By Elisabeth Rosenthal
The New York Times, September 1, 2019
As voters fume about the high cost of health care, politicians have been targeting two well-deserved villains: pharmaceutical companies, whose prices have risen more than inflation, and insurers, who pay their executives millions in salaries while raising premiums and deductibles.
But while the Democratic presidential candidates have devoted copious airtime to debating health care, many of the country’s leading health policy experts have wondered why they have given a total pass to arguably a primary culprit behind runaway medical inflation: America’s hospitals.
Data shows that hospitals are by far the biggest cost in our $3.5 trillion health care system, where spending is growing faster than gross domestic product, inflation and wage growth. Spending on hospitals represents 44 percent of personal expenses for the privately insured, according to Rand.
A report this year from researchers at Yale and other universities found that hospital prices increased a whopping 42 percent from 2007 to 2014 for inpatient care and 25 percent for outpatient care, compared with 18 percent and 6 percent for physicians.
So why have politicians on both the left and right let hospitals off scot-free? Because a web of ties binds politicians to the health care system.
Every senator, virtually every congressman and every mayor of every large city has a powerful hospital system in his or her district. And those hospitals are as politically untouchable as soybean growers in Iowa or oil producers in Texas.
As hospitals and hospital systems have consolidated, they have become the biggest employers in numerous cities and states. They have replaced manufacturing as the hometown industry in a number of rust-belt cities, including Cleveland and Pittsburgh.
Can Kamala Harris ignore the requests of Sutter Health, Kaiser Permanente, U.C.L.A. or any of the big health care systems in California? Can Elizabeth Warren ignore the needs of Partners HealthCare, Boston’s behemoth? (Bernie Sanders may be somewhat different on this front because Vermont doesn’t have any nationally ranked hospitals.)
Beyond that, hospitals are often beloved by constituents. It’s easy to get voters riled up about a drug maker in Silicon Valley or an insurer in Hartford. It’s much riskier to try to direct their venom at the place where their children were born; that employed their parents as nurses, doctors and orderlies; that sponsored local Little League teams; that was associated with their Catholic Church.
And, of course, there’s election money. Hospital trade groups, medical centers and their employees are major political donors, contributing to whichever party holds power — and often to the out-of-power party as well.
To defend their high prices, medical centers assert that they couldn’t afford to operate on Medicare payments, which are generally lower than what private insurers pay. But the argument isn’t convincing.
The cost of a hospital stay in the United States averaged $5,220 a day in 2015 — and could be as high as over $17,000, compared with $765 in Australia. In a Rand study published earlier this year, researchers calculated that hospitals treating patients with private health insurance were paid, overall, 2.4 times the Medicare rates in 2017, and nearly three times the rate for outpatient care. If the plans had paid according to Medicare’s formula, their spending would be reduced by over half.
Most economists think hospitals could do just fine with far less than they get today from private insurance.
While on paper many hospitals operate on the thinnest of margins, that is in part a choice, resulting from extravagance.
It would be unseemly for these nonprofit medical centers to make barrels of money. So when their operations generate huge surpluses — as many big medical centers do — they plow the money back into the system. They build another cancer clinic, increase C.E.O. pay, buy the newest scanner (whether it is needed or not) or install spas and Zen gardens.
If hospitals were paid less via regulation or genuine competition, they would look different, and they’d make different purchasing decisions about technology. But would that matter to medical results? Compared with their European counterparts, some American hospitals resemble seven-star hotels. And yet, on average, the United States doesn’t have better outcomes than other wealthy nations. By some measures — such as life expectancy and infant mortality — it scores worse than average.
As Uwe Reinhardt, the revered Princeton health economist who died in 2017, told me, “If you want to save money, you have to pay less.” That means taking on hospital pricing.
Elisabeth Rosenthal, a former New York Times correspondent, is the editor in chief of Kaiser Health News, the author of “An American Sickness: How Healthcare Became Big Business and How You Can Take It Back” and a contributing opinion writer.
By Don McCanne, M.D.
Certainly the insurance and pharmaceutical industries are appropriate targets as we try to explain to the public how we can dramatically improve the financing of health care so that it becomes more accessible and truly affordable for each and everyone of us. In this article, Elisabeth Rosenthal explains why we should be looking at the hospital industry as well.
Two of the most important reasons for our high health care costs are administrative excesses and high prices. Hospitals are guilty of contributing to high costs on both counts, primarily because they not only tolerate but actually support our highly flawed method of health care financing, while actively opposing a method that would reduce administrative waste and price gouging.
It is the private insurance industry that has been a major player in tolerating and perpetuating high health care prices, and, of course, their role in increasing the administrative burden for hospitals and the rest of the health care delivery system is infamous. The hospital lobbyists are actively supporting the private insurance industry.
The single payer Medicare for All model of health care financing would change the way we fund hospitals. Instead of paying itemized fees or DRGs for each patient and the various services and products that they utilize, under single payer hospitals would be funded through global budgets, much like we fund the fire department. We would be paying the legitimate costs of operating the facility rather than payments based on driving up both prices and volume of services. Also expansion of system capacity and addition of capital improvements would be separately budgeted based on community need, thus avoiding excess capacity that embodies the Romer rule (if you have an empty bed, it will be filled), while still ensuring adequate capacity for the community.
Right now the opponents to Medicare for All are emphasizing that individuals would lose their choice of private health plans, when that financing model is responsible for much of the waste, deficiencies, and inequities in our system. Our drumbeat needs to be louder on the true sources of high costs and inequities – the perpetrators of the administrative waste and high prices. We will not adequately address those until we change the financing system to single payer through an improved version of Medicare that truly includes everyone.
Why are the hospitals in bed with the insurers instead of with us? Money. They are being paid generously for the services they offer. They seem to dismiss financial hardship and personal bankruptcy for too many of their patients as simply a cost of doing business, but those hardships stem from the fact that they are doing business with the wrong people – the private insurers. That doesn’t mean that they won’t accept funds from the public insurers, especially Medicare and Medicaid, but they don’t see that as a source of huge surpluses that they can plow back into their systems, sometimes surrounding themselves with extravagance.
Of course, there are also hospitals in communities with high rates of poverty and excess numbers of uninsured and underinsured, and many of these hospitals struggle. Single payer Medicare for All would play an important role as the great equalizer, a role that underfinanced Medicaid and charity cannot fulfill.
We can do far better, but the public has to understand how.
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