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No Slide Title WHY AMERICA WILL CURB THE FUTURE GROWTH OF HEALTH-CARE INCOMES AND -EMPLOYMENT Uwe Reinhardt, Woodrow Wilson School of Public and International Affairs and Department of Economics Princeton University The National on Congress on Healthcare Clinical Innovations, Quality Improvements and Cost Containment Washington, D.C. October 26-28, 2011 OUTLINE OF PRESENTATION I. THE DUAL SOCIAL ECONOMIC ROLE OF HEALTH CARE II. THE MACRO-ECONOMIC CONTEXT III. HOW HEATH CARE COULD HEAL ITSELF IV. MORE RADICAL PROPOSALS I. THE DUAL ECONOMIC ROLE OF HEALTH CARE A few decades ago, Harvard Philosophy Professor Alfred E. Neuman received the Nobel Prize in Medicine for his discovery of (a) an innovative definition and (b) a famous cosmic law.. He edited the first journal of U.S. health policy. TRADITIONL DEFINITION OF “A PATIENT” patient (pa’shent) - n. 1. A person under medical treatment. [Middle English pacient, from old French patient, from Latin patients, from pati, to suffer.] NEUMAN’S DEFINITION OF “A PATIENT” patient (pa’shent) - n. 1. A person under medical treatment. [Middle English pacient, from old French patient, from Latin patients, from pati, to suffer.] 2. A biological structure yielding cash – acronym BSYC [from 21st century fee-for- service medicine. ] AlfredAlfred E.E. NeumanNeuman’’ss CosmicCosmic HealthHealth CareCare EquationEquation HEALTH SPENDING = HEALTH CARE INCOME (Including fraud, waste and abuse) THE DUAL OBJECTIVES PURSUED IN THE HEALTH-CARE SECTOR The Health Care & Health Facet The Income--Employment Facet REAL HEALTH-CARE HEALTH SPENDING HEALTH INCOMES PROVIDERS OF $ $ RESOURCES RETURN ON CAPITAL HEALTH- HOURLY INCOME CARE PRICES OF OF PRICES HEALTH SERVICESHEALTH SECTOR HEALTH CARE REAL RESOURCES OBJECTIVE I: OBJECTIVE II: Enhance quality of Enhance quality of patients' lives providers' lives Healthcare Incomes as a Percentage of GDP, 1980-2009 19 U.S. 17 15 France 13 11 Switzerland Percent of GDP 9 7 Germany 5 Source: OECD1980 Data Base, 2011. 1982 Canada 1984 1986 Sweden 1988 1990 1992 U.K. 1994 1996 1998 2000 2002 2004 2006 2008 What drives the difference in spending (i.e., health incomes)? It is language and the mindset it begets. European and Asian providers of health care get paid and manage back from available revenue to permissible costs. American providers of health care traditionally have gotten reimbursed for whatever it costs them to produce health care as they saw fit and then expected to be reimbursed for these costs. This will change because it has to change. The word “reimbursement” will go out of style. Increasingly, thoughtful policy analysts and politicians think of the following definition of “value” in health care: Net Social Value Gross Value The Opportunity Added by the = Added by - Costs of that Care Health System Health Care to for Society Patients Among these opportunity costs (other social priorities)of health care are: • Neglecting the education of our young • Neglecting science and R&D • Neglecting the nation’s public infrastructure • Neglecting national security and safety of our warriors • Giving up other things households enjoy PROJECTED HEALTH SPENDING 2009‐19 BY SOURCE Medicare Medicaid Other Public Priv. Insce. Out-of-Pocket Other Private $5,000 Projected NHE in 2020 = $$4.6 trillion or 19.8% of GDP $4,500 vate r Pri Private $4,000 Othe OOP $3,500 $3,000 surance vate In $2,500 Pri Government $2,000 Other Public $1,500 Medicaid Billions of Dollars $1,000 $500 Medicare $0 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 SOURCE: CMS Data and Statistics, Sept. 2010 Update. http://www.usatoday.com/news/washington/story/2011-10-23/states-limit-medicaid-hospital-stays/50886398/1 So the question is where the money for the government’s half of projected total health-care incomes (spending) is to come from, given the macro-economic and fiscal challenges our nation faces. Let us briefly review these challenges. II. THE MACRO-ECONOMIC CONTEXT U.S. health care is being battered by a number of macro- economic forces, some of which are external and beyond our control, and some of which are self-inflicted wounds. Aging of the U.S. Outsourcing of jobs population, health- to computers and care costs and other nations health workforce U.S. Health Care High income Deficit-addicted, inequality and an dysfunctional federal inexorable erosion of government and solidarity in U.S. fiscally strained state health care governments U.S.U.S. fiscalfiscal policy:policy: How`` cool! Sunshine all around! © Tsung-Mei Cheng In the words of Douglas Elmendorf, the Director of the Congressional Budget Office (CBO): SOURCE: Congressional Budget Office, http://www.cbo.gov/ftpdocs/110xx/doc11047/05-13-CBO_Presentation_to_AAAS.pdf U.S. fiscal policy during the past three decades reminds me of this scientific observation that: TheThe SurestSurest SignSign ThatThat IntelligentIntelligent LifeLife ExistsExists ElsewhereElsewhere InIn TheThe UniverseUniverse IsIs TheThe FactFact ThatThat ItIt HasHas NeverNever TriedTried ToTo ContactContact Us.Us. Nixon/ Ford Carter Reagan/Bush I Clinton Bush II Obama ???? U.S.FEDERAL GROSS DEBT 1980-2011 $16,000 $15,000 $14,000 $12,000 $9,986 $10,000 $8,000 $6,000 $5,600 $4,000 $4,000 $2,600 $2,000 $909 $0 1980 1988 1992 2000 2008 2011 SOURCE: Economic Report of the President 2011, Table B78. TOTAL TAXES AS PERCENT OF GDP, 2009 Denmark 48.2 Sweden 46.4 OECD AVGE. 44.8 Italy 43.5 Austria 42.8 France 41.9 Netherlands 39.1 Germany 37 United Kingdom 34.3 Americans Canada 31.1 are not an Spain 30.7 Switzerland 30.3 overtaxed Japan 28.1 people United States 24 26.1% IN 2008 0 5 10 15 20 25 30 35 40 45 50 55 Source: OECD Tax Data Base, http://www.oecd.org/document/60/0,3746,en_2649_34533_1942460_1_1_1_1,00.html#A_Revenu eStatistics The growing U.S. federal debt – half of it owed to foreigners – and the fiscal straits of the states pose a major problem for health care, half of which already is financed by government. II. OUR UNSUSTAINABLE HEALTH SYSTEM During the past four decades, health-care spending in the U.S. have grown on average more than 2 percentage points faster than the rest of the GDP – called “GDP + 2.” It is simple math to calculate that, if that trend continued for the next four decades, on top of the 17.6% of GDP we are spending on health care now, we’ll be spending close to 40% or so of our GDP on health care by 2050. NHE GDP SOURCE: CMS Data & Statistics, 2011 MILLIMANMILLIMAN MEDICALMEDICAL INDEXINDEX (MMI)(MMI) AverageAverage AnnualAnnual MedicalMedical CostCost forfor aa FamilyFamily ofof FourFour $25,000 CAGR 2001-11: 8.8% In more recent years: 7% to 8%. $19,393 $20,000 $18,200 $16,700 $15,600 $14,500 $15,000 $13,382 $12,214 $11,192 $10,168 $9,235 $10,000 $8,414 $5,000 $0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 http://publications.milliman.com/periodicals/mmi/pdfs/milliman-medical-index-2011.pdf Although employers ostensibly pay the larger part of the premium for their employees’ health insurance, economists are convinced that virtually all fringe benefits come out of the take-home pay of workers, certainly over the longer run. Talk in Washington now is that for Medicare we need to go from GDP+2 to something less than GDP+1 or even down to GDP + 0.5 . But the very idea of even one single basis point less than GDP + 2% drives organized health care – the AHA, the AMA, PhRMA, Advamed, etc. – to utter despair. ORGANZIED HEALTH-CARE LEADERS ANNUAL MEETING Organized health-care leaders when last sighted. Someone recently told me, however, that the health- care leaders are merely faking it for public consumption – that in reality they are bungee jumping. III. INNOVATION FOR “VALUE” IN HEALTH CARE I have heard about “value” at health-care conferences for so many years now that I deploy at these conferences the latest cutting-edge technology: TheThe NioNio FenFen ProtectorProtector TMTM U.S. Veterans, for example, wear it whenever we prattle on how much we admire and love them. Among management consultants on the speaking circuit “value” is typically defined, “concretely,” as follows: QUALITYQUALITY VALUEVALUE == COSTCOST It’s a vector Q = {q1, q2, q3, ··· qN} divided by a dollar figure. Nice try! Try to make it operational. So let us work instead with the value-ratio QALYQALY e.g., QALYs added by a treatment VALUEVALUE == COSTCOST e.g., Cost added by the treatment Which can also be written as QALYQALY QALYQALY VALUEVALUE == == REVENUEREVENUE PRICEPRICE xx VOLUMEVOLUME So providers could increase value by lowering their costs, their prices and their revenues. For example, the U.S. Business Roundtable – folks who buy private insurance on behalf of their employees – now openly speak of a value gap relative to other countries. IV. COSTS, PRICES, REVENUE AND SPENDING In December 2010, the trade association of private health insurers in the US – the AHIP – published this report on the average prices charged to larger insurers by Oregon Hospitals QUESTION: Why did private insurers and employers behind them accept this steep price increase – in the midst of a deep recession? COMPARATIVECOMPARATIVE PRICESPRICES FORFOR AA NORMALNORMAL DELIVERY:DELIVERY: TotalTotal hospitalhospital andand physicianphysician costcost US 95 pctl. $13,799 US average $8,435 US low $6,379 Switzerland $3,485 Germany $2,147 But are these alien babies as good as France $3,768 American babies? Canada $2,266 Australia $4,592 $0 $2,000 $4,000 $6,000 $8,000 $10,000 $12,000 $14,000 $16,000 SOURCE: International Federation of Health Plans, 2010 Comparative Price Report. COMPARATIVECOMPARATIVE PRICESPRICES FORFOR ANAN APPENDECTOMY:APPENDECTOMY: TotalTotal hospitalhospital andand physicianphysician costcost US 95 pctl.
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