Paul B. Ginsburg

Hospital discharge one week after acute myocardial infarction.

Sixty-seven consecutive patients who had suffered an acute myocardial infarction but no serious complications during the first to fourth hospital days were considered for a trial of hospital discharge at one week. Thirty-three of the 67 patients were discharged at one week, the remainder having a mean hospital stay of 11 +/- 2 days. The incidence of late complications and recurrent infarctions, as well as mortality and functional status, were determined in all patients six months after discharge. No serious complications occurred in either subgroup within three weeks after discharge. There were no deaths in either subgroup and no difference in functional status at six months. Patients without serious complications during the four days after an acute myocardial infarction can be spared the economic costs and psychologic stress of prolonged hospitalization.

The Growing Power Of Some Providers To Win Steep Payment Increases From Insurers Suggests Policy Remedies May Be Needed

In the constant attention paid to what drives health care costs, only recently has scrutiny been applied to the power that some health care providers, particularly dominant hospital systems, wield to negotiate higher payment rates from insurers. Interviews in twelve US communities indicated that so-called must-have hospital systems and large physician groups--providers that health plans must include in their networks so that they are attractive to employers and consumers--can exert considerable market power to obtain steep payment rates from insurers. Other factors, such as offering an important, unique service or access in a particular geographic area, can contribute to provider leverage as well. Even in markets with dominant health plans, insurers generally have not been aggressive in constraining rate increases, perhaps because the insurers can simply pass along the costs to employers and their workers. Although government intervention--through rate setting or antitrust enforcement--has its place, our findings suggest a range of market and regulatory approaches should be examined in any attempt to address the consequences of growing provider market clout.

Is Health Spending Excessive? If So, What Can We Do About It?

The case that the United States spends more than is optimal on health care is overwhelming. But identifying reasons for excessive spending is not the same as showing how to wring it out in ways that increase welfare. To lower spending without lowering net welfare, it is necessary to identify what procedures are effective at reasonable cost, to develop protocols that enable providers to identify in advance patients in whom expected benefits of treatment are lower than costs, to design incentives that encourage providers to act on those protocols, and to provide research support to maintain the flow of beneficial innovations.

Fee-For-Service Will Remain A Feature Of Major Payment Reforms, Requiring More Changes In Medicare Physician Payment

Many health policy analysts envision provider payment reforms currently under development as replacements for the traditional fee-for-service payment system. Reforms include per episode bundled payment and elements of capitation, such as global payments or accountable care organizations. But even if these approaches succeed and are widely adopted, the core method of payment to many physicians for the services they provide is likely to remain fee-for-service. It is therefore critical to address the current shortcomings in the Medicare physician fee schedule, because it will affect physician incentives and will continue to play an important role in determining the payment amounts under payment reform. This article reviews how the current payment system developed and is applied, and it highlights areas that require careful review and modification to ensure the success of broader payment reform.

Tracking health care costs: Trends stabilize but remain high in 2002

Health care spending per privately insured person increased 9.6 percent in 2002, a slight reduction from the 10 percent increase in 2001. This is the first time in five years that the spending trend did not accelerate. Nonetheless, health care spending grew nearly four times faster than the U.S. economy grew in 2002. Growth in hospital spending accounted for the largest portion of the overall increase (51 percent) for the second straight year. Moreover, hospital price inflation--which accelerated significantly in 2002--accounted for a larger share of hospital spending growth in 2002 than in 2001. Premium increases accelerated again in 2003, despite 2002s slight deceleration of the overall spending trend.

Tracking health care costs: Trends turn downward in 2003

Health care spending per privately insured person increased 7.4 percent in 2003. While lower than the 2002 increase, it still outpaced growth in the overall economy by a margin that exceeds the historical average. The trend for drug spending decelerated the most. Meanwhile, hospital spending grew 9 percent in 2003-1.8 percentage points less than the 2002 increase. This reflected a sharp deceleration in growth of hospital use, while growth in hospital prices accelerated for the sixth year in a row. The trend for health insurance premiums fell in 2004. Employers raised patient cost sharing for the third year in a row.

Consumer-driven health care: promise and performance.

This paper analyzes the evolution of consumer-driven health care in terms of its original vision, its subsequent implementation, and the transformations it has endured as it moves into its second decade. The market is generating product designs that combine elements of consumerism with elements of managed care, but the trend is always toward a stronger role for consumer choice and a weaker role for management of those choices by physicians, insurers, employers, and regulators.

Seeking Lower Prices Where Providers Are Consolidated: An Examination Of Market And Policy Strategies

The ongoing consolidation between and among hospitals and physicians tends to raise prices for health care services, which poses increasing challenges for private purchasers and payers. This article examines strategies that these purchasers and payers can pursue to combat provider leverage to increase prices. It also examines opportunities for governments to either support or constrain these strategies. In response to higher prices, payers are developing new approaches to benefit and network design, some of which may be effective in moderating prices and, in some cases, volume. These approaches interact with public policy because regulation can either facilitate or constrain them. Federal and state governments also have opportunities to limit consolidations effect on prices by developing antitrust policies that better address current market environments and by fostering the development of physician organizations that can increase competition and contract with payers under shared-savings approaches. The success of these private- and public-sector initiatives likely will determine whether governments shift from supporting competition to directly regulating payment rates.

Slower Growth in Medicare Spending — Is This the New Normal?

There are indications that the unsustainably rapid growth in Medicare spending has recently slowed — and that this slowdown is not a fluke, but rather the result of tighter Medicare payment policies whose effects will only be bolstered by the Affordable Care Act.

Employment-Based Health Benefits Under Universal Coverage

In the context of proposals for universal coverage, a key emerging issue is the role of employer-sponsored coverage. Such coverage has been slowly eroding and has been criticized for providing little meaningful plan choice. Increased reliance on the individual insurance market in its present form is unlikely to meet societys goals, but directing those without access to employer coverage who receive subsidies to regional insurance exchanges could make such coverage much more attractive. But real-world experience with such a reform is needed before considering the substitution of individual coverage for employer-based coverage.