Out-of-Pocket Health Costs Are Rising, But Not That Much

As a share of total health spending, they’re actually shrinking.

“Dad, I got a bill for $1,113.” One of our daughters was incensed. “I went to my doctor with a simple question. She sent me downstairs where they drew a few tubes of blood for tests. It took two minutes. How do I owe over $1,000?”

She’s not the only one outraged by out-of-pocket health costs in the U.S. Many of us feel we are paying more for less and less insurance coverage. We blame high-deductible plans, rising co-pays and other policies that seem to shift more costs onto patients. Headlines such as “Out-of-pocket health spending in 2016 increased at the fastest rate in a decade” amplify the unhappiness.

But the perception of ever higher out-of-pocket health-care costs obscures important facts.

It’s true that, in 2016, those costs rose 3.9 percent. But health-care costs overall increased 4.3 percent, so as a percentage of total health-care spending, out-of-pocket costs actually fell. And this has been the case for several years. In 2010, total out-of-pocket costs amounted to almost $300 billion, 11.5 percent of national health expenditures. By 2016, they rose to slightly more than $350 billion, but fell to 10.6 percent of total spending.

What’s going on? Well, a lot of people point to businesses shifting more workers into high-deductible health plans. Such plans save an employer, on average, more than $1,500 per insured family. In 2017, more than half of all insured American workers had health insurance with a deductible exceeding $1,000 — that’s almost twice as many as had such policies when Obamacare passed. But that’s not all that’s changed.

The Affordable Care Act has also limited many Americans’ exposure to extremely high out-of-pocket spending. By expanding insurance coverage, it has lowered the number of Americans who pay the full bill for all their health care. And it placed a legal limit on out-of-pocket costs for people who have insurance. (Disclosure: We both helped design the Affordable Care Act.)

Before Obamacare, Americans who contracted cancer or had a serious accident or gave birth to a premature baby could be forced into bankruptcy. Today, even high-deductible plans must limit out-of-pocket expenses to $14,300 for a family or $7,150 for an individual. This seems like a lot of money — and it is — but these limits have significantly reduced bankruptcies caused by catastrophic health-care costs. And they’re a big reason that, despite higher deductibles, out-of-pocket spending has fallen as a share of overall health spending.

To some extent, people’s outrage can be explained by the psychology of high deductibles. Most people are not very sick, and find it daunting to have to pay $3,000 before their insurance benefits kick in.

What’s more, people tend to deal with deductibles irrationally. Even patients with chronic illnesses who go to the doctor a lot, get a lot of tests and are maybe even hospitalized — and therefore are sure to reach their deductible limit in the year — hold off getting medical tests and treatments at the start of the year, research has shown. Yet delaying medical care because of the deductible can undermine a person’s health. This is why the Affordable Care Act requires insurers to cover, without deductibles, preventive services and three primary care visits. This, too, has enabled Americans to save on health-care costs.

Of course, it’s very unpleasant to receive a bill for $1,113 — but it is dramatically more so to face bills amounting to $20,000 or $30,000 when you get seriously ill. We believe health insurance should involve more protection against very high costs, even as it provides more exposure to small ones. That’s effectively what is happening.

Originally published at bloombergview.com on January 4, 2018.

This column does not necessarily reflect the opinion of the editorial board or Bloomberg LP and its owners.


Virtual Reality Can Conquer Real Pain

It’s a promising medical weapon to deploy in the opioid crisis.

Despite all efforts to combat the opioid epidemic, the crisis continues to destroy lives and contribute to the growing gap in life expectancy by income and education in the U.S. But it appears that some relief may come from an unexpected source: virtual reality. Anyone who thinks virtual reality is just a sideshow for gamers should pay close attention to the stunning results it’s achieving in the medical world.

A virtual reality game called SnowWorld — in which patients throw snowballs at snowmen while virtually immersed in a white, snow-covered environment — has been used for more than 20 years to relieve the pain experienced by burn victims, and it’s been surprisingly effective. As David Rhew, the chief medical officer at Samsung Electronics America, recently explained to me, the promising results from burn management have led to broader use of virtual reality in an array of medical settings, including the type of chronic pain that leads to opioid abuse.

In one trial at Cedars-Sinai Medical Center in Los Angeles involving 100 patients experiencing significant chronic pain, half the patients played a 15-minute virtual reality game called Pain RelieVR, in which the patient tries to shoot balls at moving objects in an immersive 360-degree environment. The other half were shown an ordinary video of relaxing nature scenes.

Sixty-five percent of the virtual reality patients experienced pain relief, compared with 40 percent in the control group, and the change among the game-players was more substantial. Virtual reality seems to do more than a two-dimensional movie to shift the brain’s experience in a way that helps patients handle pain.

To be sure, this study involved only a brief virtual reality experience, and it did not randomly assign the patients to each group. But other studies of virtual reality in chronic pain management are showing similar results. The conclusion of a review done several years ago remains true today: “Virtual reality has consistently been demonstrated to decrease pain, anxiety, unpleasantness, time spent thinking about pain and perceived time spent in a medical procedure.”

Perhaps the most remarkable medical results from virtual reality involve spinal cord injuries. In a small study of eight Brazilian patients who were paralyzed below the waist, researchersused virtual reality, a robotic suit and tactile limb feedback to train the subjects’ brains to develop alternative neural pathways to the affected limbs. After a year, all of them experienced some improvement, and half were upgraded from full lower-body paralysis to partial. (None of these patients were able to walk independently, but they were closer to being able to do so. One patient could move her legs by herself while supported by a harness.)

There’s some concern that virtual reality, if used to treat opioid addicts, might become the focus of new kind of addiction, but even so, it wouldn’t be as deadly as the very real one we currently face.

The use of virtual reality as a medical tool is in its infancy, and the results to date should be viewed as promising rather than definitive, especially given the exceedingly small sample sizes in studies so far. Nonetheless, there’s reason to be hopeful, since the results are fully consistent with the well-researched placebo effect in addressing pain, depression and other health problems.

The brain is remarkably powerful, perhaps even able to reawaken limbs that have been paralyzed for years. Virtual reality might be able to help channel that power in beneficial ways.

Originally published at bloombergview.com on June 13, 2017.

This column does not necessarily reflect the opinion of the editorial board or Bloomberg LP and its owners.

Health Care Is Reforming, Just Not in Washington

Business leaders see better value for the dollar before the end of the decade.

As lawmakers in Washington continue their debate over how to modify the U.S. health-insurance market, health-care investors and business leaders around the world need to see past the political drama and run their businesses with a view toward improving value in health care. If they succeed, it will make a bigger difference for the cost and quality of care — globally and for most Americans — than whatever action is taken by Congress.

We’ve just finished a study involving 300 senior health-care executives from leading companies in health-care services, pharmaceuticals, biotechnology and medical devices, along with top investors in the field. And it’s clear that they see big changes in the years ahead, driven largely by pricing pressure across the industry.

The pricing pressures, in turn, are expected to drive innovation. Interestingly, in the coming years, changes in how health-care payments are made are expected to be the most important form of innovation, though scientific breakthroughs will also play a critical role. What’s more, these leaders expect health-care companies to engage in new partnerships and collaborations — including with nontraditional competitors in the technology world, such as Google, IBM, Apple and Fitbit.

Most surprisingly, we found strong expectations that value-based payments for medical care will displace the traditional fee-for-service model, transforming the industry over the next five to ten years. Despite doubts after the recent presidential election that the movement away from fee-for-service would continue, more than half of American executives and four-fifths of American investors who responded to the survey after Nov. 8 said they believe the majority of U.S. health-care payments will be value-based before 2020 — that is, in less than three years, a stunning shift. And the industry still expects the government to lead the way; most respondents said the U.S. Centers for Medicare and Medicaid Services will drive the payment change, though many also see private health insurers playing an important role.

To be sure, there were differences among subsets of the industry. Pharmaceutical and biotech executives, for example, tended to be more skeptical about value-based payments, with more than 70 percent doubting they would prevail before 2020. These leaders clearly had other issues on their minds; they were the most worried about pricing pressure and political risks, especially in the U.S. Almost three-quarters of American pharma and biotech executives listed the “political environment” as one of the top three drivers of drug pricing pressure, for example, whereas only about 40 percent of European pharma/biotech executives did.

And while the 300 respondents broadly agreed that innovation through new health-care payment and delivery models and scientific breakthroughs can be expected in the years ahead, investors more so than executives also pointed to other forces, including improved diagnostics and personalized medicine, and more transparency in health-care pricing and quality.

Industry leaders also expect to see a lot of dynamism in health care. More than 40 percent of executives said new partnerships will help transform health care, including partnerships with tech companies and other nontraditional competitors. In fact, 80 percent of all respondents said nontraditional competitors will change the industry, either through new partnerships or other means.

Here again, people’s views varied depending on their particular business. About 30 percent of respondents in medical devices and health-care services said nontraditional players will transform the industry over the next few years, but only 14 percent of pharma and biotech respondents agreed. More drug and biotech leaders pointed to innovation in key therapeutic areas and scientific breakthroughs. Advances in oncology and central nervous system therapies are most needed medically, they said, and offer the greatest opportunity for innovation and growth. Gene editing, therapeutic vaccines and gene therapy top their list of disruptive technologies.

Against the backdrop of incessant political chatter over repealing and replacing Obamacare, we found an industry poised for dramatic transformation, led by innovation in payment models, science and technology, and supported by new competitors, new partnerships and other strategic transactions.

Our study, in turn, provides guideposts for both government and business leaders on the best path forward in delivering higher-value health care. The money we spend on medicines, for example, should increasingly reflect the higher-value innovations that executives and investors anticipate. And U.S. policymakers must satisfy widespread expectations that they will move toward value-based payments that reflect the benefits of investment in innovation.

Originally published at bloombergview.com on May 15, 2017.

This column does not necessarily reflect the opinion of the editorial board or Bloomberg LP and its owners.

A Better Goal for Trump on Health Care

Forget about repealing Obamacare. Work instead on lowering medical costs and improving treatment.


Rather than renew their failed effort to repeal and replace Obamacare, President Donald Trump and congressional Republicans should move on to another aspect of health care: the need to contain costs and improve value.

Such a shift would allow them to be far more productive. For many if not most Americans, cost trends and value matter more than what’s happening on the individual insurance exchanges. Progress on this front would raise people’s take-home pay and improve the nation’s long-term fiscal balance, while also constraining the growth in premiums for those who buy insurance on the exchanges.

All the recent debate over the individual insurance market has made it easy to lose sense of the broader picture. In 2015, more than 155 million Americans received health insurance through an employer, and another 43 million, through Medicare, according to the Kaiser Family Foundation. Roughly 80 million more received coverage through Medicaid or the individual market — the areas where Obamacare expanded access — but even here, most of the coverage still reflects pre-Obamacare Medicaid. Consider that repealing Obamacare would reduce insurance coverage by about 30 million people in 2026, according to the Congressional Budget Office. While that’s a very large number, the population with coverage through other sources is many times greater, and these Americans still spend too much for too little on health care.

So what could the Trump team do to improve value? The way to start is by addressing the extreme variation in health costs across the U.S. Within Medicare, most of the variation reflects the amount of care provided — especially in post-acute care (the care a person receives after he or she leaves a hospital, including in skilled nursing facilities). Within the world of employer-provided insurance, in contrast, most of the variation reflects prices paid.

The accumulated evidence suggests that more care is not better, at least on average. That has been confirmed by clever research just published in the Journal of Health Economics, which analyzed how costs and outcomes vary depending on which ambulance company happens to pick up a particular patient. It turns out that ambulance companies tend to funnel patients to particular hospitals, so the rotation among ambulance companies provides an almost random rotation of patients to different hospital systems. The results show that there is little if any connection between overall spending and subsequent mortality rates. But they also show that higher in-hospital spending seems to be associated with better outcomes.

In contrast, higher levels of spending after patients leave the hospital (the part that drives variation in Medicare costs) is associated with lower-quality care.

These results light the path forward for President Trump: Find ways to lower prices in employer-provided insurance, and to reduce utilization (especially of post-acute care) in Medicare. In future columns, I will explore each of these paths in more detail.

This agenda would also enable Trump to involve Democrats, whom he will need as part of a new governing coalition to pass spending bills and a debt limit increase this year. After all, plenty of Democrats would rather find ways to deliver better-value health care than debate proposals to take people’s insurance coverage away.

Originally published at bloombergview.com on April 25, 2017.

This column does not necessarily reflect the opinion of the editorial board or Bloomberg LP and its owners.

The Wrong Way to Lower Health-Insurance Premiums

Republicans’ Obamacare replacement would bring lower-value policies.

For proponents of the American Health Care Act, perhaps the most encouraging nugget in the Congressional Budget Office’s otherwise critical analysis is that insurance premiums could fall by 10 percent on average by 2026. Even this prediction is more mirage than reality, however, in part because of an obscure concept known as “actuarial value.”

As many opponents of the Republicans’ Obamacare replacement legislation have already noted, for many people, the decline in premiums would be smaller than the cutback in their subsidies, so they would still end up paying more. And in any case, the predicted fall in premiums partly reflects a troubling rise in the share of older Americans without insurance, a change that would shift the enrollment pool to younger, less expensive beneficiaries.

From Bloomberg View – Articles by Peter R. Orszag

Selling Health Insurance Across State Lines Won’t Save Money

An idea that sounds easy is too complicated to work.

The effort to replace Obamacare faces increasing challenges, the more it is subjected to the harsh light of scrutiny. A good example is the proposal, apparently central to the Republican replacement plans, to allow people to buy health insurance across state lines.

This idea has been put forward as an elixir to all sorts of health sector problems. In his joint address to Congress, President Donald Trump argued that allowing people to buy health insurance in other states would “create a truly competitive national marketplace that will bring costs way down and provide far better care. So important.”

From Bloomberg View – Articles by Peter R. Orszag

Here’s How Trump Will Change Obamacare

Congress will take symbolic steps while states do the work.

Promises made by Donald Trump and Republicans in Congress to repeal and replace the Affordable Care Act are proving to be more complicated than they sounded on the campaign trail. With reality now setting in, what’s most likely to happen?

I expect to see Republicans stage a dramatic early vote to repeal, with legislation that includes only very modest steps toward replacement — and leave most of the work for later. Next, the new administration will aggressively issue waivers allowing states to experiment with different approaches, including changes to Medicaid and private insurance rules. At some point, then, the administration will declare that these state experiments have been so successful, Obamacare no longer exists.

In other words, the repeal vote will be just for show; the waivers will do most of the heavy lifting.

From Bloomberg View – Articles by Peter R. Orszag