The Regulatory State Reaches the Wellness Industry

The Equal Employment Opportunity Commission (EEOC) has finalized rules on how employers can use wellness programs. By current federal standards, the rules are concise: 19 pages pertaining to the Americans with Disabilities Act and 17 pages pertaining to the Genetic Information Nondiscrimination Act. Both laws are extremely popular. The ADA (1990) passed by 91-6 in the U.S. Senate and 377-28 in the U.S. House of Representatives. The GINA (2008) passed by 95-0 in the Senate and 414-1 in the House.

These laws are meant to prevent discrimination. However this bumps against the real world where health insurers cannot charge different premiums to individuals who are sick. The Accordable Care Act (2010) allows employers to offer incentives to workers who participate in wellness programs, and can offer financial incentives up to 30 percent of premium (or up to 50 percent for anti-smoking programs). However, participation in a wellness program also necessitates surrendering personal health information to an employer who would otherwise be barred from having it (under the Health Insurance Portability and Accountability Act, 1996).

The Fantasy of Single-Payer Health Care in the States

(A version of this Health Alert was published in the Washington Examiner)

One of the defining characteristics of Bernie Sanders' socialism is single-payer healthcare, a fully taxpayer-funded universal medical system. Single-payer healthcare has long had a following in the United States, but it is unlikely to become federal policy. Obamacare's setbacks have made Americans less confident than ever that the federal government could operate such a system.

So single-payer advocates are focusing on individual states. This November Coloradans will vote on single-payer healthcare. A couple of years ago, Vermont's governor tried to institute it, but gave up short of the finish line. Other states will surely try. I would put Oregon and (maybe) Hawaii at the top of the list of states to watch.

If successful, this would be a Canadian-style roll-out of single-payer healthcare, which began in individual provinces in the mid-20th century and subsequently won federal support. However, there are significant obstacles to any state instituting true single-payer healthcare in 21st-century America, even if the people or politicians choose it.

Health Services 50 Percent of GDP Growth

This morning’s third estimate of GDP for the first quarter significantly increased the estimate of health spending, such that it comprised one half of GDP growth in the first quarter.

Spending on health services continue to dominate weak GDP growth. Growth in health services spending of $33.3 billion (annualized) comprised 50 percent of GDP growth. However, there was shrinkage in personal consumption expenditures on goods and private domestic investment. This meant personal expenditures on services grew much more than GDP overall. Growth in spending on health services amounted to 62 percent of growth in personal consumption expenditures and 35 percent of spending on services. Spending on health services grew by 6.4 percent, almost twice as much as growth in spending on non-health services (Table I).

Consumer Price Index: Rx Prices Decline

Hard to believe, but prescription drug prices actually declined in May’s Consumer Price Index – down by 0.4 percent versus all-items CPI increasing by 0.2 percent and even medical care CPI increasing by 0.3 percent (Table I).

Health Technology Forum: DC June 22 - The Doctors Speak!

Join us on June 22 at 6 p.m. in Washington, DC for the next Health Technology Forum: DC.

Health Technology Forum: DC has hosted entrepreneurs and others with great solutions to our healthcare challenges.

Now, it's time for the doctors to speak! Join us for a panel of physicians who will explain the impact technology is having on their practices. What is working well? What is working poorly? What new health technologies do they want to see in the next few years to improve their abilities to take care of patients?

Learn more and RSVP at this link.

Producer Price Index: Pharma Prices Finally Tame

The Producer Price Index (PPI) for final demand goods grew 0.7 percent last month, or 0.3 percent less food and energy. Remarkably, prices for pharmaceutical preparations and medical devices grew less. Pharmaceutical prices were actually flat (Table I).

The Real Lesson of John Oliver’s Medical Debt Forgiveness Stunt

Late-night TV host John Oliver recently caused a stir by attacking debt collectors in a clever way. He set up his own collection agency, bought $15 million of medical bad debt, and then forgave it all. This was all done on TV, to the cheers of his audience.

Oliver claimed to have outdone Oprah Winfrey, who once gave a car to each person in her studio audience. Oprah’s car give-away cost $8 million, just over half of Oliver’s. So, Oliver wins the charitable ego competition, right?

Obamacare Slightly Increased Short-Term Uninsured

The best measurement of people who lack health insurance, the National Health Interview Survey published by the Centers for Disease Control and Prevention (CDC), has released early estimates of health insurance for all fifty states and the District of Columbia in 2015. There are two things to note.

First: About 70 percent of residents, age 18 to through 64, had “health insurance” in 2015, which is the same rate as persisted until 2006. Obamacare has not achieved a breakthrough in coverage. It has just restored us to where we were less than a decade ago.

What has also happened is a significant change from private coverage to government welfare (primarily Medicaid). The shift has been about five percentage points since 2006, and ten percentage points since 1997. (That is, there was no net change in coverage before the Great Recession, but there was crowding out of private coverage in favor of welfare.)

Categorizing people on welfare programs like Medicaid as having insurance is inaccurate, for the same reason categorizing people receiving cash welfare with employed people into one category of people “earning incomes” would be inaccurate.

Second: The National Health Interview Survey is the best survey because it asks people three questions: Whether they were uninsured at the time of the interview, whether they were uninsured for any time within a year, and whether they were uninsured for more than a year. Unfortunately, it does not differentiate between private coverage and welfare.

Between 2013 and 2015, the number of people who were uninsured for one year or more declined by 12.7 million, from 30.5 million to 17.8 million. However, the number uninsured for less than a year increased slightly from 16.9 million to 17.7 million.

I believe this reflects churning between private coverage, Medicaid, and Obamacare exchanges in the increasingly fragmented post-Obamacare landscape. People fall through the cracks, overwhelmed and confused by an unnecessarily complicated “market.”

Reform Medicare Part D To Improve Access To Medicines

Specialty drugs are typically high-cost prescription drugs used to treat complex chronic and/or life threatening conditions. Many do not have substitutes available at lower costs.  Over the last decade, the Medicare Part D benefit has imposed high out-of-pocket costs as a way to control costs of specialty drugs. This is causing many patients not to fill prescriptions. Some patients may be adding costs to the system by getting drugs more expensively by injection in doctors’ offices, where they are covered by Medicare supplemental insurance.

Quarterly Services Survey: Strong, Inconsistent Growth in Health Services Revenue

This morning’s Quarterly Services Survey from the Census Department showed good growth in revenues for health services, but it was inconsistent within the industry. Overall, first quarter revenue grew 0.7 percent from the fourth quarter and 5.2 percent from the first quarter of 2015 (Table I).

Obamacare 2016 Premium Hike 8 Percent

We are already anticipating double-digit premium hikes for Obamacare plans in 2017, based on insurance filings in a sufficient number of states to show the trend.

Obamacare’s defenders point out two limits to these leading indicators. First, they are requested, not approved rate hikes. Second, Obamacare beneficiaries can trade down. A person whose plan hikes premiums double digits can switch to a plan with a lesser increase. Both criticisms are fair.

Nevertheless, now that the dust has settled on 2016, and all the data on this year’s enrollment analyzed, we can confirm from two pro-Obamacare sources that premiums in Obamacare’s exchange plans increased by an average of eight percent from 2015 to 2016. General measures of price changes, such as Consumer Price Inflation, were effectively flat over the period. That is, the eight percent Obamacare premium hike was a real, not nominal, price hike.

Eight Thousand Non-Health Jobs Lost in May

The true scope of this morning’s miserable jobs report is disguised by the headline figure of 38,000 jobs gained. In fact, health services added 46,000 jobs while civilian non-health, non-farm employment dropped eight thousand (Table I). The warping of our economy towards the government-controlled health sector has reached the tipping point I have suggested for months.

Misleading Rhetoric on Cancer Payment Reform

A few weeks ago, Medicare proposed a pilot program to test a new way to pay doctors who inject drugs. Cancer is the big kahuna, cost-wise, when it comes to injected drugs. Medicare payment policy leads to certain industry practices to profit from the status quo. When the status quo is threatened, the “preservatives” immediately form a defensive coalition to stop the change.

Although I do not endorse this precise reform, the campaign to roll it back has become irresponsible and misleading. Currently, physicians who inject drugs are paid by Medicare a margin of 6 percent on top of a reported price called the Average Sales Price (ASP). The concern is that the oncologists make more margin off an expensive drug than a less-expensive drug.

People who sell injection drugs to physicians sometimes refer to their sales technique as “selling the spread.” Physicians, especially oncologists, sometimes say they cannot earn a living off the fees Medicare pays them, so they need to earn the “spread,” too. I do not believe there is evidence “selling the spread” leads oncologists in general to prescribe inappropriately, but others do. Further, whether this reimbursement leads to artificially expensive drugs is a different issue than oncologists’ prescribing behavior.

The New Medicare Gold Rush

(A version of this column was published by Forbes.)

Over the next few years, Medicare will significantly change how it pays hospitals, physicians, and other providers. This is sparking a gold rush among investors. BDO, a leading management consulting firm, released a report last month describing significantly increased private equity investment in long-term care facilities, rehabilitation facilities and home health agencies. BDO reported 79 deals in 2015, in which private equity sponsors invested $5.92 billion, up from just $1.67 billion in 2014. The previous high-water mark was $3.58 billion in 2011.

Health Construction Boomlet Collapses in April

The boomlet in health construction from February and March lost its wind in April. While construction overall dropped at a seasonally adjusted annual rate of 1.8 percent, health construction dropped by 3.0 percent (Table I).