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Cash Flows and Hospital Woes

10 Sunday Jan 2021

Posted by pnoetx in Coronavirus, Health Care

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Tags

CARES Act, Covid-19, Don Wolt, Elective Procedures, HealthData.gov, HHS, Hospital Layoffs, Hospital Utilization, ICU Occupancy, Influenza Admissions, Inpatient Occupancy, KPI Institute, Observational Beds, Optimal Utilization, PPE Shortfalls, Seasonal Occupancy, Staffed Beds

Here’s one of the many entertaining videos made by people who want to convince you that hospitals are overrun with COVID patients (and here is another, and here, here, and here). That assertion has been made repeatedly since early in the pandemic, but as I’ve made clear on at least two occasions, the overall system has plenty of capacity. There are certainly a few hospitals at or very near capacity, but diverting patients is a long-standing practice, and other hospitals have spare capacity to handle those patients in every state. Those with short memories would do well to remember 2018 before claiming that this winter is unique in terms of available hospital beds.

An old friend with long experience as a hospital administrator claimed that I didn’t account for staffing shortfalls in my earlier posts on this topic, but in fact the statistics I presented were all based on staffed inpatient or ICU beds. Apparently, he didn’t read those posts too carefully. Moreover, it’s curious that a hospital administrator would complain so bitterly of staffing shortfalls in the wake of widespread hospital layoffs in the spring. And it’s curious that so many layoffs would accompany huge bailouts of hospital systems by the federal government, courtesy of the CARES Act.

In fairness, hospitals suffered huge declines in revenue in the spring of 2020 as elective procedures were cancelled and non-COVID patients stayed away in droves. Then hospitals faced the expense of covering their shortfalls in PPE. We know staffing was undercut when health care workers were diagnosed with COVID, but in an effort to stem the red ink, hospitals began laying-off staff anyway just as the the COVID crisis peaked in the spring. About 160,000 staffers were laid off in April and May, though more than half of those losses had been recovered as of December.

Did these layoffs lead to a noticeable shortfall in hospital capacity? It’s hard to say because bed capacity is a squishy metric. When patients are discharged, staffed beds can ratchet down because beds might be taken “off-line”. When patients are admitted, beds can be brought back on-line. ICU capacity is flexible as well, as parts of other units can be quickly modified for patients requiring intensive care. And patient ratios can be adjusted to accommodate layoffs or an influx of admissions. Since early in the fall, occupancy has been overstated for several reasons, including a new requirement that beds in use for observation of outpatients with COVID symptoms for 8 hours or more must be reported as beds occupied. However, there are hospitals claiming that COVID is stressing capacity limits, but nary a mention of the earlier layoffs.

So where are we now in terms of staffed hospital occupancy. The screen shot below is from the HHS website and represents staffed bed utilization nationwide. 29% of capacity is open, hardly a seasonal anomaly, and there are very few influenza admissions thus far this winter, which is rather unique. 37% of ICU beds are available, and COVID patients, those admitted either “for” or “with” COVID, account for less than 18% of inpatients, though again, that includes observational beds.

Next are the 25 states with the highest inpatient bed utilization as of January 7th. Rhode Island tops the list at just over 90%, and eight other states are over 80%. In terms of ICU utilization, Georgia and Alabama are very tight. California and Arizona are outliers with respect to proportions of COVID inpatients, 41% and 38%, respectively. Finally, CA, GA, AL and AZ are all near or above 50% of ICU beds occupied by COVID patients.

So some of the states reaching the peak of their fall waves are pretty tight, and there are states with large numbers of very serious cases. Nevertheless, in all states there is variation across local hospitals to serve in relief, and it is not unusual for hospitals to suffer wintertime strains on capacity.

Los Angeles County is receiving much attention for recent COViD stress placed on hospital capacity. But it is hard to square that narrative with certain statistics. For example, Don Wolt notes that the state of California reports available ICU capacity in Southern CA of zero, but LA County has reported 10% ~ 11% for weeks. And the following chart shows that LA County occupancy remains well below it’s July peak, especially after a recent downward revision from the higher level shown by the blue dashed line.

Interestingly, the friend I mentioned said I should talk with some health system CEOs about recent occupancies. He overlooked the fact that I quoted or linked to comments from some system CEOs in my earlier posts (linked above). It’s noteworthy that one of those CEOs, and this report from the KPI Institute, propose that an occupancy rate of 85% is optimal. This medical director prefers a 75% – 85% rate, depending on day of week. These authors write that there is no one “optimal” occupancy rate, but they seem to lean toward rates below 85%. This paper reports a literature search indicating ICU occupancy of 70% -75% is optimal, while noting a variety of conditions may dictate otherwise. Seasonal effects on occupancy are of course very important. In general, we can conclude that hospital utilization in most states is well within acceptable if not “optimal” levels, especially in the context of normal seasonal conditions. However, there are a few states in which some hospitals are facing tight capacity, both in total staffed beds and in their ICUs.

None of this is to minimize the challenges faced by administrators in managing hospital resources. No real crisis in hospital capacity exists currently, though hospital finances are certainly under stress. Yes, hospitals collect greater reimbursements on COVID patients via the CARES Act, but COVID patients carry high costs of care. Also, hospitals have faced steep declines in revenue from the fall-off in other care, high costs in terms of PPE, specialized equipment and medications, and probably high temporary staffing costs in light of earlier layoffs and short-term losses of staff to COVID infections. The obvious salve for many of these difficulties is cash, and the most promising source is public funding. So it’s unsurprising that executives are inclined to cry wolf about a capacity crisis. It’s a simple story and more appealing than pleading for cash, and it’s a scare story that media are eager to push.

Coronavirus Framing #7: Second Wave Uncertainty

19 Friday Jun 2020

Posted by pnoetx in Pandemic

≈ 1 Comment

Tags

Air Conditioning, Asian Flu, Case Fatality Rate, CDC, Coronavirus, COVID Time Series, Covid Tracking Project, Effective Herd Immunity, George Floyd, HHS, High Cholesterol, Hong Kong Flu, Johns Hopkins, Operation Warp Speed, Pooled Testing, Reverse Seasonal Effect, Rich Lowry, Social Distancing, Testing, Vitamin D Deficiency

We’re now said to be on the cusp of a “second wave” of coronavirus infections. It’s become a new focus of media attention in the past week or so. Increased infections have been reported across a number of states, especially in the south, but I’m not especially alarmed at this point for reasons explained below. Either way, the public policy response will certainly be different this time, at least in most areas. We’ve learned that a more targeted approach to managing coronavirus risk is far less costly, which means eschewing general lockdowns in favor of focusing resources on protecting the most vulnerable. That approach is supported by research weighing the costs and benefits of the alternatives (also see here and here).

The targeted approach I’ve advocated does not call for any less caution on the part of individuals. That means avoiding prolonged, close contact with others, especially indoors. I don’t mind wearing a mask when inside stores or public buildings, but I believe it should be voluntary. I do my best to stay out of close proximity to most others in public places anyway, masked or otherwise. This is voluntary social distancing. I also believe public health authorities should be more active in disseminating information on known correlates of coronavirus severity, such as Vitamin D deficiency, high LDL cholesterol, and the “reverse seasonal effect” caused by low humidity in air-conditioned spaces. I would also strongly agree that the effort to identify and mass produce vaccine candidates, known as Operation Warp Speed, should be ramped up considerably, with heavier funding and more than five vaccine candidates.

We’ve seen a continuing increase in coronavirus testing since my last “framing” post about a month ago. Testing has increased to a daily average of almost 500,000 over the past two weeks. At present we appear to have an excess supply of testing capacity in many areas, as Rich Lowry notes:

“The problem with testing nationally is becoming less a shortfall of availability of the tests and more a shortfall of people showing up to get tested. An insider in the diagnostics industry says that laboratories are reporting that they are ‘sample starved’ — i.e., they aren’t getting enough specimens. He notes, ‘We have all seen stories about sample-collection sites in some regions not seeing that many patients.’

An HHS official says that in May there was the capacity to do twice as many tests as were actually performed, calling it a function of ‘allocation and efficiency, but more just demand.’ Says Giroir, ‘We really see areas in the country now that there’s more tests available than people who want to get tested or the need for testing.'”

Before turning to some charts, a word about the data in the charts I’ve been using throughout the pandemic. Some of the nationwide information was directly from the CDC or the Johns Hopkins dashboard. In other cases, I’ve reported state level data and some nationwide data published by The COVID Tracking Project (CTP) and the COVID Time Series (CTS) dashboard, which uses state data from CTP. I first noticed a few discrepancies in the national totals in April, which have become larger with growth in the counts of cases and deaths. Here is a key part of CTP’s explanation:

“For many states, the CDC publishes higher testing numbers than the states themselves report, which raises questions about the structure and integrity of both state and federal data reporting. … Another point of contrast between the CDC’s new reporting and the official state data compiled by The COVID Tracking Project is that the CDC has not released historical, state-level testing data for the first three months of the outbreak.”

Thus, the CDC currently reports almost 120,000 U.S. deaths, while CTP reports about 112,000. Nevertheless, I will continue to report numbers from both sources for the sake of continuity, and I will try to remember to note the source in each case.

The first chart below shows the number of daily tests from CTP; the second chart shows the number of daily confirmed cases (CTP). Since mid-May, daily testing has increased by more than 50%, calculated on a moving average basis, and is now approaching half a million per day or more than 3 million per week. Pooled testing is coming, which will ultimately increase testing capacity several-fold. Daily confirmed cases have been hovered just above 20,000 since around Memorial Day, with a recent turn upward to around 24,000.

Early in the pandemic, I made the mistake of focusing too heavily on case numbers. Yes, I adjusted for population size and was aware that the initial shortage of tests was restraining diagnoses. Still, I did not foresee the great expansion in testing we’ve witnessed, the great transmissibility of the virus in some regions, nor the large number of asymptomatic cases that would ultimately be diagnosed.

The daily percentage of positive tests (CTP), which is smoothed in the chart below using a seven-day moving average to eliminate within-week variability, has declined gradually since early April to about 4% before the uptick in the last few days. Still, that’s a drop of about 75% from the peak when tests were in very short supply. Those were days when even heavily symptomatic individuals were having trouble getting tested.

We’d hope to see a resumption in the decline of the positive percentage as testing continues to grow, but even with a relatively constant positivity rate, the number of daily confirmed cases must grow as testing expands. There may be several reasons the positivity rate has remained stubbornly near 5% over the past few weeks. One is the obvious reversal in social distancing as states have opened up. People became less fearful about the virus in general, and protesters jammed the streets after the George Floyd murder in Minneapolis. Another reason is that there are new areas of focus for testing that might be picking up cases. For example, hospitals in some states are now testing all admissions for COVID-19. This will tend to pick up more infections to the extent that individuals with co-morbidities are hospitalized at higher rates in general and are also more susceptible to the coronavirus. Finally, testing more broadly is likely to pick up a larger share of asymptomatic cases even as the “true rate” of infection declines.

The daily death toll (CTP) attributed to coronavirus has continued to decline. See below. It is now running at about a third of the peak level it reached in mid-April. There are several reasons for the decline. One is the lower number of active cases, changes in which lead deaths by a few weeks. Awareness and testing capacity have undoubtedly led to earlier diagnosis of the most severe cases. There is also the strong possibility that the virus, having felled some of the most susceptible individuals, is now up against more hosts with effective immune responses. An ongoing degree of social distancing, more humid weather, and more direct sunlight have probably reduced initial viral loads from those experienced early-on, when the case load was escalating. Finally, treatment has improved in multiple ways, and there are now a few medications that have shown promise in shortening the duration and severity of infection.

The course of the pandemic has varied greatly across countries and across regions of the U.S. The New York City area was especially hard hit along with several other large cities, as well as Louisiana. CTS shows that states with the highest cumulative number of coronavirus deaths (New York (blue line), New Jersey (green), Massachusetts, Illinois, and Pennsylvania in the charts below) have experienced downward trends in positive cases per day (the first chart below), leading daily deaths downward in May and early June (the second chart — NY’s downtrend began earlier). I apologize if the charts below are difficult to read, but they have resisted my efforts at resizing. Note: I’m mainly focused on trends here, and I have not shown these series on a per capita basis.

More recently, almost two dozen states have begun to see higher daily case diagnoses. Several of these had more favorable outcomes in the early months of the pandemic and were in more advanced stages of reopening. The charts below (CTS) show results for Arizona, Florida, Georgia, and Texas. The new “hot spots” in these states are mostly urban centers. It’s not clear that the reopenings are to blame, however. The protests after George Floyd’s murder may have contributed in cities like Houston, though no increase in New York is apparent as yet. The states in the chart are all in the south or southwest, so the increases have occurred despite sunny, warm conditions. It’s possible that hot weather has prompted more intensive use of air conditioning, which dries indoor environments and can promote the spread of the virus. These southern states have not yet experienced a corresponding increase in deaths, though that would occur with a lag. 

Missouri has seen an slow upward trend in its daily positive test count over the past four weeks, even though the state’s positive rate has trended down slowly since early May. I show MO’s confirmed cases per day below (in green) together with Illinois’ (because my hometown is on the border and the two states are a nice contrast). IL is much larger and has had a much higher case load, but the downward trend in new cases in IL is impressive. Coronavirus deaths per day are shown in the second chart below, with seven-day averages superimposed. Deaths have also trended down in both states, though MO has experienced a few bad days very recently, and MO’s case fatality rate is slightly higher than in IL.

We’ll know fairly soon whether we’re really headed for a second major wave. However, the case count, in and of itself, is not too informative. Testing has increased markedly, so we would expect to see more cases diagnosed. The percent of tests that are positive is a better indicator, and it has flattened at a still uncomfortable 5% for about a month, with a slight uptick in the past few days. Even more telling will be the future path of coronavirus deaths. My expectation is that more recent infections are likely to be less deadly, if only because of the lessons learned about protecting the care-bound elderly. I also believe we’re not too far from what I have called effective herd immunity. 

The pandemic has taken a heavy toll, especially among the aged. In fact, total deaths in the U.S. have now exceeded both the Hong Kong flu of the late 1960s and the Asian flu of the late 1950s. Unfortunately, risks will remain elevated for some time. However, any reasonable estimate of the life-years lost is considerably less than in those earlier pandemics due to the differing age profiles of the victims. In any case, the coronavirus pandemic has not been the kind of apocalyptic event that was originally feared and erroneously predicted by several prominent epidemiological models. It can be tackled effectively and at much lower cost by focusing resources on protecting vulnerable segments of the population. 

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Gains From Medicare Trade

08 Thursday Dec 2016

Posted by pnoetx in Medicare, Privatization, Profit Motive

≈ 2 Comments

Tags

ACA, American Enterprise Institute, CMS, Donald Trump, Health Savings Accounts, HHS, IPAB, John C. Goodman, MACRA, Medicare, Medicare Advantage, Medicare Part C, Medigap, Obamacare, Original Medicare, Premium Support Plan, Privatization, Tom Price

Boomers and Medicare

Here’s a bit of zero-sum ignorance: private profits are robbed from consumers; only non-profits or government can deliver full value, or so this logic goes. Those who subscribe to this notion dismiss the function of private incentives in creating value, yet those incentives are responsible for nearly all of the material blessings of modern life. What the government seems to do best, on the other hand, is writing checks. It’s not really clear it does that very well, of course, but it does have the coercive power of taxation required to do so. Capital employed by government is not a “free” input. It bears opportunity costs and incentive costs that are seldom considered by critics of the private sector.

The role of private profit and the zero-sum fallacy come up in the context of proposals to privatize government services. In what follows, I discuss a case in point: privatization of Medicare. Rep. Tom Price, the Chairman of the House Budget Committee, is Donald Trump’s nominee to head HHS. In November, Price said Congress would attempt to pass legislation overhauling Medicare in the first year of the Trump Administration. James Capretta of the American Enterprise Institute (AEI) explains some of the features of the possible reforms. Price has supported the concept of a premium support plan whereby seniors would purchase their own coverage from private insurers, paid at least in part by the government (also see here).

Medicare and Its Ills

The Medicare program is beset with problems: it has huge unfunded liabilities; it’s cash flows are being undermined by demographic trends; fraud and bureaucratic waste run rampant; it’s unpopular with doctors; and the regulations imposed on healthcare providers are often misguided.

Writing checks to health care providers is really the primary “good” created by the federal government in the administration of Medicare. The Centers for Medicare & Medicaid Services (CMS), a branch of the Department of Health and Human Services (HHS), also performs regulatory functions mandated by legislation, such as the Affordable Care Act (ACA).

More recently, CMS has been implementing the Medicare Access and Chip Reauthorization Act of 2015 (MACRA), which will introduce changes to the payment formulas for physician compensation under the plan. Economist John C. Goodman offers a cogent explanation of the ill-conceived economic planning at the heart of Medicare regulation and its implementation of MACRA in particular:

“…the government’s current payment formulas create perverse economic incentives — to maximize income against the formulas instead of putting patient welfare first. The goal is to change those incentives, so that providers will get paid more if they lower costs and raise quality.

But after the new formulas replace the old ones, provider incentives in a very real sense will be unchanged. They will still have an economic incentive to maximize income by exploiting the formulas, even if that is at the expense of their patients.“

After describing several ways in which Medicare regulation, now and prospectively, leads to perverse results, Goodman advances the powerful argument that the market can regulate health care delivery to seniors more effectively than CMS.

“If the government’s metrics are sound, why not allow health plans to advertise their metrics to potential enrollees and compete on these quality measures. Right now, they cannot. Every communication from health plans to Medicare enrollees must be approved by CMS. … Under MACRA, health plans profit by satisfying the government, not their customers. … Better yet, why not let the market (rather than government) decide on the quality metrics?“

Private Medicare Exists

Wait a minute: profit? But isn’t Medicare a government program, free from the presumed evils of profit-seekers? Well, here’s the thing: almost all of the tasks of managing the provision of Medicare coverage are handled by the private sector under contract with CMS, subject to CMS regulation, of course. That is true even for Part A and Part B benefits, or “original Medicare”, as it’s sometimes called.

Under “original” Medicare, private insurers process “fee-for-service” claims and payments, provide call center services, manage clinician enrollment, and perform fraud investigations. Yes, these companies can earn a profit on these services. Unfortunately, CMS regulation probably serves to insulate them from real competition, subverting efficiency goals. Goodman’s suggestion would refocus incentives on providing value to the consumers these insurers must ultimately serve.

Then there are “Medigap” or Medicare Supplement policies that cover out-of-pocket costs not covered under Parts A and B. These policies are designed by CMS, but they are sold and managed by private insurers.

And I haven’t even mentioned Medicare Parts C and D, which are much more significantly privatized than original Medicare or Medigap. The Part C program, also known as Medicare Advantage, allows retirees to choose from a variety of privately-offered plans as an alternative to traditional Medicare. At a minimum, these plans must cover benefits that are the equivalent to Parts A and B, as judged by CMS, though apparently “equivalency” still allows some of those benefits to be declined in exchange for a rebate on the premium. More optional benefits are available for an additional premium under these plans, including a reduced out-of-pocket maximum, a lower deductible, and reduced copays. Part C has grown dramatically since its introduction in 1996 and now covers 32% of Medicare enrollees. Apparently these choices are quite popular with seniors. So why, then, is privatization such a bogeyman with the left, and with seniors who are cowed by the anti-choice narrative?

What’s To Privatize?

Not privatized are the following Medicare functions: the collection of payroll-tax contributions of current workers; accounting and reporting functions pertaining to the Trust Fund; decisions surrounding eligibility criteria; the benefit designs and pricing of Part A (hospitalization) and Part B (optional out-patient medical coverage, including drugs administered by a physician); approval of provider plan designs and pricing under Parts C; regulation and oversight of all other aspects of Medicare, including processes managed by private administrative contractors and providers of optional coverage; and regulation of health care providers. 

The Independent Payment Advisory Board (IPAB) was created under the Affordable Care Act (ACA), aka Obamacare, to achieve Medicare costs savings under certain conditions, beginning in 2015. Its mandate is rather confusing, however, as IPAB is ostensibly restricted by the ACA from meddling with health care coverage and quality. Proposals from IPAB are expected to cover such areas as government negotiation of drug prices under Part D, a Part B formulary, restrictions on the “protected status” of certain drugs, and increasing incentives for diagnostic coding for Part C plans. Note that these steps are confined to optional or already-private parts of Medicare. They are extensions of the administrative and regulatory functions described above. Despite the restrictions on IPAB’s activities under the ACA, these steps would have an impact on coverage and quality, and they mostly involve functions for which market solutions are better-suited than one-size-fits-all regulatory actions.

The opportunities for privatization are in 1) creating more choice and flexibility in Parts A and B, or simply migrating them to Parts C and D, along with premium support; 2) eliminating regulatory burdens, including the elimination of IPAB.

Impacts On Seniors Now and Later

Privatization is unlikely to have any mandatory impact on current or near-future Medicare beneficiaries. That it might is a scare story circulating on social media (i.e., fake news), but I’m not aware of any privatization proposal that would make mandatory changes affecting anyone older than their mid-50s. Voluntary benefit choices, such as Part C and D plans, would be given more emphasis.

There should be an intensive review of the regulatory costs imposed on providers and, in turn, patients. Many providers simply refuse to accept patients with Medicare coverage, and regulation encourages health care delivery to become increasingly concentrated into large organizations, reducing choices and often increasing costs. Lightening the regulatory burden is likely to bring immediate benefits to seniors by improving access to care and allowing providers to be more patient-focused, rather than compliance-focused.

Again, the most heavily privatized parts of Medicare are obviously quite popular with seniors. The benefits are also provided at lower cost, although the government pays the providers of those plans extra subsidies, which may increase their cost to taxpayers. Enrollees should be granted more flexibility through the private market, including choices to limit coverage, even down to catastrophic health events. Consumers should be given at least limited control over the funds used to pay their premia. That would include choice over whether to choose lower premia and put the excess premium support into consumer-controlled Health Saving Account (HSA) contributions.

Other Reforms

Pricing is a controversial area, but that’s where the terms of mutually beneficial trades are made, and it’s what markets do best. Pricing flexibility for private plans would be beneficial from the standpoint of matching consumer needs with the appropriate level of coverage, especially with fewer regulatory restrictions. Such flexibility need not address risk rating in order to have beneficial effects.

Regulations imposed on physicians and other providers should be limited to those demanded by private plans and the networks to which they belong, as well as clear-cut legislative rules and standards of practice imposed by professional licensing boards. The better part of future contributions to the Trust Fund by younger workers (i.e., those not grandfathered into the existing program) should be redirected toward the purchase today of future benefits in retirement, based on actuarial principles.

Perhaps the best cost-control reform would be repeal of the tax deductibility of insurance premia on employer-paid insurance plans. This provision of the tax code has already inflated health care costs for all consumers, including seniors, via demand-side pressure, and it has inflated their insurance premia as well. If extended to all consumers, tax deductibility would be less discriminatory toward consumers in the individual market and most seniors, but it would inflate costs all the more, with unevenly distributed effects. Unfortunately, rather than eliminating it entirely, qualification for the tax deduction is very likely to be broadened.

Conclusions

The Medicare program is truly in need of an overhaul, but reform proposals, and especially proposals that would put decision-making power into the hands of consumers, are always greeted with reflexive shrieks from sanctimonious worshippers of the state. The most prominent reform under consideration now would offer more of what’s working best in the Medicare program: private choices in coverage and costs. Solving the long-term funding issues will be much easier without a centralized regime that encourages escalating costs.

Earning a profit is usually the mark of a job well done. It is compensation for the use of capital and the assumption of risk (i.e., no bailouts). Physicians, nurses, chiropractors, insurance agents and customer service reps all earn compensation for their contributions. Providers of capital should too, including the owners of health insurance companies who do well by their customers. And if you think the absence of profit in the public sector creates value, remember the damage inflicted by taxes. Capital isn’t “free” to society just because it can be confiscated by the government.

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