Oct 26, 2010
Wall Street Reform: "One of the most important victories we achieved"
Former George W. Bush adviser Mark McKinnon on union funding for political campaigns
DOT, EPA Propose Nation's First-Ever Emissions, Fuel-Efficiency Standards
Eliminating Lifetime Limits Helps Paul Focus on Care
The Pakistan Paradox - Unless we're prepared to deal with it as an enemy, we must make do with it as a friend
Organizing for America's Director Mitch Stewart: "The calls I'm getting, from all over the country"
Mandelson: Prosperity Is More Than Just Money - Democracy, freedom, and entrepreneurial opportunity are at least as important
Michelle Obama: "Don't wait—vote early"
A $1.50 Lens-Free Microscope - The device could diagnose disease in the developing world and enable rapid drug screening
The Free Checking Restoration Act - Middle-class consumers are paying the price for the Dodd-Frank financial reform. The next Congress can undo the damage.
Soros: Why I Support Legal Marijuana - We should invest in effective education rather than ineffective arrest
Nancy Pelosi Who? - Democrats deny being Democrats
Committed to Vote in South Carolina
Geithner's Global Central Planning - The Chinese government's accumulation of U.S. debt represents a tragic investment decision, not a currency-manipulation effort
Remarks to Participants in the Edward R Murrow Program for Journalists
Big Insurance, Big Medicine - ObamaCare is already driving a wave of health-care consolidation—and higher costs
WSJ, Oct 26, 2010
ObamaCare's once and future harms have been well chronicled, but the major effects so far are less obvious and arguably more important: A wave of consolidation is washing over the health markets, and the result is going to be higher costs.
The turn toward consolidation among insurance companies is not new, and neither is it among doctors, hospitals and other providers. Yet the health bill has accelerated these trends, as all sides race to anticipate and manage political risk and regulatory uncertainty. This dynamic is leading to much larger hospital systems and physician groups, and fewer insurers dominated by a handful of national conglomerates. ObamaCare was sold using the language of choice and competition, but it is actually reducing both.
The first surge will come among the 1,200 insurers doing business in the U.S., given that a major goal of ObamaCare is to convert these companies into de facto public utilities. Those regulations are now being written—and once they're up and running some medium-sized carriers will collapse under the new mandates and higher overhead. State insurance commissioners warned the Administration this month that "improper or overly strident application . . . could threaten the solvency of insurers or significantly reduce competition in some insurance markets." They also implied that bankruptcies are likely.
With these headwinds, investors and Wall Street analysts are now predicting a lost decade for health insurance stocks. But it may be more accurate to say that there will be a lot of losers and some very big winners. Mergers and acquisitions will increase dramatically once companies get a better look at the regulation and figure out the valuation of M&A targets. Larger carriers will swallow smaller ones quietly before they fail.
Both publicly traded and nonprofit insurers have been heading in this direction for years, as in any industry where there are returns to scale. Size is also important in a low-margin business in which capital is costly and political clout vital. But scale is far more central now, because ObamaCare standardizes benefits. Once insurers lose the freedom to design their own products, they'll essentially be selling commodities, and survival will depend on enrollment volume and market share.
The same thing will happen to stand-alone and community hospitals—always a precarious business. Nearly a third of U.S. hospitals are currently operating in the red and will get steamrolled by ObamaCare, and many of them will be annexed by national chains and larger local systems.
This trend got a preview two weeks ago when Mercy Health Partners announced that it was seeking buyers for three Catholic hospitals in northeast Pennsylvania. CEO Kevin Cook told local media that ObamaCare was "absolutely" a factor in the decision to sell, only to backtrack once his comments were used in campaign ads against House Democrats Paul Kanjorski and Chris Carney, who voted for the bill.
Though it received little attention over a year of debate, ObamaCare actively promotes provider consolidation. Writing this summer in the Annals of Internal Medicine, Nancy-Ann DeParle and other White House health advisers argued that "The economic forces put in motion by the Act are likely to lead to vertical organization of providers and accelerate physician employment by hospitals and aggregation into larger physician groups."
Ask and ye shall receive. Across the country, providers are building giant hospital systems and much tighter doctor alliances like multispecialty groups to get out ahead of a concept known as "accountable care organizations," or ACOs. To modernize the delivery of medical services, ACOs would encourage doctors to work in teams to use resources more efficiently, streamline treatment and improve quality. The model is the Mayo Clinic and other large integrated systems.
At the moment ACOs are only a gleam in some bureaucrat's eye, and no one has a clue how they'll operate in practice until the government releases a working regulatory definition next year. Yet the percussive effects are already being felt across medicine.
Hospitals are now on a buying spree of private physician practices in the rush to build something that will qualify as an ACO. Some 65% of doctors who changed jobs in 2009 moved into a hospital-owned practice, while 49% of doctors out of residency were hired by hospitals, according to the Medical Group Management Association. In its 2010 census, the American College of Cardiology reports that nearly 40% of private cardiology groups are currently integrating with hospitals or merging with other practices.
Doctors are selling because complying with the ever-growing list of mandates has become more cumbersome; and while staff physicians on salary do gain predictability, they also lose the autonomy of independent practice. The other problem is price controls in Medicare, which are about 20% below private payments for doctors and 30% lower for hospitals. Hospitals are also scooping up practices to lock in referral sources and make up for ObamaCare's Medicare cuts. As it is, two-thirds of hospitals lose money today on Medicare inpatient services, according to Medicare.
ACOs are also driving consolidation among hospitals. Anecdotally, Marquette General Hospital and Bell Hospital formed a strategic ACO partnership in July that will dominate Michigan's upper peninsula. In Omaha, Methodist Health System and the Nebraska Medical Center recently followed suit. Similar alliances are underway in Detroit, Baltimore, Chicago, greater Boston, Roanoke and southwest Virginia—even Youngstown, Ohio.
The accountable care movement could do some good if it spreads best practices. But no one should entertain the illusion that it will reduce costs perforce and "bend the curve." In fact, the most concrete effect of this wave of consolidation may be to increase private health spending significantly.
Unlike Medicare and Medicaid, private reimbursement rates are determined by negotiations, often highly antagonistic. Insurers always attribute premium increases to the underlying cost of care, while doctors and hospitals always argue that there isn't enough competition among health plans. Both claims are "true," some of the time—but it depends on which side has more market power.
Insurers extract lower rates by steering patients and revenue to certain providers through their networks. Providers gain bargaining leverage when health plans can't credibly threaten to exclude them, whether because their share of the market is too large or due to public demand for "must have" hospitals. Consolidation will increasingly feed off itself as providers and insurers vie to get the whip hand in rate negotiations.
Most neutral experts believe the balance of power has tipped toward providers over the last decade, though this isn't always anticompetitive. Higher rates generally reflect investments in staffing, technology, specialization and sometimes consumer preferences. There is also the cost-shift to private insurance to offset Medicare's price controls. However, most economic studies on hospital M&A over the last two decades show that consolidation increases unit prices, though there is significant disagreement over the magnitude.
Accountable care organizations may become little more than a pretext for building up market power and fixing prices. The American Medical Association wants the government to stop insurers from individual contracting in favor of "exclusive dealing arrangements" with ACOs. In effect, the AMA wants a mandatory collective bargaining tool that would convert ACOs into unions.
"In a lot of states, the problem is just you don't have competition at all," President Obama said in February at his health summit. "We want competition."
Yet the consolidation wave is churning the insurance markets and reshaping clinical medicine with almost no public scrutiny. A rational system would give consumers an incentive to reward those businesses that innovate and deliver higher quality at lower cost, whether they are providers or insurers. ObamaCare is already moving the U.S. even further from the rational world, and this forced retreat will continue the longer it is left in place.