One hesitates to make too much of a single report, but the Altarum Institute’s July Report, “Health Care Price Growth at 20+ Year Low,” certainly commands one’s attention. According to Altarum’s analysis, the health sector pricing trend ran at a 1.0 percent annual rate in May 2013, lowest since January of 1990. What is striking about Altarum’s health care pricing trendline is that it has declined for the last three years in spite of an alleged economic recovery.
It also runs parallel to a subsiding utilization trend, suggesting that the health sector has been unable to offset reduced utilization with price increases. Since the beginning of the recession, pricing has subsided from double the rate of the GDP deflator to parity, and it has closely tracked the deflator with only two deviations for more than eight years. Clearly, something more than the recession is at work here.
These trendlines confirm what this observer sees from his contacts in multiple sectors of the health industry: a widespread and durable “top line flu”. The growth in enterprise revenue for most health providers and manufacturers has been static (e.g. very low single digits or actually declining) over the last two years. Most investor-owned hospitals, pharmaceutical companies, device manufacturers, and physician practices (pretty much everyone except the consultants and IT vendors) have reported both revenue stasis and earnings compression.
My economist friends point to rising consumer copayments as inhibiting price increases. The Kaiser Family Foundation has reported almost a quadrupling of the number of covered workers in high deductible health plans (from 5 percent to 19 percent) since the end of the recession. It is also possible that a disinflationary mindset has inhibited providers and suppliers from seeking outsized price increases to compensate for lost sales volume. For suppliers, the marked decline of “physician preference” marketing has also hurt both sales and margins.
Hospital pricing. Performance of hospital prices will provide more fodder for those concerned about hospital consolidation pushing prices up. On the one hand, overall hospital prices rose an annualized 1.8 percent for May 2013, fractionally higher than the consumer price index (CPI) at 1.4 percent. However, when one strips out the “administered price” portion (Medicaid and Medicare), hospital prices to privately insured patients rose 4.8 percent annualized in May, nearly five times rate of health prices as a whole. Altarum suggests that cost shifting might explain this significant disparity. However, even this increase to private patients was not enough to raise overall health costs significantly.
Government payment to hospitals has trended lower for multiple reasons. Many state Medicaid plans have cut hospital rates in the past several years to help balance state budgets. And in addition to the ACA’s mandated reductions in hospitals’ disproportionate share payments and DRG updates, the sequester took a significant further bite out of DRG payments during the winter.
Since most hospital contracts with private insurers are multi-year, it’s difficult to argue that compensating upward revisions in private health insurance contract rates would yet be reflected in national economic statistics. Moreover, not all hospitals are part of systems capable of exerting pricing power on private health plans. Have-not hospitals have had their prices constrained by payer contracts, compensating for the effect of leverage by market hegemons. We’ll have more evidence in a year to confirm or disconfirm the cost shifting/pricing power hypothesis.
There’s another indicator of a tougher hospital pricing environment. According to the Advisory Board’s Dan Diamond, hospital employment has actually contracted in one-quarter of the monthly jobs reports from the Bureau of Labor Statistics since January 2009, including a 6000 person force reduction in May, 2013. On balance, hospital executives would much rather raise rates than lay off staff, so the fact that the nearly unbroken decades-long expansion of hospital headcounts is faltering suggests a very difficult pricing environment for hospital services.
Health insurance premiums. Broad based relief from rising prices across the health sector will put the behavior of health insurance premiums in 2014 into high relief. Small employers and individuals facing double digit premium renewal increases will legitimately wonder what justifies them if both healthcare prices and utilization are essentially flat.
There is no actuarial roadmap to guide health insurance pricing in an environment where most traditional underwriting strategies have been outlawed by ACA. Guaranteed issue and guaranteed renewal, elimination of lifetime caps, prohibitions on pre-existing conditions restrictions, enrollment of children to age 26 on their parents’ policies all have costs that must be spread across insurers’ risk pools. Optimism about private insurer pricing in 2014 has given way to watchful waiting and anxiety.
Yet the Altarum Report confirms that if one is to embark on an aggressive program of health insurance expansion and public subsidy, there could hardly be a more propitious time than right now. Sustained relief from rising health costs could help alleviate fiscal pressure on government budgets and on the broader economy.