Health – Page 6 – Donald Marron

Prevention, Health Costs, and Value

Cost has played a leading role in the policy debate over health care / health insurance. That’s appropriate since private health costs put such a burden on workers and families, and public health costs place such a burden on state and federal budgets.

I worry, however, that the focus on costs and spending sometimes overshadows what ought to be the real goal: getting as much value as possible from our health care system.

A case in point is the debate over preventative care.

Policymakers are desperate for painless ways to pay for expanded health care coverage. Many of them have therefore become enamored of the idea that increased spending on preventative care could reduce overall health spending. As I noted yesterday, however, there’s a problem with that idea: it generally isn’t true.

If your only goal is paying for expanded health care, that finding is both unwelcome and fatal – the search for painless pay-fors will have to look elsewhere.

If your goal is increasing the value we get from our health system, however, your inquiry isn’t done. Instead, you should say “That’s too bad; I was hoping it would save money. But while we’re talking about it, do the benefits of preventative care justify the higher spending?”

Good question.

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Does Prevention Reduce Costs?

One of the common memes in the health debate is the claim that increased spending on preventative medical care (e.g., cancer screening) can reduce overall health spending.

That idea is very attractive, since it seems to offer a free lunch: greater health at lower cost. It has just one small problem, though: it isn’t true.

As the Congressional Budget Office describes in an analysis released on Friday:

Although different types of preventive care have different effects on spending, the evidence suggests that for most preventive services, expanded utilization leads to higher, not lower, medical spending overall.

That result may seem counterintuitive. For example, many observers point to cases in which a simple medical test, if given early enough, can reveal a condition that is treatable at a fraction of the cost of treating that same illness after it has progressed. In such cases, an ounce of prevention improves health and reduces spending—for that individual. But when analyzing the effects of preventive care on total spending for health care, it is important to recognize that doctors do not know beforehand which patients are going to develop costly illnesses. To avert one case of acute illness, it is usually necessary to provide preventive care to many patients, most of whom would not have suffered that illness anyway. Even when the unit cost of a particular preventive service is low, costs can accumulate quickly when a large number of patients are treated preventively. Judging the overall effect on medical spending requires analysts to calculate not just the savings from the relatively few individuals who would avoid more expensive treatment later, but also the costs for the many who would make greater use of preventive care.

In short, an ounce of prevention may save a pound of cure for the patients it helps. But those ounces of prevention can add up to tons of costs when spread over millions of patients.

And that’s not all.

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Good and Bad News for the House Health Bill

In my recent paper about how the Congressional Budget Office analyzes health proposals, I noted that one of the most important things that CBO does is to provide additional information about its cost estimates. Cost estimates often can’t speak for themselves, so it’s important that members of Congress and other interested observers ask for additional clarification about key issues.

Well, four leading House Republicans recently took this step, and CBO’s response is a doozy. It contains too much to summarize here, so let me focus on the two most important points:

CBO reiterated its conclusion that the introduction of a public plan (as specified in the bill) would not undermine private health insurance markets. Most Americans would continue to get their health insurance through employers.

CBO confirmed that the bill would worsen future deficits.

Supporters of the bill will emphasize the first finding as evidence that the public plan won’t gut private insurance markets. Opponents of the bill will emphasize the second finding as evidence that the bill is fiscally reckless.

Neither of these conclusions should be a surprise to anyone, since the basic facts were reported in CBO’s original cost estimate. However, the new letter does provide useful context.

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A Note on End-of-Life Health Care

It’s often said that end-of-life care makes up a disproportionate share of overall health care spending. For one very thoughtful discussion, see this article in Daily Finance.

Such claims strike me as plausible as an after-the-fact accounting matter. But I’ve always wondered how often patients and their caregivers know that they are providing end-of-life care? And how often do they have hopes – perhaps even expectations – that the patient will recover, but the treatments don’t succeed?

The recent passing of my father-in-law illustrates this question. He died early this morning after almost two weeks in intensive care fighting pneumonia and trying to recover from a recent stroke.

Until yesterday, the plan was simple: provide fairly aggressive treatment in the ICU to defeat the pneumonia so that he could return home. It would take time to assess damage from the stroke, but at least he would be able to get care at home from his extended family.

That plan collapsed yesterday as the pneumonia worsened, his kidneys failed, and he had a final stroke.

The record books will thus record about 10 days of ICU care for him in his final 10 days of life. From the perspective of Esther and her family, though, it really felt like 9 days of ICU care with the hope of improving and extending his life, and 1 day of ICU care knowing that the end was imminent.

Although my father-in-law likely didn’t benefit from that last day of ICU care, it’s also worth noting that some of his family members did, because they had an opportunity to come say their good byes in person (even if he couldn’t hear them).

All of which is to say that his end-of-life care provided some benefits – some probability of recovery plus some solace for family members – even as it ultimately failed at substantial cost. Spending on end-of-life care is a natural place to look for potential cost reductions as we try to “bend the curve” on health spending. The challenging part, however, will be balancing potential savings against the potential benefits of such care.

(For completeness, I should note that in our case, the balancing of these costs and benefits was entirely a private matter because Esther’s father had no private insurance and was not eligible for Medicare because he had moved back to Mexico. Similar episodes play out thousands of times every day, however, for people covered by private and/or public health insurance.)

Another Budget Blow to Health Reform

Policymakers are discovering that the road to health care reform in anything but smooth. The latest speed bump involves the Administration’s proposal to rein in future Medicare costs by empowering a new panel (the Independent Medicare Advisory Council) to recommend future spending reductions. If accepted by future Presidents, the commission’s recommendations would take effect unless Congress intervened.

As I mentioned the other day, there is some logic to this approach. Politics sometimes play an unseemly — and costly role — in decisions about Medicare payment rates. Limiting Congress’s role in setting those rates might therefore by a money-saver.

The devil is in the details, however, and earlier today the Congressional Budget Office concluded that the details don’t add up to much.

CBO estimates that the proposed legislation would save a paltry $2 billion over the next ten years, less than 1/500 of the 10-year cost of health reform. That estimate reflects CBO’s assessment of various possible outcomes:

[T]he probability is high that no savings would be realized, …, but there is also a chance that substantial savings might be realized. Looking beyond the 10-year budget window, CBO expects that this proposal would generate larger but still modest savings on the same probabilistic basis.

Advocates of the IMAC approach will clearly have to go back to the drawing board if they want to get larger savings in the first 10 years. The good news for them is that CBO explains why the estimated savings over the next ten years are so low and provides some guidance on what might be necessary to increase them.

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The Politics of Oxygen

Today’s WSJ has a fun profile of Peter Orszag, the Director of the Office of Management and Budget, and the challenges he faces making cost control a key part of health care reform.

I particularly enjoyed this episode:

The battle heated up in June, when Mr. Orszag visited Capitol Hill to discuss health care with a small group of House Democrats. The meeting started well, with one lawmaker after another echoing his message that spending controls were critical to any health-care overhaul, according to two administration officials.

Then one member said her top priority was winning higher payments for oxygen suppliers, the officials say. Mr. Orszag was taken aback. Officials had been trying for years to cut payments to suppliers of oxygen and other medical equipment, which critics say are inflated. Yet when a new competitive bidding process was set to take effect last year, industry supporters in Congress were able to delay the plan. They are still fighting to block changes.

“One of the reasons we currently have such disjointed and skewed incentives is that we have an excessively political process,” Mr. Orszag said in an interview.

I think Peter is absolutely correct.

When I first worked for Congress, I was stunned by the amount of time and effort that members gave to issues that struck me as minutiae. This was particularly severe in health care. Congressional staff — and, at times the members themselves — would worry about things like payment rates for wheel chairs, bidding rules for oxygen suppliers, and other micro-health financing issues.

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House Bill Fails Budget Tests

Lawmakers face more work if they want to pay for health reform. According to the latest analysis by the Congressional Budget Office (CBO) and the staff of the Joint Committee on Taxation, the House health bill fails two key budget tests:

New spending isn’t fully paid for. House committees haven’t identified enough spending reductions or tax increases to offset the spending. As a result, the bill would increase the deficit by $239 billion over the next ten years.

The bill would widen the structural deficit. CBO estimates, for example, that the program would increase the deficit by $65 billion in 2019, the final year of the budget window.

These budget challenges stem from the fact that the House bill would increase spending in two major ways:

House Bill - Net Budget

First, the House bill would increase health insurance coverage. As noted in a previous CBO analysis (and summarized in a recent post), that effort would have a net budget impact of $1.04 trillion over the next ten years; spending would increase by almost $1.3 trillion, while tax revenues would increase by about $240 billion.

Second, the bill would change the formula that determines how much Medicare pays physicians. Those payment rates are scheduled to be cut 21% next year under an arcane formula (the sustainable growth rate mechanism). The House bill would replace those cuts with increases in coming years, at a cost of $245 billion over the next ten years.

As I’ve noted in previous posts (e.g., here), a key risk is that health reform would put the U.S. on an even worse fiscal trajectory. As shown in the following graph, that’s exactly what would happen under the current House bill:

Offsets Dont Keep Up

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CBO, Health, and the Budget

As I’ve discussed in a series of posts (e.g., here and here), the Congressional Budget Office (CBO) has a pivotal role in the health debate. By telling Congress how potential policy changes would affect the budget, CBO analyses can make or break proposed legislation.

As a result, I think it’s important that participants in the health debate – policymakers, analysts, journalists, and ordinary citizens – understand how CBO approaches health issues. That can sometimes be a challenge, however. As I note in a new paper:

CBO analyses often rely on sophisticated economic modeling and are usually framed in ways that match the specific, sometimes arcane, requirements of the congressional budget process. As a result, the cost estimates and related analyses may sometimes be challenging to understand. The unfortunate result can be confusion about what the scores mean and, equally important, what they do not mean.

That’s not a knock on CBO, which I think does a great job; it’s just the nature of the work.

To help reduce potential confusion, my paper (“Understanding CBO Health Cost Estimates”) discusses how CBO approaches cost estimates and some of the particular issues that arise in health policy. Many of the insights come directly from recent CBO reports (CBO takes transparency seriously), while others are based on my own experiences at CBO.

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Raising the Curve, Not Bending It

Doug Elmendorf, the director of the Congressional Budget Office, has one of the most difficult and important jobs in Washington: delivering tough budget news to Congress.

Americans are fortunate that he is so good at it.

Today, Doug’s message was particularly stark — and, in many circles, unwelcome — as he reported that the health reform proposals now under consideration by Congress would worsen our already-daunting fiscal outlook.

As noted by the Associated Press:

From the beginning of the health care debate, Obama has insisted that any overhaul must “bend the curve” of rapidly rising costs that threaten to swamp the budgets of government, businesses and families.

Asked by Senate Budget Committee Chairman Kent Conrad, D-N.D., if the evolving legislation would bend the cost curve, the budget director responded that — as things stand now — “the curve is being raised.”

Explained Elmendorf: “In the legislation that has been reported, we do not see the sort of fundamental changes that would be necessary to reduce the trajectory of federal health spending by a significant amount. And on the contrary, the legislation significantly expands the federal responsibility for health care costs.”

Even if the legislation doesn’t add to the federal deficit over the next years, Elmendorf said costs over the long run would keep rising at an unsustainable pace.

CBO on the House Health Bill

On Tuesday, the Congressional Budget Office (CBO) released a preliminary analysis of the House health bill, aka the Tri-Committee bill. Among the key findings:

1. The bill uses five levers to increase health insurance coverage:

Expanding Medicaid
Subsidies for purchasing insurance through new exchanges
An individual mandate (enforced by a penalty if you lack coverage)
Play or pay (requiring employers to offer qualifying insurance or pay a tax)
A public plan (whose rates would be lower than those of many private plans)

2. These provisions would sharply reduce the number of uninsured. In 2019, for example, CBO estimates that the number of uninsured would fall from 54 million to 17 million, a decline of 37 million. Many of those who would remain uninsured are particularly difficult to reach (e.g., individuals who qualify for Medicaid but don’t enroll) or are unauthorized immigrants (who aren’t a focus of the legislation). Put another way, the bill would result in 97% of the non-elderly (excluding unauthorized immigrants) having health insurance by 2015.

3. The bill would increase spending by almost $1.3 trillion over the next 10 years. The penalties and fees would raise a bit less than $240 billion over the same period, so the 10-year net budget cost would be slightly more than $1 trillion. The bulk of the penalties and fees — $208 billion — would be paid by employers (who would then pass on some or all of the costs to workers). The remaining fees — $29 billion — would be paid by uninsured individuals. As Keith Hennessey notes, the prospect of levying such fees on the uninsured raises some difficult political and policy questions.

4. Enrollment in the public plan would be substantial, perhaps 11 to 12 million people by 2019. The plan, operated by the Secretary of Health and Human Services, would pay providers at levels very similar to those in Medicare. As a result, CBO expects that the public plan would offer lower premiums than many private plans.

5. The analysis is preliminary in two key ways:

It does not include any of the potential offsets — e.g., tax increases and Medicare spending reductions — that lawmakers would need to pay for the bill.
The CBO estimate is based on “specifications” that the committees asked CBO to evaluate. CBO has not yet had time to analyze the actual language of the proposed bill. It’s always possible that the language would have different impacts than the less-detailed specifications.

UPDATE: The Committee for a Responsible Federal Budget takes a stab at toting up the likely offsets for this bill. A surtax on high earners would be the single largest item, at $544 billion over ten years.