networks, insurers can negotiate lower prices. More importantly, they can direct enrollees to providers who have lower overall costs and higher quality. Dranove has written two books about this. Don’t take his word for it. The independent Robert Wood Johnson Foundation has published two comprehensive studies showing that the competition triggered by networks has been successful in reducing costs and improving quality.

By definition, some providers are excluded from narrow networks, and this is where the trouble begins. Excluded providers who have lost out in the cauldron of competition always complain the loudest. In sports, there are pejoratives to describe such complaining losers, and it is the rare referee who is moved by their complaints. In healthcare, they are called an interest group, and when providers complain they have the ear of legislators. We should have no sympathy for them.

What about patients? Some patients knowingly choose health plans with narrow networks in order to save money, and should not be surprised to find that some of their favorite providers are excluded. Others may be in the dark about their networks. The solution isn’t to regulate narrow networks out of existence; it is to shine some light on network structure.

Another concern may be that low income enrollees who cannot afford broader networks might be at a disadvantage. But if we want to provide big enough subsidies so that all enrollees have broad networks, we will have to either (a) raise taxes further, or (b) limit the number of uninsured we can enroll. Neither choice seems better than the status quo.

Now, this does not mean that we think there is no place for regulation of narrow network plans. We don’t think that the newly formed ACA exchanges, or any market, should be the proverbial Wild West. For example, if we want consumers to make educated choices across insurance plans, then they require timely and accurate information about which providers are in which networks. We would think this would be more than feasible, though was somehow unable to provide this information to many of the initial enrollees. We understand that providers go in and out of networks all the time and it would be burdensome for insurers to inform enrollees of all network changes in real time. But insurers could provide regular updates. We also wonder if insurers have the capability of identifying, through billing records, when a particular patient’s provider has gone out of network, and sending that patient an immediate update. In these situations, patients should be allowed to change their choice of plans outside of the open enrolment period in the same way they might be able to if they had another qualifying event such as the birth of a child. These small steps should prevent some of the worst case scenarios described in the New York Times article.

In addition, narrow network plans are only effective if there are multiple high quality providers offering services in an area. Given the recent wave of provider consolidations, it is critical that anti-trust authorities carefully monitor these mergers. After all, competition can only work in truly competitive markets.

But what we must avoid is mandating broader access. This would spell the end of market-based health reform. If insurers cannot exclude some providers, then providers have little incentive to lower prices and become more efficient. In the wake of the last managed care backlash, patients equated access to quality and virtually all insurers decided they needed to include in their networks virtually all providers. The result was double digit price growth that ended a decade of pricing tranquility. In the new post Great Recession economic reality, enrollees must have a low price alternative to high cost, broad network plans.

Many states have already attempted to mandate minimum access through Any Willing Provider laws. These laws require insurers who have come to terms with a specific provider to accept all providers who agree to those same terms. This may sound fair, but the economic implications of AWP for patients are anything but fair. Under AWP, no providers need negotiate with insurers or accede to an insurer’s request for discounts. Providers can bide their time, knowing that they can always force their way into the network. Having lost all their leverage, insurers can no longer demand discounts, and prices invariably rise. Research confirms this dim dynamic.

The push for broad access seems to be especially strong in sparsely populated states such as Montana. But proposals to assure access, which often take the form “At least X% of enrollees must live within Y miles of a provider” do more to drive up costs than any other rules we can imagine, because they grant effective monopoly rights to rural providers. Insurers facing such rules have two options (a) accede to the pricing demands of the local monopolies, or (b) drop coverage in areas where providers have been granted local monopolies. Montanans may as well have nationalized healthcare.

Health policy makers love to talk about the need to reduce costs, improve quality, and expand access – and like to talk themselves into believing that through government intervention they can achieve all three. They would do well to heed the economist’s “golden rule”: There is no free lunch.

July 7, 2014

Contraception Stamps

Filed under: Uncategorized — David Dranove and (from Oct. 11, 2013) Craig Garthwaite @ 9:17 am

There is a broad consensus (and a strong economic argument) that Americans should be protected against the potential financial catastrophe that can result from unexpected costly illnesses. This is the essence of health insurance. We count ourselves among those that broadly agree with this consensus opinion. Put plainly, unexpected medical bills should not be a source of financial insecurity. The Affordable Care Act represents President Obama’s best effort to provide this protection. But the ACA does far more than simply provide financial security in the form of health insurance to a large number of previously uninsured Americans. When the ACA reaches beyond this goal, it tends to get into the most trouble.

Americans like having health insurance, so to serve its broad political goals, the Obama administration has tried to label all aspects of the ACA as elements of health insurance. But the labels do not always fit. Recall that the administration was placed into the awkward position of defending the individual mandate as a tax in court, despite clear statements by various supporters of the ACA that it did not involve new taxes on those earning under $250,000 a year. In some people’s minds this continues to bring into question the legitimacy of the entire legislation.

This week, the debate has been about the mandate that employers include contraception in the basic insurance benefit that they are mandated to provide as part of employee compensation. Plans that do not offer this coverage do not meet the minimum requirements of the ACA and therefore employers would be required to pay steep fines per employee. In the “Hobby Lobby” decision, the Supreme Court ruled that owners of closely held corporations could not be compelled to provide certain types of birth control as part of their employee health insurance plans if they objected. The court then followed this up by granting a temporary injunction that allows Wheaton College to avoid filing a form facilitating the provision of contraceptives to its employees by a third party insurer. A final ruling from the Supreme Court on that issue will come in the future.

This is a fight that the Administration frankly didn’t need to and shouldn’t have picked. Recall that we got in this situation when the HHS (now perhaps our nation’s most powerful agency) decided to include contraception as part of the “essential health benefit that must be offered as part of all qualifying insurance plans.” And with that relatively simple decision, we’re off! Since that point the administration has been attempting to tailor its contraceptive mandate to avoid infringing on the religious beliefs of different groups. First, explicitly religious organizations were exempted. Then religious non-profit organizations were given the accommodation that serves as the center of the recent Wheaton College decision. Finally, as a part of the Hobby Lobby decision, closely held for-profit corporations have access to this potentially problematic non-profit workaround.

Had the administration thought more clearly about the underlying economics, and demonstrated a bit more political boldness (after all, wasn’t boldness one of the reasons America supported the President in 2008), it could have avoided this Rube Goldbergeseque solution. For the sake of argument, we will accept that affordable contraception is an underprovided public good requiring a government subsidy (a point that has a good deal of validity). But contraception is predictable and does not involve substantial expense – compared to say a new child. As such, it is by definition not an insurable product, and tying its provision to insurance is asking for trouble…the type of trouble that the Supreme Court has provided. Besides, tying contraception to insurance all but guarantees that millions of women will not receive the subsidy; witness the millions of Americans who still lack health insurance.

There are better ways to subsidize public goods than tying them to health insurance, especially when the goods in question are not insurable. If the administration believes that contraception is an underprovided public good, then why not carve this troublesome feature out of the ACA and offer contraception stamps? Like food stamps, they could be exchanged at the pharmacy for the purchase of qualified contraception products. This would eliminate the employer middleman and better target the subsidies to the low income individuals who need it the most.

We will tell you why the administration didn’t pursue this path. While we have no qualms about it, we suspect that most Americans would not accept this notion of directly subsidized contraception. By labeling contraception a healthcare service that requires insurance coverage, and rolling the subsidy into the ACA, political acceptance is all but assured. Unfortunately, the rules of the ACA effectively lock most Americans into their employer-sponsored insurance (another problematic provision of the law), so this approach ties contraception to employment, ties the hands of employers, and guarantees legal challenges along the lines of Hobby Lobby. This only serves to further politicize the ACA and assure that far more important reforms to the ACA will be delayed even further into the future.

Contraception is not the only uninsurable good or service that CMS has added to the minimum benefits package, which includes far less controversial preventive health measures that are routine and expected. But, as we previously discussed, it is only a matter of time before lobbyists and weigh in on other benefits that are not cloaked in the legitimacy of prevention. Judging by the experiences of the states, which collectively impose over 2000 “insurance” mandates, most of these mandates will actually be subsidies for uninsurable services. Lobbyists have long known that by labeling these subsidies “health insurance,” political hurdles melt away. In the case of contraception, the Obama administration has learned this lesson well.

Given that this Supreme Court felt confident enough in their economic logic to call the mandate a tax, we are surprised that they did not take this opportunity to question the entire notion of “insuring” contraception. So we are glad to have had this opportunity to do it for them.

June 23, 2014

Business Strategy in Unlikely Places: Why Kobe Bryant is a Strategist and Jurgen Klinsman is Just a Coach

Filed under: Uncategorized — David Dranove and (from Oct. 11, 2013) Craig Garthwaite @ 8:35 am

This week we offer a brief interlude from the world of healthcare to kick off a new intermittent series: “Business Strategy in Unlikely Places.” On semi-regular basis we will talk about various topics in business strategy, which is the “other half” of our job here at Kellogg.

In addition to being economists and strategy professors, we are both big fans of sports in general and basketball in particular. Therefore, we couldn’t help but notice the recent tiff between Kobe Bryant (one of the best basketball players in the world over the last two decades) and Jurgen Klinsman (the coach of the United States national soccer team).

It all stems back to an interview in the New York Times magazine where Klinsman said many controversial things. First, he admitted that he thought the United States couldn’t win the World Cup this year, which may be accurate (although for a few minutes yesterday we felt irrationally exhuberant about our chances) but was strange to hear from that source. More interestingly, Klinsman said the following in response to people who were critical of him leaving veteran Landon Donovan off of the 2014 World Cup Roster:

“This always happens in America … Kobe Bryant, for example—why does he get a two-year contract extension for $50 million? Because of what he is going to do in the next two years for the Lakers? Of course not. Of course not. He gets it because of what he has done before. It makes no sense. Why do you pay for what has already happened?”

Perhaps unsurprisingly, Bryant was none too pleased about this comment and had the following response to ESPN Magazine:

“I thought it was pretty comical, actually. I see his perspective. But the one perspective that he’s missing from an ownership point of view is that you want to be part of an ownership group that is rewarding its players for what they’ve done, while balancing the team going forward. If you’re another player in the future and you’re looking at the Lakers organization, you want to be a part of an organization that takes care of its players while at the same time, planning for the future.”

While we could write this off to sour grapes from Bryant, in reality he is sketching out an important strategic point. To understand this point requires a bit of context. Under the collective bargaining agreement of the NBA, teams are constrained in how much they can pay in salary each year and the maximum amount that can be paid to any player in a year. As a result, star athletes such as Bryant are likely paid less than their actual value to the team. When Bryant led the Lakers to five titles, he brought in hundreds of millions of dollars in additional revenue for the team owners. But his salary has been capped at a bit over $20 million, and he could not receive more than a token bonus for his superlative effort.

The upshot of this is that, as a result of the salary cap, the Lakers could not pay Kobe Bryant his true value during his prime years. Without getting lost in the intricacies of the salary cap, the same is more or less true for all teams trying to hire superstars. The superstars are always paid less than they are worth and they are paid pretty much the same at each team. How then can the Lakers and other teams compete to land top talent?

Unable to up the ante on salary for current superstars, teams engage in elaborate courtships where they sell other attributes. The Miami Heat offer the twin attractions of South Beach and no state income tax. Los Angeles offers its glamorous life style, Boston has tradition, while New York offers, well, New York. Dranove thinks Chicago has much to attract star athletes, including a strong shot at winning a title (Are you reading this Carmelo? No? Why not?). Garthwaite thinks star free agents should be intrigued by the possibility of bringing the Pistons back to their “Bad Boys” glory.

But what if a team could “promise” a current superstar an increase in salary above the cap? League rules prohibit offering this in writing; even verbally committing to pay more would bring down the long arm of the NBA law. However, a team could credibly commit to pay current superstars more than they are worth after their stars have faded (sorry Kobe, we are talking about you). This circumvents the salary cap and effectively allows teams to pay current superstars what they are worth. The question is how can a team do this? Well at least one way is by demonstrating they have done so in the past. This costly signal helps convince future players that they also could ultimately earn more by signing with this team.

Think about it this way. Kevin Durant, the best young player in the NBA, will become a free agent in 2016, exactly when Bryant’s latest contract will expire. The Lakers would love to land Durant. So would every other team. Durant is worth much more than the maximum allowable salary, so no team can outbid any other in the traditional way, and whichever team lands him will pay him less than he is worth. But the Lakers can “outbid” other teams for Durant’s services by demonstrating that they will eventually pay him more than he is worth. How can they assure Durant that statements about “taking care of him” in the future are not just some elaborate cheap talk? By doing the same thing, right now, for Kobe Bryant.

It may appear to Klinsman that the Lakers are paying Bryant for his “past performance.” In reality, they are simply structuring their compensation differently to avoid regulations. Of course, this is most effective in leagues with strict salary caps – something that is not true for European soccer leagues. In an uncapped league, you can just pay players their market value in the current year.

Economists call these types of arrangements implicit or relational contracts. We happen to know a bit about them because our strategy department here at Kellogg has some of the best people in the world who consider these arrangements (Niko Matouschek, Jin Li, and Michael Powell). In situations where firms cannot explicitly write out all provisions of a wage and bonus structure, these types of contracts can be powerful strategic tools. In the NBA, relational contracts might allow a team to effectively attract players who otherwise would view them as interchangeable with their competitors.

June 17, 2014

What Starbucks New Tuition Benefit May Tell Us about the Future of Employer Provided Health Insurance

Filed under: Uncategorized — David Dranove and (from Oct. 11, 2013) Craig Garthwaite @ 9:31 am

Starbucks, which taught America to love lattes, made news this week with the announcement of a new tuition benefit for its partners (Starbucks-speak for employees).  At first glance this move seems like simply another benefit in Starbucks relatively (for its industry) generous compensation package.  In particular, Starbucks has long been heralded for providing health insurance for all partners working more than 20 hours per week.  It is this connection to health insurance that we wish to explore.  While Howard Schulz the founder and current CEO of Starbucks has long said the firm offers health insurance because it is the “right thing to do” for their employees, we have always suspected a more profit maximizing goal for this compensation decision.  If we put on our strategy hats (we are both members of Kellogg’s Strategy Department), we can deduce that as a profit-maximizing firm, what Starbucks giveth with tuition benefits it may soon taketh away from health insurance benefits.  In the process, Starbucks may be heralding the demise of employer sponsored health insurance, something we have predicted in previous blogs.

While Starbucks is nominally a fast food firm, it seeks to hire a different kind of employee than its competitors.  Starbucks employees are more productive (i.e. they generate more revenue per employee) and they are expected/required to contribute to the warm environment Starbucks offers its customer.  From its creation, Starbucks has positioned itself as the “third place” in American society, i.e. a place to gather that was neither home nor work. This is why chatty and productive employees (think, college educated individuals looking for full-time employment or a struggling actor waiting for his big break) are worth more to Starbucks than they would be to one of its competitors such as McDonalds.  While McDonalds may now offer a competitive latte, no one would mistake it for a third place.  

Starbucks must, on a daily basis, find ways to attract and retain its employees.  Rather than simply pay them more (an expensive proposition), Starbucks has long exploited a unique feature of the American employment and health insurance markets.  Private firms are generally able to offer health insurance for rates that are far less than their employees can obtain in the individual insurance market.  As a result, Starbucks can attract workers with a package of wages and health benefits that is worth more to the employee than a similar amount of compensation paid entirely in wages.  Given that many of their competitors are not seeking to hire the same kinds of employees, Starbucks can retain part of this spread within the firm.  Workers who highly desire health insurance, whom more often than not are the types of workers Starbucks would like to hire, are delighted by this wage/benefit package. 

The Affordable Care Act changes this calculus.  Workers who opt into exchanges can now obtain health insurance at an actuarially fair price. That wage/benefit package from Starbucks doesn’t seem so attractive any longer.  Many would rather take an all-wage package elsewhere – a package that featured higher wages, albeit without health benefits – and apply some of those higher wages towards the price of a cheap silver or bronze plan on the exchange.  This is particularly true when we consider that Starbucks offering health insurance benefits makes their employees ineligible for the large subsidies on the exchanges. 

Facing this situation, Starbucks needs to look to a different fringe benefit with the same two characteristics as health insurance:  (1) that Starbucks can obtain the benefit at a discount, and (2) that the benefit is attractive to the kind of employee that Starbucks wishes to hire.   Enter the tuition benefit.  Starbucks has apparently used its purchasing clout to obtain a discounted tuition from Arizona State University for its online undergraduate degree program, and is passing on the discount to its workers.  Because this program does not make strategic sense unless Starbucks has a purchasing advantage, we expect more details about the discount to emerge in the fullness of time.  

As in the case of health insurance, do not believe for a moment that Starbucks is offering tuition benefits as a public service.  Indeed, the language that CEO Schulz used to describe the tuition benefit is strikingly similar to his description of why the firm offers health insurance benefits: “I feel so strongly this is the right thing to do and Starbucks as a company is going to benefit in ways that probably we cannot identify today.”  We suspect that Schulz knows full well how the company will benefit. We also suspect that, despite its protests the contrary, Starbucks will eventually announce that it is dropping insurance coverage in favor of higher wages.  The company is too savvy about its benefits to miss this obvious move. 

We should also note that this is not a question of “right” and “wrong” or a greedy corporation slashing benefits.  Instead, it is about Starbucks (and likely other firms) realizing its employees are better off getting their wages from their employer and their insurance from and insurance company.  That is why, beyond being an interesting business strategy example, Starbucks’ recent moves offers a glimpse into the future (or lack thereof) of employer health insurance.  Ultimately, what we are seeing is the not so gradual erosion of one of the primary benefits of employer health insurance, i.e. the pricing benefits of group coverage.  With the creation of individual insurance exchanges, Americans no longer need their employer to provide their health insurance.  In fact, given the nature of the fairly generous tax subsidies they may no longer want their insurer to offer them insurance.  As a result, as we have previously predicted, many employers and particularly those with a large number of low-income employees will stop offering health insurance.  To borrow a phrase from Schulz, in this new economic environment this choice will be the “right thing to do” for their employees.

Firms that previously took advantage of the inefficient individual insurance market will have to look to other strategies.  This week the firm that brought us the Frappuccino we have may have also brought us the first strategy for this new context.   

June 16, 2014

What we do in our spare time (i.e. we have a new paper)

Filed under: Uncategorized — David Dranove and (from Oct. 11, 2013) Craig Garthwaite @ 6:06 am

It seems that you can’t spend more than five minutes socializing with health economists these days without the topic of Sovaldi and the prices of new drugs coming up (we economists are a wild and crazy bunch).  As we blogged a couple of weeks ago, this new cure for hepatitis C is far more effective than existing treatments and has fewer side effects but is also quite expensive (though it should be noted that it is not actually more expensive than many of the previous treatments, it is just more expensive per day and the lower number of side effects has caused a greater number of patients to seek out treatment).  Calls are coming from all quarters to force lower prices on Sovaldi’s manufacturer Gilead.

As we discussed, constraints on the profitability of drugs once they are released, such as price controls, are concerning because they limit future innovation.  A host of previous economic studies have shown that increases in expected profits have caused greater research activity by pharmaceutical firms as measured by new products, clinical trials, or both

What has been generally absent from this existing literature is whether these increased investments result in products that are socially valuable or if they are simply rent seeking by firms.  In general, new products can increase welfare by offering more value than existing products or lowering prices and increasing the quantity sold.  However, if demand is relatively inelastic (as is the case with many pharmaceuticals) lower prices do little to change demand and just represent business stealing by firms. In this setting, new products are only welfare increasing if they are sufficiently differentiated from existing offerings.     

Critics of the pharmaceutical industry often claim that there is little true innovation and most new products are simple modifications of existing blockbusters.  If this were true, most research by pharmaceutical firms is just a very expensive form of business stealing.  We would be remiss not to note that these critics have been noticeably silent in the case of Solvadi, which represents real innovation. 

Previous studies examining the link between profits and research investments for pharmaceutical companies have not directly confronted the question of the social value of these investments. Ultimately the social value of innovation after changes in marginal profits is an open empirical question and one that we hope to help answer.  To that end, we (along with our co-author Manuel Hermosilla) just released a new NBER working paper [ungated] (yes we do something other than blogging or teaching Kellogg’s MBAs). 

In this new paper we examine the social value of changes in research investments by biotechnology firms into drugs targeting the elderly after the creation of Medicare Part D – the pharmaceutical insurance program for elderly Americans.  These biotechnology firms have traditionally been associated with innovative activity.  For example, they disproportionately produce biologic products and the firms in our sample have a history of focusing on products targeting unmet medical needs.  As a result, the products they develop are less likely to be simple modifications of existing products than those from traditional pharmaceutical firms.

Similar to the previous literature, we find a marked increase in clinical trial activity for drugs targeting conditions with a large share of patients that are on Medicare.  This appears to have been caused by the insurance expansion, i.e. prior to Part D there was no noticeable difference in the number of clinical trials based on the elderly patient share.

Given that the increase in clinical trials occurred among biotech firms, they are likely for products that represent a scientific advancement of some type. The question is the degree to which they provide an increase in treatment availability – a key indicator of their contribution to social value.  We therefore examine two indicators of this outcome:  (1) the number of existing treatments for the targeted condition and (2) regulatory indicators of the product targeting an unmet need. 

First, we categorize the conditions in our data based on the number of available pharmaceutical treatments.  We then estimate the response to Part D based on the number of treatments for the targeted conditions and find that the increase in clinical trial activity was primarily for diseases with five or more existing treatments.  Importantly, we find that there was no change in the number of clinical trials for conditions with one or fewer treatments.  While the products aimed at conditions with five or more treatments may be more effective than existing treatments, our results show that marginal changes in profits do not spur investments in products targeting conditions that currently lack treatments.

We recognize that products aimed at conditions with existing treatments may still improve welfare improving the standard of care.  So we next turn our attention to three FDA indicators of products that address an unmet need: priority review, fast track and orphan drug status.  We estimate no increase in the prevalence of products receiving these designations as a result of the creation of Part D.

To understand the mechanism driving our results, we should consider the investment decision facing biotechnology firms.  Regardless of firm size or origin, products make their way to market based on their profit potential.  Truly novel products earn large profits and are there pursued by firms in all time periods.  However, those products offering simply another treatment option in the arsenal or providing price competition for existing products might generate limited profits.  As a result, there may be a large number of products for these conditions which were not sufficiently profitable in expectation prior to an insurance expansion but become profitable after a small change in market size. If this were the case, we would expect a differential response to the creation of Part D based on the number of existing conditions.  This is what we observe.

So this brings us back to the question of price controls and more specifically the case of Sovaldi.  Our results demonstrate that marginal changes in profits do not appear to increase investments in products that serve an unmet need.  However, the question is how large of a change is required to see a change in the incentives to develop truly novel products?  Unfortunately, we (and by that we mean all economists) simply don’t know the answer to that question. What we do know, is that the easiest path is to ignore the negative dynamic incentives for innovation and impose strict price controls on new drugs offering valuable benefits, i.e. the very types of drugs we have been asking the pharmaceutical sector to develop for years.  For example, Doctors without Borders is pushing for Sovaldi to be made available for $250 in the developing world—which is their estimate of the marginal cost.  Certainly this policy would dampen incentives to develop more products that would be socially valuable.

While we must avoid the temptation of draconian price controls, our results provide more nuance to the argument against any action affecting the prices of blockbuster drugs.  Modest efforts at controlling expenditures on these new medications do not appear to dampen incentives to invest in socially valuable products.  Recently, struggling to afford the cost of this new medication, some state agencies are rationing access.  For example, the Oregon Medicaid System is limiting access to the treatment to only its sickest residents with hepatitis C.  The hope is that over time, new products from AbbVie and potentially Merck will emerge.  Importantly, these new drugs may be even better than Sovaldi – as we would expect from the incentives provided by the high prices.  At a minimum, these new products should lower prices and transfer resources from pharmaceutical firms to patients (either through lower future premiums or taxes).  Our results demonstrate that small changes such as the rationing of access based on the progression of the disease might be a reasonable way for health plans to adjust to the high cost of new treatments without foreclosing the development of new treatments. 

June 6, 2014

The Future of the Physician

Filed under: Uncategorized — David Dranove and (from Oct. 11, 2013) Craig Garthwaite @ 8:39 am

On Wednesday June 4, the Kellogg School of Management hosted its annual MacEachern Symposium. A packed auditorium listened to an impassioned discussion about The Future of the Physician. Presidential adviser Ezekiel Emanuel and AMA President Ardis Hoven were among the speakers. While Emanuel was optimistic about the impact of the Affordable Care Act on hospital-physician integration and the resulting potential for cost savings and quality improvements, Hoven was concerned about the impact of the business of healthcare on the medical profession. In this blog, we offer our perspective on the evolving role of the physician.

The hit television series Marcus Welby, MD last aired in 1976. Dr. Welby was the physician of every baby boomer’s dreams, whose patients always felt cared for and always got better. By the end of the century, Dr. Welby had been replaced by Dr. House, an MD cum Sherlock Holmes with Narcissistic Personality Disorder and an opiate addiction. While his bedside manner is decidedly not Welbyesque, Dr. House still embodied the basic premise of the all-knowing and dedicated provider that solves problems with little concerns for costs or standard practice.

But in the real world, physicians are evolving along a different—and we argue—better path. The 20th century physician was self-employed, championed the interests of patients, and had complete control over the medical system. But this system had at least two primary problems: (1) ever escalating costs and (2) dramatic variations in physician practice patterns with little connection to outcomes. We shudder to think how much Dr. House spent on his patients. This system is no longer sustainable.

Enter the 21st century physician, who is increasingly an employee of a large provider organization that scrutinizes every medical decision based on both cost and quality. We may all be better off for this transformation – the question is will we accept it? If past is prologue, we fear that American public is still not ready.

This transformation began with the HMO movement of the 1980s, abruptly halted in the backlash of the 1990s, but has returned with a vengeance. Despite their seeming ability to restrain cost growth, the HMOs of the 1990s were vilified. These organizations were caricatured as cruel attempts by insurance companies to deprive Americans of medical care. They’ve even served as the villain in Denzel Washington’s hostage movie John Q.

Given these facts, HMOs needed a reboot. Enter Obamacare’s Accountable Care Organizations (ACOs) – i.e. HMOs 2.0. Organized by physician groups or hospitals, ACOs contract with Medicare and private payers and attempt to hold down costs and meet performance measures in order to reap huge financial returns. To meet these objectives, ACOs are relying on the very top down control of medical decision-making that made people revolt against HMOs. This entire process is made much easier when ACOs employ physicians, many of whom are more than happy to sacrifice their autonomy in order to have a guaranteed income and a better work/life balance. Employment (by group or by hospital) is not just a viable option, it is desirable.

Employment is just the first step. Historically, we have forced many participants in the medical community, such as pharmaceutical companies, to test their products through clinical trials that rely on the scientific method. Physicians, however, develop their practice styles through personal experiences with small numbers of patients and their immediate colleagues. The result has been a patchwork of treatment patterns, broad differences in outcomes, and little consideration of costs.

Increasingly, the medical profession has accepted the idea of routinizing care delivery though protocols, and ACOs are using big data to implement diagnostic and treatment checklists. Some doctors push back against these efforts, saying these checklists effectively force them leave their judgment at the examining room door. They fear that physicians will be transformed from professionals relying on personal experience and judgment to technicians following a user’s manual. That may be, but if these technicians are making the right diagnoses and ordering the correct treatments, saving lives and money in the process, then we are all for it. Protocols are not perfect, of course, because patients are not identical. The best ACOs will use protocols as the default option and allow their physicians to occasionally use their discretion when necessary. But we have erred on the side of unlimited discretion for too long.

Much like lunch, this move to ACOs will not be free. Effective ACOs work by controlling the full scope of medical care delivery, and this will often necessitate restricting patient choice of provider. No longer can we simply shop around for the physician that will provide expensive and unnecessary treatments in order to satiate patient demand. Many fear this world, because they confuse choice with quality. In a world where people seek out physicians based on personal recommendations or Yelp-like rating system where personality matters more than skill, a little less choice might be exactly what we need.

If one of today’s ACOs recruited Dr. Welby, he might run in the opposite direction. To which we say, good riddance. The days of “physician as father figure” are long behind us. But we were looking at those days through rose colored glasses. Tomorrow’s physicians will be grounded with the information they need to make the right medical decisions and the incentives to properly balance cost and quality, even if they must rely on others to guide those decisions. Gregory House once asked, “What would you prefer – a doctor who holds your hand while you die or one who ignores you while you get better?” This may have been the dichotomy that Dr. House inherited from Dr. Welby, but it is false. It is possible for employee physicians to be compassionate and even cost conscious, while making their patients better. There is every reason to believe we are moving in that direction.

May 27, 2014

Is there a just price for pharmaceuticals?

Filed under: Uncategorized — David Dranove and (from Oct. 11, 2013) Craig Garthwaite @ 6:17 am

In America’s ongoing efforts to address the rate of health care spending, there has been a renewed focus on the prices paid for pharmaceuticals.  The poster child is Gilead’s Sovaldi, a once-a-day oral treatment that represents the first real cure for hepatitis C – a condition affecting over 3 million Americans.  Prior to Sovaldi, treatment for this condition required a painful course of Interferon which had many side effects and was ineffective for many people.  No one doubts that Sovaldi is a breakthrough product, the type of innovation that clearly increases welfare.  In addition, everyone seems to agree that the current cost of Sovaldi – approximately $84,000 for a 12 week course of treatment – is unreasonable and potentially crippling to the nation.  Even the well-known “champion” of price controls and improved access to medical services at low prices, the insurance industry’s trade association America’s Health Insurance Plans (AHIP), has come out against the “unsustainable” price of this medication.

While seemingly everyone agrees with AHIP, don’t count us in.  The pricing of pharmaceuticals is a very difficult economic question and we would like a little bit more caution in the attacks against innovative pharmaceutical firms.  We can all agree that firms developing products that simply imitate existing products are primarily rent seekers (ironically this activity, while decried by many, likely lowers prices for consumers).  We don’t think that we need high prices to reward this behavior. But this clearly is not the case with Sovaldi.  Everyone agrees that this drug is both a true scientific advancement and an expansion of available treatments for a chronic, extremely unpleasant, and potentially contagious medical condition – a combination that almost unequivocally benefits shareholders and patients.  These are the very products we want more of in the future.

So let’s stop patting ourselves on the back for attacking the evil pharmaceutical firms and their high drug prices and instead ask a deceptively simple question:  Why is the price for Sovaldi (and other recent lifesaving treatments) so high in the first place?  While there are many factors, two predominate.  First, these branded drugs are provided by firms that have monopoly production rights as a result of their patent protection.  Second, these drugs provide what most people value more than anything else – healthier and longer lives.  Even more so than prior blockbuster drugs like the statin Lipitor, there is a direct connection between the latest generation of expensive products like Sovaldi, and the substantial health benefits they deliver.

Okay, so these drugs save lives and are therefore incredibly valuable.  Why do we allow pharma companies to extract so much of this value, in the form of patents?  For one thing, patents do not last forever, as the effective patent lives of most new drugs is only about 8-10 years.  After that, these innovations become available to all, forever, at a fraction of the original price.  If we take the long view, the innovators reap just a small portion of the benefits they deliver.  But much more importantly, the patent system promotes innovation.  Take away monopoly pricing, and you take away the profits that motivate research.  (Even this statement, which appears to come straight from the PR department of a pharmaceutical firm, has important limits and nuances that we discuss below.)

Let us be clear, patents create a trade-off between different inefficiencies: one static and another dynamic.  Patents create a static inefficiency because they allow firms to charge monopoly prices and therefore an inefficiently low quantity is sold in the current time period.  We can easily solve that problem by instituting price controls or allowing the government to use its monopsony power to bid down prices – as they do in Europe and Canada where the same drugs are often sold at less than half the U.S. price.  However, this “solution” creates its own inefficiency – a low quantity of products developed for the future.   Here is another way of looking at it: Someone who is sick with something for which there is a cure today would naturally be a proponent of price controls.  But someone with an untreatable condition might want to be a bit circumspect about the long arm of government in this setting.  And the same is true for anyone who might, in the future, develop an untreatable condition.  And that means all of us!

If innovation is so great, then perhaps we should support price increases.  Let Gilead double its price! Triple it!  We could have every scientist in the world working on the next $300,000 pill.   Without trying to be stereotypical economists, it isn’t at all clear that drug prices are too low, and this is not what we are claiming.  Here we make two points.  First, we note that Gilead has not been granted the power to just arbitrarily pick a price out of the air.  If that were the case they, they wouldn’t have stopped at $84,000.  Instead, Gilead gets to pick the profit maximizing price for a monopolist.  Second, we are not claiming that any price is justified just that mandated price reductions may lead us down a slippery and dangerous slope.  Certainly, a “modest” reduction in pharmaceutical prices will not stop all lifesaving treatments from coming to market.  We will have new research coming out addressing this point in the coming weeks.  But much like Justice Potters Stewart’s difficulty with pornography, the definition of a “modest price decrease” is hard to pin down.  And here is the point:  We do not have faith that government bureaucrats can appropriately account for the variety of incentives necessary if they were in charge of either setting prices by fiat or effectively setting prices by exploiting their monopsony power.  It is indeed a slippery slope, and we fear the consequences if we take the first step.

Isn’t it unfair that drugs are so much less expensive in other nations?  Certainly!  But as we tell our children and MBA students, life isn’t fair. If prices were higher in Western Europe and Canada, the case for reducing prices in the U.S. would be more compelling.  There would still be enough of a profit incentive to motivate R&D.   But we shouldn’t hold our breath waiting for others to raise prices.  Americans are stuck in a bad equilibrium in which we have to choose among two options: subsidizing innovation for the citizens of the world, or allowing innovation to grind to a halt?  While our cold economist hearts give a resounding slow clap to the free riding strategy of the Europeans, given the wide range of conditions for which we still lack effective treatments, we would rather err on the side of caution – even if it means that American consumers must serve as the greater fool. 

We should also caution that even a limited attempt at setting prices for drugs like Sovaldi might have a chilling effect across the market.  Firms will make their investment decisions with the specter of price controls lurking overhead.  We worry about the potential long terms effects of this decision.

We finally note that this is a problem that the market appears poised to address.  AbbVie is readying a competing product to Sovaldi and Express Scripts, the nation’s largest pharmacy benefits manager is readying plans to pit these two products against each other in order to lower prices.  This seems like a much better means of achieving a lower price for Sovaldi, though we can’t help but recognize the irony that it puts the opponents of Gilead and Sovaldi in the position of rooting for “me too” products. 

May 19, 2014

If We Want Lower Health Care Spending, We Are Going to Have to Pay for It

Filed under: Uncategorized — David Dranove and (from Oct. 11, 2013) Craig Garthwaite @ 7:43 am

Ultimately, spending less on health care is a relatively easy task: We either need to consume fewer services, or spend less on the services that we consume. But much like we teach our Kellogg students about maximizing profits, the devil is in the details. It’s certainly tempting to ask the government to swoop in on a white stallion and solve the all our problems by fiat. For example, we could have the government simply exploit its monopsony power and set prices, but an artificially low price will lead to an inefficiently low quantity of services and future innovation (stay tuned, we will have more to say about this next week). Similarly, we could explicitly ration quantities (as opposed to implicitly doing it through a large uninsured population). But how could we hope to determine the right level of care? Ultimately, if we ask the government to unilaterally fix this problem, instead of a white stallion we could behold a pale horse and all that it entails.

The good part, perhaps the best part, about the Affordable Care Act is that it attempts to address this problem using market forces. The question is whether we are ready for what these market forces will entail. We will focus today on the role of market forces in the insurance market to control prices in the newly established ACA exchanges. This month the Obama administration announced that it would allow insurers to use “reference pricing” for insurance programs in the exchanges. Under a reference pricing system, insurers set the maximum price they will pay for a specific set of services and if patients go to a facility that costs more than that amount they are required to pay the difference. This system has recently been implemented by the California Public Employee Retirement System (CalPERS) and there were two main effects: (1) surgical volumes decreased at high price facilities and increased at low price facilities, and (2) the prices paid by individuals covered by CalPERS decreased at high price facilities but were essentially unchanged at low price facilities. While this is only one study for a single insurance system, it does provide the pattern that we would expect following a reference pricing system and is therefore provides encouragement.

In many ways, reference pricing is a close cousin of the narrow network systems that we previously described. Under narrow networks, insurance companies choose a limited set of facilities that are willing to accept their prices. Patients who want more choices can pay higher premiums for plans with wider networks. Under reference pricing, patients can go to a wider range of providers but they bear more of the cost of these choices. The organizing principal is the same for both systems: if patients want choice they are going to have to pay for the privilege.

The theory behind reference pricing is fairly clear. But will it work in practice? That is less clear. There are two main threats that we can see: (1) poor implementation and (2) political backlash. When it comes to implementation there are several important points to consider. Perhaps most important, reference pricing is not a panacea. It is most applicable for encounters with the medical system which involve a defined episode with relatively easy to understand quality measures. Think knee replacements and MRIs and not the management of Type II diabetes. This system is not well suited for managing chronic conditions. In addition, reference pricing is only as effective as the level of competition in the marketplace. Without a robust and competitive local provider market, patients lack sufficient options to shop around and this system won’t lead to reduced prices. Finally, price competition in the absence of good information about quality can create a race to the bottom, in which providers skimp on quality (e.g., reduced staffing and training, shorter therapy sessions, etc.) in order to drive down costs and, as a result, compete better on price. Patients must have sufficient information to make choices across providers based on price and quality. Obviously the first step here is some form of price transparency – a feature that is generally absent from today’s health care system. A recently announced partnership between major health insurers and the independent Health Care Cost Institute could go far to fix this problem. Perhaps more difficult is that reference pricing requires readily identifiable quality metrics (that can’t be easily gamed by providers or lead to perverse outcomes) that can be easily communicated to patients. For this, we need to think beyond standard outcomes like infection rates and incorporate important patient reported measures of quality such as pain reduction, ability to perform activities of daily living, and perhaps some measure of customer service. Given the experiences on the exchanges, where narrow network plans have been unable to accurately communicate information on which providers are in their networks, we have some fears as to whether these firms are ready to provide this type of critical quality information. Without a good quality reporting system, patients might end up choosing solely on price – an outcome that few would herald as a success.

Beyond the potential problems of implementation, we fear that the bigger threat to reference pricing will ultimately be politics. We first note that these systems are very similar to the HMO systems of the 1990s, which appeared to limit the growth of health spending before they were stamped out by a combination of a consumer protests and political handcuffs. Much like the backlash to HMOs and the more recent narrow network plans, it will only take a few patients being “forced” to pay high bills in order to get access to their preferred provider before the complaints will surface. Or perhaps it will happen before the first bill is even sent. Expect that the nation’s priciest providers will band together and speak out on “behalf” of consumers. Either way, it will take some national courage to stand up to these august providers and their feigned concerns for consumer welfare.

In the end it boils down to the proverbial lack of free lunches. It we want to lower health care spending we have to give up something. If we don’t accept some market based solutions, we will find a lunch menu filled with far worse options.

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