catch me if you can: hospitals, physicians, and the game of medicare payment policy department of...
TRANSCRIPT
Catch Me If You Can: Hospitals, Physicians, and the
Game of Medicare Payment Policy
Department of Health Evaluation Sciences
University of Virginia School of Medicine
October 13, 2004
Rick Mayes, Ph.D.Assistant Professor of Public Policy
2
Underlying Medical Inflation: The Rise and Fall (and Rise Again?) of Managed Care
8.5%
0.8%
6.0%
14.0%
18.0%
12.0%
13.9%
12.9%
10.9%
8.2%
5.3%
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
18.0%
20.0%
1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Year
Health Insurance Premiums
Overall Inflation
Workers' Earnings
Sources: Census Bureau, Kaiser Foundation, CMS, 2004.
3
Since 2001, on average . . .
- 5 million fewer jobs now provide health insurance in the U.S.
- the avg. cost of health insurance premiums has increased 59% (versus 10-12% in wages & general inflation)
- employee contributions for health insurance have grown: by 57% for single coverage (total of $3,695 annually, 2004) by 49% for family coverage (total of $9,950 annually, 2004) avg. premium for family coverage ($14,565 projected, 2006)
- A growing proportion of the overall increase in premiums for employers has been “shared” with employees, particularly those in small businesses.
Underlying Medical Inflation: Health Insurance Premiums
Source: Henry J. Kaiser Family Foundation/Health Research and Education Trust Survey of Employer Health Benefits, Health Affairs Sept./Oct. 2004.
6
Source: American Hospital Association’s Annual Survey of Hospitals (n=6,800 hospitals), 2005. Pearson’s correlation coefficients:
1984-1997: Medicare and Private ratios: r = -.86 1980-2003: Medicare and Private ratios: r = -.73 1984-1997: Medicaid and Private ratios: r = -.39 1980-2003: Medicaid and Private ratios: r = -.56
Hospital Payment-to-Cost Ratio by Payer, 1980-2003
101%
91%
99%102%
88%
83%80% 80%
91%
114%116% 116%
Medicare
96%
101%
88%
95%
Medicaid
92%
97%95%
93%
Private
115%
122%
131%
122%124%
70%
80%
90%
100%
110%
120%
130%
140%
81 83 85 87 89 91 93 95 97 99 2001 2003
Year
Rat
io (
in p
erce
nt)
7
Cost-Shifting (or Cross-Subsidization)
• Perhaps best thought of as a lubricant within a massive series of financial feedback loops between:
- government (Medicare, Medicaid)
- providers (hospitals, physicians) and
- private payers (insurance companies,
employers, patients).
8
Source: Glenn Melnick, “Uninsured Americans,” Hearing Before the Subcommittee on Health of the Ways and Means , U.S. House of Representatives, 108th Cong., 2nd Sess. (9 March 2004); Professor Melnick’s testimony from the Center for Health Financing, Policy and Management, School of Policy, Planning and Development, University of Southern California.
Technical Note: Data are derived from the Medicare Prospective Payment System’s Impact File, Centers for Medicare and Medicaid Services (CMS, 2004), available at http://www.cms.hhs.gov/providers/hipps/ippspufs.asp, last visited October 1, 2004).
Ratio of Hospital Charges (List Prices) to Costs in the U.S., 1993-2003
167%
175%
181%
186%
191%
211%
200%196%194%
164%
159%
150%
160%
170%
180%
190%
200%
210%
220%
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Year
9 Source: MedPAC (June 2004)
Number of Independent Diagnostic Testing Facilities,2000-2002
1,7842,012
2,4032,655
3,615
3,197
0
500
1,000
1,500
2,000
2,500
3,000
3,500
4,000
2000 2001 2002
YearEntities
Locations
Segmentation of U.S. Health Care System Increasing
10Source: CMS, Office of the Actuary, 2004.
Medicare Payments to Ambulatory Surgery Centers (in $ Billions), 1993-2003
$0.6$0.7
$0.8$0.9
$1.0$1.1
$1.2
$2.1
$1.4
$1.8
$1.6
$0.0
$0.5
$1.0
$1.5
$2.0
$2.5
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Year
Segmentation of U.S. Health Care System Increasing
12
POLICY implications of the significant rise in physician-owned: ambulatory surgery centers, specialty hospitals, and diagnostic imaging centers:
1.) prospects for improved quality, lower costs, and more professional autonomy
- not a new phenomenon (e.g., heart hospitals in London 1857, psychiatry clinics, ear
and eye hospitals, obstetrics & gynecology hospitals)
- Adam Smith and the advantages of specialization (e.g., pins and “focused factories”)
2.) financial impact on community hospitals: fair or unfair competition?
- “cherry picking” the best-insured private patients by, largely, for-profit entities
- “skimming” lower-cost, healthier Medicare cases within individual DRGs
- cardiac, orthopedic, radiological services: huge proportion of hospitals’ net revenues
3.) impact on communities’ overall access to care
- declining volume & smaller patient populations make charity care harder to provide
- vulnerability of emergency services, burn units, psychiatric facilities
- complicates doctor-hospital relationships (e.g. staff privileges, economic credentialing)
- can easily exacerbate the development of a multi-tiered health care system
13
Present & Future Concerns• (1) The ultimate cost shift is both prevalent and
increasing in scope and degree: employers passing on a larger and larger share of their increased health care costs to their employees . . .
- higher monthly wage deductions and/or increased co-payments,
deductibles, out-of-pocket costs (especially for employees’ dependents)
• (2) Beyond this strategy, more and more employers have simply stopped offering health insurance . . .
- (15% of the U.S. population is uninsured; 45 million individuals or the
aggregate population of 24 states, Census 2003)
14
Conclusion: How much should the government pay medical providers?
TOM SCULLY: “My frustration is that you’re trying to be a government contractor. Hospitals usually get about 50% of their revenues from Medicare & Medicaid; doctors, on average, generally come into practice getting roughly 30% or so from Medicare & Medicaid.
So if you’re a doctor or if you’re a hospital, fundamentally a big chunk of your business is as a government contractor. And your expectation, I think, when dealing with the government—whether you’re in the Pentagon or in health care—is boring consistency, decent operating margins that don’t flop around. If you’re Boeing, you don’t want to have a 25% margin one year and a negative 2% the next year, right?”
- Interview with Tom Scully, Administrator, Ctrs. for Medicare & Medicaid Services, 2001-2003