Saturday, March 20, 2010

Understanding the Actuaries: Financial Projections in Health Reform


Health Reform will likely become law this weekend.  Many have stated that the recent financial projections from the Congressional Budget Office (CBO) that show the reform package saving money in the first ten years, and reducing the debt in the following ten years gave the wavering moderate Democrats enough political protection to vote for the bill and put it over the top.  The CBO is a very credible agency that is charged by Congress with making actuarial financial projections based on the assumptions that Congress gives it, as well as the specific wording of a bill using accepted standards of actuarial analysis.  The best way to understand actuarial science is through two old jokes.  (My take on this is influenced by my own background as a physician who was a Principle of an Actuarial Firm.)

Jokes About Actuaries

Joke #1 – Three people are trapped in a deep ditch.  They are an engineer, a builder, and an actuary.  The engineer is very upset and says “We will never get out.  There is nothing I can design to allow us to escape!”  The builder then says, “I have no lumber or tools so we will never be able to get out.”  The actuary is sitting at the bottom of the pit smiling.  He say, “Don’t worry.  I will get us out of here.  All we have to do is first assume a ladder.”

Joke #2 – A businessman has to make some financial projections for his company and does not know whether to hire a mathematician, an accountant or an actuary so he decides to interview all three in order to decide.  He first calls in the mathematician and he asks, ‘How much is 2 plus 2?”.  The mathematician answers “4”.  He next calls in the accountant and he asks “How much is 2 plus 2?”.  The accountant answers “That depends on whether we are talking about a cash basis or an accrued basis and whether it is pre tax or post tax.”  The businessman then calls in the actuary and asks “How much is 2 plus 2?”.  The actuary answers  “How much do you want it to be?”  The actuary is promptly hired.

It Is All About the Assumptions

In my professional life, I have spent a great deal of time helping actuaries by defining assumptions based on medical and epidemiological facts.  Those assumptions often dramatically change projections.  In the case of the current health reform package, the leadership of the Congress has developed assumptions that are designed to create a more favorable financial projection.  Thus, at the eleventh hour, the health care bill was modified to also include reform of education loans which has nothing to do with health care.  What that did do, since the CBO assesses the financial impact of the bill, is it included any savings in the education loan reform as being credited towards health reform.  Perhaps the most troubling assumption of the many that were used is the assumption that cuts in Medicare will occur even though there are no concrete proposals to cut costs in that program.  I have written previously about the fact that there is a companion bill which prevents a lowering of Medicare fees to physicians.  The bill assumes that costs will be cut by the following mechanisms:

Proposed Strategies for Reducing Health Care Spending.*

Establish insurance exchanges.

Reduce excessive Medicare payments.

Shift from a volume-based to a value-based payment system in Medicare.

Tax generous insurance plans.

Empower an independent Medicare advisory board.

Address and reduce fraud and abuse within the Medicare program.

Enact malpractice reform.

Invest in information technology and comparative-effectiveness research.

Invest in prevention.

*Adapted from Cutler.4

While Professor Cutler in his Wall Street Journal Op Ed piece outlines optimistically that these components will save money, experience states that each of these efforts will have consequences and political battles that will likely subvert the goals of creating savings.  Many of these strategies can also be put into place without the added expense of increasing coverage dramatically as this bill does and even without new legislation.  The unasked question is why, if they are able to be done, have they not been done already!  The assumptions that create the savings are based on all of these strategies being done in a non-political way that is only designed to save money.  That is rarely the reality.  We are also already investing in information technology and we are already supposed to be reducing fraud and abuse in Medicare yet costs are still rising. 

The History of Congressional Estimates in Health

This habit of creating assumptions that are overly optimistic did not start with this bill.  In 1965, the House Ways and Means Committee estimated that the hospital insurance portion of the Medicare program, Part A, would cost about $9 billion annually by 1990.  Actual Part A spending in 1990 was $67 billion.  In 1967, the House Ways and Means Committee predicted that the new Medicare program, launched the previous year, would cost about $12 billion in 1990.  Actual Medicare spending in 1990 was $110 billion—off by nearly a factor of 10.  Each time these estimates were prepared by actuaries working from assumptions from Congress.  One could go on and on.  It is safe to say that the estimate of the current health reform costing just under a trillion dollars is likely to be very low.

Who Cares?

Perhaps we should not care.  Perhaps the good coming out of the bill is so important that the high costs which every thinking person should recognize should not even be a factor in our assessment of the new law to be.  That may be the case but at the very least, we all deserved a bit more openness and honesty about the costs during the course of the debate.  A recent article in the New England Journal of Medicine put the health reform debate in the context of our national debt.  In the article, Michael E. Chernew, Ph.D., Katherine Baicker, Ph.D., and John Hsu, M.D., M.B.A., looked at our national debt and saw some danger lurking in creating a new national entitlement to increase that debt.  We are currently in debt to a point of danger to our national welfare and security.  Compared to other countries, our debt as a percentage of our Gross Domestic Product (GDP) is seen in this chart.


While the United States was once the example of fiscal strength and prudence, we are now rapidly becoming a profligate spender of other people’s money to a degree greater than Turkey and Spain.

The Answer

I don’t have one.  I only know that I am happy to see certain parts of the health reform bill become law.  I also know that the likely cost of the health reform bill is probably at least double the current CBO estimates (and I am being very conservative).  I am just fearful of the financial future of our country.  Just remember that actuaries are always slaves to the assumptions that they are given.  Unfortunately, if we are stuck in a financial hole, we can’t assume a ladder. 

Wednesday, March 17, 2010

The Fight for Health Reform

My Own Malaise

One would think that with my expertise and profession, I would be listening to the discussions about the President’s health care proposal with tremendous interest.  Instead, I find myself avoiding the news reports about the proposed legislation.  Rather than a discussion of health care, I see an exercise in raw political power that frankly, leaves me cold.  From the left of the political spectrum, I see almost rabid desire to put into place the basis for a government healthcare system based on a universal “right” of health care that is divorced from any cost discussion, being paid by taxes, presumably only on evil rich people who are defined as anyone who does not work directly for the government or in academe.  On the right we hear about the evils of any government assistance for people truly in need as a slippery slope towards communism.  We seem to have lost any middle in this argument.  Thus I feel only depression and malaise at the way the “end game” on health reform is being played.  The Congressional leadership has decided that the left is in charge so they will move ahead steamrolling those who disagree.  Those on the right appear to be accepting the inevitable while also taking political advantage of the issue for the next election cycle.  I just have deep disappointment in our government leaders who seem more intent on winning at any cost than on finding solutions for the country. 

Lowering Health Care Costs as a False Goal

The goals of health reform are supposedly twofold: increasing coverage of those who are uninsured and lowering costs.  The current legislation is totally focused on coverage for those uninsured and is actually likely to increase costs radically above any CBO estimate despite that being trumpeted as a goal.  The CBO, by law, is required to base cost estimates on only those facts and assumptions that the Congress supplies.  The Congress has created false assumptions that Medicare will show decreases in cost without any plan to decrease costs.  In health care, the only way to decrease costs is to lower payment to providers, namely physicians, hospitals, and other health care professionals and organizations, and/or lower the volume of services which is most easily accomplished by eliminating certain services as benefits.  Lowering payments to physicians is not specified in the bill but there is a fee reduction of 21% currently scheduled, however that has already been reversed by a separate bill passed by the Senate.  This separate bill is a companion to health reform that is not in the CBO calculations and it actually guarantees that physician fees will not be lowered.  Since this is separate legislation it avoids inclusion in the calculation of costs related to health reform.  Recently a bill did pass the Senate maintaining physician salaries for the short term at least.  The AMA memo to their members about that bill read as follows:

AMA renews call for permanent reform of Medicare payment formula for America’s seniors and the physicians that care for them

For immediate release:
March 10, 2010

Statement attributable to:
J. James Rohack, MD
President, American Medical Association

“Today, the U.S. Senate voted to again delay this year’s steep 21 percent Medicare physician payment cut to October 1, pushing the problem off into the near future.  If the House adopts this Senate bill, America’s seniors and their physicians will be left in limbo, and access to health care for Medicare patients will continue to be in grave danger.  Physicians cannot keep their practice doors open to all Medicare patients without clear direction from Congress on Medicare payment rates. Already, Medicare payment rates are far below the costs of providing patient care, and physicians are left wondering how they can continue to run a medical practice if Congress does not inject security and stability into the Medicare program.

“Short-term actions are the wrong answer to a long-term problem.  These band-aid fixes have only served to increase the size of the cuts and the cost of reform. The longer Congress delays, the higher the cost to the American taxpayer.  It’s time to fix the formula and ensure that seniors can count on Medicare now and for years to come.”

If the AMA is unsuccessful, we will then be in a position in which physicians will be earning significantly less for serving Medicare patients.  Physicians in response, will either stop accepting Medicare, or shift costs to commercial insurers.  The logical next step would be an outcry by the public to either raise the rates paid to physicians or force physicians to accept lower fees and lower incomes.  If they are forced to accept lower incomes, there may be many who would be happy with that turn of events however it will create a problem of the best and the brightest deciding to go into other fields that are more lucrative.  That could be a loss to all of us.  That is currently a problem in England with the medical profession lacking new young British physicians.  If the AMA is successful, we then face the problem of ever increasing health care costs unless rationing is put in place. 

Rationing means limiting the services rendered, however the current bill actually adds services by mandating certain benefits that are not the norm right now.  Under the bill, a Federal Board will determine which benefits should be mandated.  While many people worry about the rationing of care leading to fewer services, the other side of that coin is the Federal Board increasing coverage for those services that have powerful politics behind them, even if they are not medically helpful.  Thus we will likely see different groups lobbying for coverage of their pet area increasing the volume of services and increasing costs while other services are rationed to lower costs.  We already know that in states that mandate in vitro fertilization for infertility, now only do those costs directly related to in vitro services increase but the number of sick newborns also increase and that increases neonatal intensive care costs dramatically.  Will costs of mandates such as that be offset by rationing of dialysis for the elderly for example?  We just don’t know.

There are answers to this conundrum however those answers, such as health savings accounts and other vehicles which results in informed decisions by patients leading to self rationing are rejected out of hand by this current legislation.

What is the Real Goal?

If the bill is likely to increase costs then what is the real goal and how will it be achieved?  Certainly the social goal of universal coverage is laudatory however it appears to go beyond that.  Two lead opinion pieces in the most recent American Journal of Public Health suggest the long term political goals of this legislation.  In “Selling the Obama Plan: Mistakes, Misunderstanding, and Other Misdemeanors”, Howard Waitzkin of the University of New Mexico waxes eloquent about how everyone loves Medicare and how all that needs to happen is for Medicare to be the only insurer for the entire population.  He does ignore the fact that Medicare is running out of money as it has virtually no controls for cost in place.  The only way the costs would be controlled would again be lower payments to providers and rationing.  While Dr. Waitzkin expresses unhappiness with the current proposal as not going far enough, he also sees the single payer system as being put into place in the long run.  For him, that is a sign of optimism and for me, it is a tremendous fear as it will signficantly decrease medical innovation and our cultural emphasis on care for the individual.  In some ways, Dr. Vincente Navarro of Johns Hopkins University goes even further in his companion article “Consequences of the Privatized Funding of Medical Care and of the Privatized Electoral Process”.  According to Dr. Navarro, Obama’s biggest mistake thus far is that he has not gone far enough in general and has thus “antagonized the left by excluding single-payer”.  Dr. Navarro then goes on to say that this is all a problem created by a privatized electoral system.   Thus it is more government control in health care and even in electoral politics that is the ultimate goal for Dr. Navarro. 

The Audacity of Hope

The audacity of my hope is that even if this bill passes, the effects will be modulated by future legislation by new representatives in coming years.  This bill is phased in over years so I can only hope that any damage done by it can be overturned in the next few years.  This bill does have positive aspects  such as the elimination of pre existing condition provisions and we should in some way focus on the good that can come out of the legislation.  In the meantime, I just stay in my malaise.  It is probably why I could never be in politics.  It just depresses me.

Saturday, February 13, 2010

Inspiration Needed

I have been remiss in updating this blog recently, and partly it has been my tendency to wait until I see something that truly inspires me or at least amuses me enough to write about.  There has certainly been nothing in the health care debate that is either inspiring or amusing and there have not been any blockbuster scientific studies that I have read that have really caused me to sit up and take notice.  But I did receive an email from a faithful reader who asked me whether I thought it would be likely for former President Bill Clinton to have had the same care under the health care reform approaches being put forth by our Congress.  That inspired me.

What Happened to Bill?

For those of you who have not been reading the news, President Clinton has stents placed in two of his coronary arteries this past week after having chest pain.  He is a patient with known coronary artery disease who underwent bypass surgery in 2004.  According to new reports, he developed chest pain and was taken to the hospital where the procedure was done.  He was discharged twenty four hours later in good spirits and presumably in good health.  Had he not had the procedure, one can confidently predict he would have had a heart attack.

Was His Care Different and Would Reform Have Made it Different?

The short answer is that I do not believe that his care was any different than anyone else’s care at Columbia Presbyterian Hospital in New York except that I believe that the attending physician, and not the physician in training, preformed the procedure and that is often not the case in a teaching hospital such as Presbyterian.  I also don’t believe that any of the health proposals on the table would have made an immediate difference in the care he received.  Over time the proposals did put into place mechanisms that could change this approach based on cost/benefit/risk analysis.

So far, the Blog isn’t even Interesting let along Inspiring!

Yet the question made me think about other factors.  President Clinton does have excellent care and has a physician who he can call, hear he has chest pain, know him well enough to understand the possibility of a heart attack, and immediately arrange for the needed, correct care.  That is the part that seems to be to be different under today’s health care and could even get more different in a number of the proposals being made.  In today’s world of medicine for the average person, their contact with the doctor is very short and relatively impersonal.  There is no time taken to really know a patient when you are seeing twenty to thirty patients a day.  Of course there is a small number of people who the average doctors knows well, and a small number of doctors who know all their patients well, but those exceptions are on the tail end of this bell curve.  That is bad now and could conceivably get worse as we move towards a world in which physicians are incented and even rewarded for doing their work quickly and as close to a median norm as they can be. 

Personal Attention as a Vice or a Virtue

While we need to foster more evidence based medicine, more use of electronic information systems and more normative behavior among doctors, we also have to remember that medicine ultimately is personal and caring.  While I want my doctor to know the right thing to do in a situation and I want him to stick with practice guidelines and best practice standards, I also want him or her to understand that best practices are all based on statistical probabilities and that there are always people who are not in the center of the probability curve but two  standard deviations away.  A good doctor will have the judgment to ignore best practice when a patient who does not fit the norm appears.  I fear that the virtue of following “best practice” will turn out to be great for 80 – 90% of patients and potentially deadly for the rest.  Best practice medicine can easily become lowest common denominator medicine.  The present proposals, and even many of today’s approaches make the virtues of following the cookbook of best practice so overwhelming that it becomes a vice.  The moment that a physician is afraid to do the right thing for a patient because it doesn’t fit the normative notion of “best practice”. is the moment our system becomes dangerous for some of us.

Back to Bill

I don’t believe that will ever be a problem for our former President.  I have not been able to determine if President Clinton was told to call 911 and get an ambulance and then be first seen in the emergency room although I doubt it even though every protocol I know for the “best practice” of dealing with acute chest pain in a person with known coronary artery disease would call for that approach.  Under our new incentives, will his physicians be punished with lower payments or even black marks against him or her for licensure or future contracting?  Under a new system, will President Clinton have been required to first have a stress test before going straight to the angiography suite as the costs of angiography are grappled with?  I don’t know the answers and only hope that my family’s care will always be the kind of personal care that the President received.

One Last Word

I love getting questions as they do inspire me so please send them.