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Avik Roy, Contributor The Apothecary is a blog about health-care and entitlement reform. Follow on ForbesFollowingUnfollow
Pharma & Healthcare| 5/12/2012 @ 12:05PM |2,059 views How Employer-Sponsored Insurance Drives Up Health Costs 10 comments, 9 called-out + Comment now + Comment now
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A new study in Health Affairs is attracting attention for its depiction of how powerful hospitals are extracting “steep payment increases” from insurers. But what the study really tells us is how much the exceptional cost of American health insurance is caused by our system’s original sin: the fact that, due to a quirk in the federal tax code, most of us don’t buy insurance for ourselves, but instead have it bought on our behalf by our employers.
“In the constant attention paid to what drives health costs,” the authors begin, “only recently has scrutiny been applied to the power that some health care providers, particularly dominant hospital systems, wield to negotiate higher payment rates from insurers.” If you’re a regular reader of The Apothecary, you know from where some of that scrutiny has come. And hence, you won’t be surprised to learn that the Health Affairs study does indeed find that powerful hospital systems have the power to dictate prices to insurers.
“Must-have” hospitals possess pricing power
There are some predictable nuances to the authors’ findings, which are based on the Community Tracking Study from the Center for Studying Health System Change. (The study’s lead authors, Robert Berenson and Paul Ginsburg, hail from that institution.) The authors found that top-tier, “must-have” hospitals had the strongest leverage over insurers. These are the brand-name hospitals, like Harvard-affiliated Partners HealthCare in Boston, that insurers have a tough time leaving out of their provider networks. Second-tier hospitals that provide unique services, like organ transplantation, have some leverage over insurers, but not as much as the “must-haves.”
Third-tier hospitals—typically community hospitals and Medicaid-oriented safety-net institutions—had the least amount of leverage. The Community Tracking Study conducted 539 interviews with local health care leaders in twelve metropolitan areas, from March-October 2010: Boston; Cleveland; Indianapolis; Little Rock; Miami; Phoenix; Seattle; Greenvile, S.C.; Lansing, Mich.; northern New Jersey; Orange County, Calif.; and Syracuse, N.Y.
Insurers have been responding to hospital consolidation with their own. In many areas, a single carrier—often Blue Cross Blue Shield—has dominant market share, which, in theory, allows the insurer to compensate for hospitals’ market power. But a secondary finding of the Health Affairs study—and, arguably, its most important one—was that these dominant insurers were not using their market power to get tough with hospitals.
“Even in markets with dominant Blue Cross Blue Shield plans—in our sample, these markets included Boston, Greenville, Indianapolis, Little Rock, Lansing, and Syracuse—respondents thought that hospital negotiating strength was growing. Perhaps more important, dominant Blue Cross Blue Shield plans were perceived as not using all of their potential bargaining power.”
Why is it that these dominant insurers are rolling over when powerful hospitals demand higher prices? It’s quite easy to explain.
Fourth-party insurance is worse than third-party insurance
The fundamental cause of this problem is the fact that only 10 percent of Americans with health insurance buy it for themselves. Due to an artifact of World War II-era wage controls, if employers take money out of your paycheck and use it to buy health insurance for you, you don’t pay income or payroll taxes on those funds. However, if you decide to buy insurance for yourself, you have to do so with after-tax dollars. As I described in a 2010 article for National Affairs, this quirk gives employers a “major incentive to provide generous benefit packages.”
For example, a worker who pays federal and state income taxes at a combined rate of 30% will receive $7,000 for every $10,000 his employer provides in gross salary. But the same employee will receive $10,000 in benefits for every $10,000 his employer spends on health insurance—a 43% improvement.
Stanford Nobelist Kenneth Arrow famously described third-party insurance as one of the principal flaws in America’s health-care market. That is to say, because patients don’t pay for their health care directly, they’re insensitive to the cost and value of that care. But the 155 million Americans with employer-sponsored insurance in fact have fourth-party insurance. Not only do they not directly pay for their care, but they don’t directly pay for their third-party insurance.
It is, therefore, no surprise that insurers cave in when hospitals demand higher prices. Workers have no idea what their employers spend on their health plans, and therefore get upset when their employers buy insurance that doesn’t provide access to brand-name hospitals. “Of critical importance [to increased hospital leverage] was employer resistance to choice-limiting networks with few providers,” write the Health Affairs authors.
If you fly from time to time, you’ve noticed that airlines have started charging for various things that used to be “free:” baggage handling, say, or in-flight dining. Many people used to the old ways complain about this, but airlines consistently find that consumers prefer lower fares to cost-inefficient, and tasteless, airplane food.
No such price signal exists in the employer-sponsored insurance market. If you bought insurance for yourself, you might be quite willing to accept health care from the “second-tier,” but reputable, hospital if it meant that you could save 30 percent on your premiums. But while you know how much you make each month in salary, you likely have no idea how much your employer pays each month for your health insurance.
The economic costs of demonizing insurers
Another, related problem, is that the left demonizes private insurers. In their eyes, the reason health care is so expensive is because these insurers supposedly jack up premiums in order to rake in ungodly amounts of “profits.” (Never mind that insurer profit margins are typically 5-6 percent, and that many private insurers are actually non-profit entities.)
Attacking private insurers also serves a political purpose, by giving progressives a rationale to replace private insurers with government-run health care. (Let’s leave aside the question of whether government-run entities are usually more consumer-oriented than private ones.)
But this political climate—in which insurers are the bad guys, and hospitals are the heroes—does a lot to drive up costs. Insurers know that they will be portrayed badly in the press if they stand up to popular, brand-name hospitals. “There is a dynamic in the market that makes it impossible for a private payer to change anything,” a Boston respondent told the Health Affairs authors. “They [the insurers] never recovered from Tufts [Health Plan] trying to take on Partners and getting beaten down. It scared everyone off…It showed that employers would not support plans in showdowns against hospital systems.”
A 2001 article from HSC describes the ill-fated showdown between Tufts Health Plan and Partners HealthCare, the hospital chain formed from the merger of Massachusetts General Hospital and Brigham and Women’s Hospital in Boston. “As the impasse played out in the media,” the authors write, “consumers and physicians flooded Partners and Tufts with phone calls expressing concern about losing access to Partners’ providers.” Eventually, Tufts caved in:
Partners HealthCare System and Tufts Health Plan announced a parting of the ways in October 2000. Although they eventually came to terms, more than three months of contentious contract negotiations took a toll. Tufts and Partners—which includes the renowned Massachusetts General and Brigham and Women’s hospitals and more than 4,000 affiliated physicians—were unable to agree on payment rates. A contract termination could have caused an estimated 100,000 people to lose access to Partners’ hospitals unless they selected another plan that included the hospital system in its network.
Claiming they had lost $42 million in treating Tufts’ enrollees in the previous two years, Partners argued it could no longer accept payments that did not cover the system’s costs. According to local news reports, in initial negotiations with Tufts, the system demanded a 29.7 percent increase over three years, or 9.9 percent per year. Partners’ previous success in gaining a double-digit payment increase from Blue Cross and Blue Shield of Massachusetts, the largest Boston health plan, also emboldened the hospital system.
Tufts counteroffered with a much smaller increase. To meet Partners’ demands, Tufts contended it would need immediate premium increases of 20-25 percent, threatening a loss of business the plan could not afford. In addition to rising medical costs, the plan was recovering from significant financial and membership losses, largely because of an ill-fated regional expansion strategy in the late 1990s.
However, Tufts faced pressure to return to the negotiating table. The timing of Partners’ contract termination during Tufts’ largest annual open enrollment period left the plan at a disadvantage, because it opened up the possibility of large-scale enrollment shifts if people wanted to maintain access to the Partners system. Moreover, as the impasse played out in the media, consumers and physicians flooded Partners and Tufts with phone calls expressing concern about losing access to Partners’ providers, while local employers pressured the two sides to come to some resolution. The state attorney general, though limited in authority to intervene, sent a letter urging the two sides to resume negotiations and avoid disrupting consumers.
Shortly after Partners broke off negotiations with Tufts, the plan attempted to contract directly with some of the large physician groups affiliated with the system. Physicians decided it was in their best interest, however, to remain aligned with the hospital system. With few remaining options, Tufts resumed talks with Partners one week after Partners broke off negotiations, and the two sides settled on a contract several days later. While neither side would disclose specifics, Tufts confirmed the deal contained significant payment increases.
The compelling solution: reform the employer tax exclusion
The solution to this problem is, from a policy standpoint, simple: equalize the tax treatment of individually-purchased and employer-sponsored health insurance. If more people bought insurance for themselves, more people would understand the tradeoffs between higher prices and access to brand-name hospitals. Those “must-have” hospitals, in turn, would be more reluctant to exploit their market power to raise insurance premiums. And insurers would, in turn, have more ability to walk away from pricey hospitals, instead of rolling over and passing those costs onto their policyholders.
While such a reform would be legislatively simple, and enjoys wide consensus among economists from both sides of the spectrum, it won’t be politically easy. Most people are happy with their current insurance arrangements, precisely because they aren’t aware of how costly they really are. That’s why President Obama promised, inaccurately, that, under Obamacare, “if you like your insurance, you can keep it.”
In addition, lots of industry stakeholders are happy with the status quo. Hospitals like it, because it gives them carte blanche to raise prices. Insurers are okay with it, because the current arrangement reduces competitive pressures for those incumbent plans with huge market share. And many businesses like it, because employer-sponsored insurance creates the phenomenon of “job lock.” It’s harder for workers to leave their jobs for better ones, especially if they fall ill on the job and risk being forced to pay for costlier insurance at their next employer.
Hence, any attempt to reform the employer tax exclusion will face immense political pressure. But that short-term political pressure is nothing, compared to the long-term political pressure that the private sector will endure under the status quo. For, as insurance gets more and more expensive, and more and more Americans are priced out of the system, calls for socialized medicine will grow louder and louder.
The best thing about Obamacare is that the debate around the program has brought considerable attention to the real problems facing our health-care system. That political window will not last forever. For market-oriented health reformers, it’s either now or never.
Follow Avik on Twitter at @aviksaroy.
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CommentsCalled-OutExpand All Comments For those who watched the video! The average family of 4 in America spends $20,000 annually on healthcare? Family of 4 means mommy, dad and 2 children? Any couple living with 2 kids ask your neighbors, how much you spent on healthcare? Oh, not in premiums, but doctor visits at $90 per visit, blood labs at $100? Maybe a colonoscopy for $1,500? Average family going through $20K? No way!
See, averaged into the average family number are very-very sick folks spending many $100s of thousands per year on life threatening diseases. Yes, terrible, but not average. It’s very easy to jumble figures, confuse and mis-direct.
Notice the article said 0 about the direct cause of 75% plus of our national health expense. CHRONIC DISEASE! Folks suffering/dying from cancer don’t care if the health premiums are tax deductible! ESRD patients waiting for a kidney transplant don’t seem to mind either. It’s not so complex. Alter the inventory of emerging disease and do our best for those suffering.
Employer based works because we spend the majority of our awake time at work with many of our best friends. Have employers present value based wellness systems to facilitate people working together for good health.
Called-out comment Permalink Flag Reply The point of insurance is to protect against future illnesses, not against illnesses that have already taken place. Having said that, there is a need to transition people from the old system into the new one.
Permalink Flag Reply Avik,
I read your work because I need a healthy dose of conservative thought, even if I normally disagree and find your writing (incredibly) imbalanced.
However, here we have a common ground.
First, insurers get the blame (and the focus of the soon-to-be-overturned law). Yet, they aren’t responsible for the cost of care – physicians, hospitals, and pharma companies drive the costs disproportionately high. Tort reform is clearly needed to hold down commercial liability insurance costs, but the absurd charges for care are due to providers, not payers. However, insurers’ use of recision, unwillingness to cover those with prior conditions and uneven use of adjudicating medical necessity have earned them their reputation. Oh, and let’s not forget their byzantine interactions with members around billing, EOBs, EOCs, ID cards, customer service, etc. Provider experiences are even more bizarre. I can’t understand why insurers accept paper claims or enrollment in the modern, internet-enabled world, but they do. The entire health system operates like 1980s firms in 2012 – though something could be said for the DOIs that require multiple mailings instead of monthly bills…but I digress…
Allowing individuals to purchase insurance and get the same tax benefit is definitely part of the problem/solution. And, as you previously wrote, allowing interstate competition is another important component. However, these issues address insurance, not the cost of care. Its the same unhealthy focus on insurance that the Democrats had in fashioning the law.
Within this this focus, you’ve not discussed preexisting conditions. This is the problem with the individual market. It is nearly impossible to obtain commercial health insurance if you have a preexisting condition. If you can fine someone to underwrite the policy, premiums may be 2x-3x larger than already high costs. A family of four in California would normally pay $1200-1400/month for health insurance. A preexisting condition could make the plan cost over $2000. Consider that the average family gross income in the state is around $45k, and you’ll see that after tax income makes such a plan unfeasible. Remember, such a plan may only cover 80% of out of pocket…the family with the preexisting condition still must pay the other 20%.
The issue comes down to the fact the many people don’t have preexisting conditions that their personal choices created. Cancer is a great example. Not every woman who suffers from ovarian cancer smoked or led an otherwise unhealthy lifestyle. Say you were hit in an auto accident and now have a permanent disability requiring regular care (e.g., back problems). How can commercial insurers profitably underwrite those that have preexisting conditions? Or must these people be shoved into state high-risk plans and burden tax payers?
I don’t pretend to have the solution that would make everyone happy. And, as you’ve written in the past, there is no silver bullet. The industry needs a box of silver ammo to resolve all the issues. However, those who clamor for single payor solutions earn points for figuring out how to make care affordable by unselfishly spreading the cost across more individuals – although they continue to ignore the true issue in American health care. The cost of the care itself. No individual tax credit can make-up for this enormous issue.
Despite all the folks who point holes at the inefficiencies that drive up the cost of care, the bottom line is those process inefficiencies amount to sizable molehill, but just a molehill The mountain really is made-up of what physicians, hospitals, and pharma companies charge and their business practices that increase the cost of care, such as following out-dated medical practices (e.g., over use of antibiotics), quality issues that cause repeat visits, and marketing practices that influence unknowledgeable consumers to request treatment they don’t need (e.g, brand name vs. generics or prescribing care instead of addressing root cause of health issue by living a healthier lifestyle). Don’t get me wrong, its not a pile of greed and ineptitude, but there’s got to be reason why the cost of care in the USA is so much higher than other western countries – and its not just tort reform issues.
Keep the conservative content coming, though I encourage you to consider more balance in what you write so that your ideas would reach a wider audience :)
Regards,
Called-out comment Permalink Flag Reply Thanks Tony. I have a point of view–I don’t think there’s anything wrong with that–but I do try to address fair-minded critiques from the other side. And I do have quite a large number of left-of-center readers.
As to your point about pre-ex, I can’t cover everything in a single blog post. But in previous posts, I’ve pointed out that pre-ex goes away if people own their own insurance, with guaranteed renewability. For the people currently suffering from pre-ex, you’d need a high-risk pool or some sort of one-time guaranteed issue, in order to get them into the system.
Permalink Flag Reply To say that the healthcare system is complex is a bit of an understatement, but it isn’t broken, and we are not in a healthcare crisis. We are in a ignorance and irresponsibility crisis. That might sound a bit harsh but we smoke, eat, and drink ourselves out of health, and then we expect someone else to foot the bill. The author is correct, group insurance policies provided by your employer are driving up healthcare costs, but the reason he gave does not even begin to scratch the surface of why it drives up costs, and are in some ways very very untrue. First of all group health insurance is not health insurance. Insurance is the one thing you spend ALOT of money on, and hope you never use. The reason you buy it and hope you never use it is because its for future risk. These days most people switch careers or jobs 8 to 9 times during their lifetime, and having insurance through your current employer is most likely temporary. In 1950 GM was the first company to pay for 50% of its employee’s health insurance, and as the author mentioned this was because of a tax deduction, fast forward to the 2000's when GM was the first company to reduce the amount it spent on employee healthcare by over 1 billion. The employer-sponsored health insurance system, as we know it, is dead. People are failing to realize that group health plans have many many sick people in them, because they cannot be denied coverage on a group plan. It is in fact the increasing number of sick people joining groups that is driving up the premiums for employer sponsored plans. People also fail to realize that individual health insurance is becoming more affordable for several reasons. First when you buy an individual plan your risk is spread across the entire nation, not just the group of people working at the same company. Second, people with pre-existing conditions can be denied coverage for individual insurance and the risk pool is much much smaller. Third, you can customize your plan to fit your needs, if you don’t go to the doctor more than twice a year, why pay an extra $75 a month in premiums to have a copay? If you pay $75 a month for 12 months you have paid $900 that year to have the OPTION to pay $25 or $35 IF you end up going to the doctor. You could have gone to the doctor roughly 9 times (through your network discount) for the $900 you paid to have a copay, and didn’t use. What sense does that make? Also, I truly feel for those who have a pre-existing condition and cannot get their own individual health insurance, and I am not trying to be cold hearted by saying they should be denied coverage, pre-existing conditions are a huge problem and it needs to be fixed but lets look at the reality of it.. Temporary group insurance plans are the reason we have a pre-existing condition problem in our country. If people had individual plans in the beginning, that they could not be kicked off of, and could take with them wherever they went and wherever they worked, the pre-existing condition problem wouldn’t exist. The only way to move forward from here is to make sure individuals, from now on, get their own insurance, separate from their employer, before they become sick. I am incredibly proud to say that I am an insurance agent working with a company, called Genesis health, that has created a groundbreaking concept that dismantles overpriced, ineffective, scotch taped together, post world war II, FAKE group insurance. I work with employers to give employees their own individual plans that reduce deductibles to 0, cuts costs by at least 22%, while simultaneously increasing benefits. The employer can also choose to pay all, part, or none of the premiums for the employee..
Called-out comment Permalink Flag Reply Great points all.
Permalink Flag Reply There are different types of health care and hospital emergency medicine seems to be paid for by the government whether one has insurance or not. It would seem to be efficient to have the government pay for these services and set the price as necessary (as is done in Workers Compensation and Medicare). These essential costs for essential services may amount to 50 to 60% of current health care costs. Individuals might be permitted to elect to take a voucher and purchase expanded hospital services including any number of elective treatments, private rooms, etc.
In regard to non-emergency services, it is certainly prudent to have insurance for general doctor visits but people should be free to simply pay with cash as needed. With a division of health services, the government would exert primary control over emergency care costs and both the insurance companies and free market would keep the cost of doctor visits in check.
Tort reform and open enrollment may also be needed to level the insurance markets. Innovation and provider competition might require health insurers to receive and maintain digital health records of all patients, identify and help create best practices (i.e. interactive online patient questioners, nurse and physician assistant triage, video examinations, and doctor referral scheduled only as needed), and steer patients to cost effective providers (through lower co-payments and other incentives). Have faith that managed competition can improve quality and reduce the cost of health care.
From a tax reform perspective the government coverage for emergency hospital care or voucher for upgraded insurance should be enough of a government contribution to permit the elimination of other health tax subsidies. Substantive changes in health care policy can not be expected before tax reform and a stable economy.
Of course, the Supreme Court could sustain Obama Care.
Called-out comment Permalink Flag Reply Here again we have to look at the unintended consequences. If an employer considers your benefit part of your income, are they going to drop the benefit and pay you the equal increase in pay? And if so is this going to raise your personal tax liability? But the reality is I think we would be hard pressed to get those dollars paid to the employee so they can afford to pay 100% of the premium.
And I don’t know what circles everyone runs in, but most companies for most employees only pay a portion of the premiums, very few unless at high levels pay 100% of both the individual and family coverage.
But the most attractive aspect of the person buying their own insurance is the mobility it gives them if they decide to leave a job and it eliminates the hated pre existing condition concerns since you already have the policy in place you won’t have that waiting period.
And to the poster below, the real numbers the average american pays is $8,000 to $12,000 in premiums, regardless who is paying it and one in every 2.5 plans now carries a deductible that averages $3,000 for an individual and $6,000 for the family. And even these are more than they can afford based on median income.
And for the record, nearly 90% of all the cost of health care is driven by 5% of the population. The elderly and the chronically ill. On the other hand the actual encounters or visits are spread much more evenly.
Regards all
Called-out comment Permalink Flag Reply What if the Federal government just eliminated the subsidies for corn production, effectively forcing up the price of meat and high fructose corn syrup. What if the subsidies were reallocated to the production of fruit and vegetables? How much would we save with fewer fat people and more healthy people? This year a record number of Americans will be signing up for Medicare and many of us will be entering our peak consumption years of medical care. FDR is only part of the cause of our health care problem. Let’s face it. As a society, we are too damn fat. Many of us also smoke too much and drink too much. How much did Christopher Hitchens cost the medical insurance industry after he was diagnosed with cancer? There is no free lunch.
Called-out comment Permalink Flag Reply Sorry one more point to make. If you are not aware, the regulations and laws governing employee sponsored insurance require that if you offer one employee health insurance you must offer it to all. This of course creates unintended consequences as well. Smaller companies will not offer these to avoid the huge costs this creates.
However if you offer it to an employee now and they choose not to participate, they are not obligated to pay the employee the additional income. So there is no incentive for the employee to decline and go to the open market to buy a policy of their own. Just another example of government intervention in private industry creating unintended consequences that limit both industry and consumer from being able to take advantage of a true free market influence.
Once you are in a company pool as the payouts increase in that pool all the premiums for that pool increase. Whereas if you were able to shop it personally you could constantly look for less costly pools.
Permalink Flag Reply Most Read on ForbesI am a Senior Fellow at the Manhattan Institute for Policy Research and a member of Mitt Romney’s Health Care Policy Advisory Group. To contact me, click here. To receive a weekly e-mail digest of articles from The Apothecary, sign up here, or you can subscribe to The Apothecary’s RSS feed or my Twitter feed. In addition to my Forbes blog, I write on health care, fiscal matters, finance, and other policy issues for National Review. My work has also appeared in National Affairs, USA Today, The Atlantic, and other publications. Professionally, I am a health care investment analyst. Previously, I worked as an analyst and portfolio manager at J.P. Morgan, Bain Capital, and other firms.
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Pharma & Healthcare| 5/12/2012 @ 12:05PM |2,059 views How Employer-Sponsored Insurance Drives Up Health Costs 10 comments, 9 called-out + Comment now + Comment now 
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