Oh no...Not again!

As the financial calamity is unfolding in Europe, I see remarkable parallels similarities between every budget crisis which has unfolded in the past 20 years. The present crisis involving Greece and the EU, has been punctuated by specific episodes where Greece faces a liquidity crisis prompting it to make an urgent request to the EU (primarily Germany) to provide access to emergency loans. The loans are made technically made contingent upon financial reform in Greece. However, once the loans are made, the leverage to hold the Greeks to their promises evaporates. With each additional cycle, those loaning the money become more and more vested in avoiding a Greek default, thus perpetuating the cycle of profligate spending, emergency bailout, followed by additional spending which outstrips economic productivity. 

  

The problem is the asymmetry of power based on the chronology of required action. Those providing the funds for bailout are required to take action up front while those who as ostensibly bound to to respond afterwards with financial reform and spending cuts are able to renege on whatever agreement that was hammered out initially. The may be because the agreement was made in bad faith but even more likely because whomever made the agreement in the first place is no longer in power when austerity actions are required to be put in place.

The same dynamic is operational in budget negotiations  in the US. Almost invariably, tax hikes are implemented immediately, sometimes retroactively. Business planning for 2011 is based upon a tax environment which may be in place as much as 12-24 months prior to 2011. However, tax rates for 2011 can be hiked basically anytime prior to when 2011 taxes are due. This can be as late as April 2012. On the other hand, spending cuts tend to be most heavily focused on out years, particularly years well after upcoming elections, after which elected officials may have little or no incentive to be held to promises which they did not make.

 This dynamic is acutely relevant to our present state in the finance of health care. I found a very interesting in Greg Mankiw's blog where he calls attention to a 1967 quote from Paul Samuelson from Newsweek magazine.

The beauty of social insurance is that it is actuarially unsound. Everyone who reaches retirement age is given benefit privileges that far exceed anything he has paid in -- exceed his payments by more than ten times (or five times counting employer payments)!

How is it possible? It stems from the fact that the national product is growing at a compound interest rate and can be expected to do so for as far ahead as the eye cannot see. Always there are more youths than old folks in a growing population.

More important, with real income going up at 3% per year, the taxable base on which benefits rest is always much greater than the taxes paid historically by the generation now retired.

Social Security is squarely based on what has been called the eighth wonder of the world -- compound interest. A growing nation is the greatest Ponzi game ever contrived.

While we were at the helm of a growing wealth generating engine which used to the the US economy, making such promises as Social Security, Medicare, and Medicaid could be done without fear that the chickens would come home to roost in any near term time frame. The asymmetry of time frame allowed for implementation (the glory) without immediate impact the wealth engine making things possible (the pain). Those Jeremiahs who could see the crisis coming and made attempts to inject fiscal discipline may have temporarily appeared to be successful. Agreements generally involved immediate revenue enhancements coupled with spending cuts in the longer term, agreements which fail to materialize well after tax increases were set in stone. They have been much like Charlie Brown, forever the optimist, committing to kick that ball,  firmly believing that Lucy will not snatch the football away.  


It is unfortunate but it appears that the process continues until one or more of the parties is incapable of continuing because they broke and flat out of money.  Ponzi schemes always end and generally not well. In the case of the US economy, when the growth rates drop and the demographics of the US population turn less than favorable, the game is over unless we learn from the events unfolding in Europe.

The Price, Cost, Reimbursement, and Value quandary

Michael Porter and Robert Kaplan have written a piece on the Harvard Business Review entitled "How to solve the cost crisis in health care". http://hbr.org/2011/09/how-to-solve-the-cost-crisis-in-health-care/ar/1 The concepts cut to the basics of economics; scarce resources, optimal allocation, and incentives. One of the most basic tenants of business management is knowing what it costs to deliver a product or service. The health care is not equipped with the tools needed to really understand the costs of health care delivery.

Porter and Kaplan outline multiple reasons why this is the case, the major one being that health care accounting confounds charges with actual costs. While this approach worked OK when margins were huge and there was enough money in the system to allow for massive cross subsidies, we are no longer in a position to run such an increasingly expensive endeavor without  knowing what it costs to deliver any given service. Furthermore, any real attempts to actually measure value must take into consider actual costs of service delivery. It is easier for low cost interventions to meet the value bar than high cost ones. When you don't know the cost figures, any attempt to assess value is doomed from the start.

It seems remarkable that such an industry consuming more than 15% of GDP of the US can operate with such a rudimentary understanding of cost. From my perspective, this is a product of a mindset which permeates medicine which I can best term Medical or Health Care Exceptionalism. What I mean by this exceptionalism in health care is that it has been viewed as an industry that can and should operate outside of basic economic principles.  This perspective is deeply flawed. While the great wealth generating engine could spin off so much wealth in the US in the second half of the 20th century, we could live under this delusion. We now are faced with reality. Scarcity matters in all human endeavors, including health care. The health care industry, like all industries, requires resources, including people, who have choices and need to be given appropriate incentives to utilize scarce resources prudently. 

Porter and Kaplan's analysis also reminded me of the analysis of another Harvard Professor, Dr. Hsaio, developer of the resource based relative value scale (RBRVS). Both use a system of measuring inputs in order to accomplish some end in health care delivery. However, there is a huge difference in how they seek to deploy their information.  Hsaio developed the RBRVS as a tool to set payments to physicians. He conflated costs of inputs with actual value to patients. Porter and Kaplan promote cost analysis as an essential tool to define resources used, not value delivered. They look to use cost information to better utilize scarce resources, not administratively set prices.

Whether cost analysis is an essential step in defining value depends upon who pays for the services and what they are trying to achieve. In my opinion, value always needs to be defined by those purchasing the services. In the health care three way transactions, it will always be fuzzy as to who is the customer and who will be most pressed to measure value and deliver value. However, we should be in agreement that actual cost to deliver a service does not equal price of that service which does not equal the value delivered to the patient. If we can get past this confusion, we can  get our bearings and start to move in a direction away from the financial abyss.