Tag Archives: Russ Roberts

Hospital Price Insanity

15 Sunday Dec 2019

Posted by in Health Care, Health Insurance

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Almost nothing is less transparent than hospital pricing. If you’re shopping for a procedure, you probably won’t hear about the negotiated prices worked out with large insurers…. you’re likely to be quoted something much higher. A high price is billed to an insurer, but the excess above their negotiated prices is “disallowed” via contractual adjustment. You and/or your small insurer might not get the same deal. As Robert Laszewski says:

“The chargemaster is complete nonsense that really doesn’t matter — unless you are an uninsured person and you’re getting these huge bills driving you toward bankruptcy. The biggest irony of the U.S. healthcare system is that only the uninsured — often people who don’t have a lot of money — are the only ones the hospital expects to pay these incredibly inflated prices!”

An uninsured patient might be billed at the higher rate, but of course few end up paying. But there is harm in this arrangement, and it extends well beyond the uninsured. You might not be surprised to learn that the government is right in the middle of it. Read on…

What a Racket!

There’s some slight of hand going on in hospital pricing that creates perverse incentives. Who has something to gain from a huge gap between the full price and the hospital’s allowable charge? The answer is both the hospital and insurers, and that’s true whether the hospital is for-profit or nonprofit. When the list price and the size of the discount increase, the insurer gets to brag to employer-plan sponsors about the great savings it negotiates. In an episode on EconTalk, Dr. Keith Smith, a partner in the ultra-competitive and cash-only Surgery Center of Oklahoma, says (only partly in jest) that the conversation between the insurer and hospital might go something like this:

“Now, what the insurers actually do is ask the hospital administrators, ‘Can you do a brother a favor and actually charge $200,000 for that, so that our percentage savings actually looks larger?‘”

This does two things for the insurer: it impresses employers as prospective plan sponsors, and it might also earn the insurer a bonus known as Claims Repricing, whereby the employer pays a commission on the discounts the insurer “negotiates”.

What about the hospitals? How do they benefit from this kind of arrangement? By inflating the “list price” of procedures, the hospital creates the appearance of a write-down or loss on a substantial share of the care it provides, despite the fact that its real costs are far below list prices and usually below the discounted “allowable amounts” negotiated with insurers as well. The appearance of loss serves to benefit the hospitals because they are compensated by the government on that basis through so-called Disproportionate Share Hospital (DSH) payments. These are, ostensibly, reimbursements for so-called uncompensated care.

This would not be such a travesty if the prices approximated real costs, but they don’t, and the arrangement creates incentives to inflate. The DSH payments to hospitals are used in a variety of ways, as Smith notes:

“Yeah; and before we get to feeling too sorry for the hospitals, all of the ones I know of claiming to go broke have a crane in front of them building onto their Emergency Room. …

So, I don’t know: again, the hospitals that are complaining about this, they are buying out physician practices, they’re buying out competitors. They seem to have a whole lot of money. They’re not suffering. Now, what they have done is used the situation you described–the legitimate non-payer–they’ve used that as a propaganda tool, I would argue, to develop a justification for cost shifting where they charge us all a whole lot more to make up for all the money that they’re losing. But they really need a lot of this red ink to maintain the fiction of their not-for-profit status.”

Non-profit hospitals are also entirely tax-exempt (income and property taxes), despite the fact that many use their “free cash flows” in ways similar to for-profit hospitals. The following describes a 2015 court ruling in New Jersey:

“The judge stated ‘If it is true that all non-profit hospitals operate like the hospital in this case… then for purposes of the property tax exemption, modern non-profit hospitals are essentially legal fictions.’ Judge Bianco found that the hospital ‘operated and used the property for a profit-making purpose’ by, in part, providing substantial loans, capital, and subsidies to for-profit entities, including physician groups.“

The bad incentives go beyond all this. Smith adds the following:

“Waste in a big hospital system is actually encouraged, many times because hospitals are paid based on what they use…. So, to the extent that the hospital uses a lot of supplies, that typically raises and increases the amount of revenue that they receive.”

Hospitals have been shielded from competition for years by the government. As Chris Pope explains, hospital pricing is designed “to accommodate rather than to constrain the growth of hospital costs“. This encourages hospitals that are inefficient in terms of costs, quality of care, and over-investment in equipment. Conversely, duplicated facilities and equipment simply add costs and don’t encourage competition given the cost-plus nature of hospital pricing and government efforts to prevent entry by more efficient operators. These restrictions include “Certificates of Need” for new entrants, and the ban on physician-owned hospitals in the Affordable Care Act (ACA). At the same time, the ACA encouraged hospital consolidation by rewarding the formation of so-called Accountable Care Organizations, which are basically exempt from anti-trust review. In the end, any reductions in administrative costs that consolidation might offer are swamped by the anti-consumer force of monopoly power.

Mandated Transparency?

The lack of price transparency really isn’t the root problem, in my view, but it is undesirable. Can government action to create transparency foster a more competitive market for the services hospitals offer? A recent Trump Administration Executive Order would require that hospitals publicly post prices for 300 “shoppable” services or procedures. The effective date of this order was recently delayed by a year, to January 2021. Hospital trade groups have challenged the order in court on the grounds that the First Amendment protects private businesses from being compelled to reveal details of privately-negotiated deals for complex services. While I try to be a faithful defender of constitutional rights, I find this defense rather cynicical. I’m not sure the First Amendment was intended to aid in concealing dishonest schemes for private benefit at the expense of taxpayers and consumers.

Avik Roy likes the price transparency rule. It would require the posting of gross charges for procedures as well as specific negotiated prices. The executive order would also require Medicare to pay no more to hospital-owned clinics than to independent clinics for the same procedure, which is laudable. Roy is sanguine about the ability of these rules to bring more competition to the market. He predicts a more level playing field for small insurers in negotiating discounts, and he thinks the order would spur development of on-line tools to assist consumers.

John C. Goodman is mildly skeptical of the benefits of a transparency mandate (also see here). Consumers with decent levels of coverage aren’t terribly motivated to make hospital price comparisons, especially if it means a delay in treatment. Also, Goodman points out a few ways in which hospitals try to “game” transparency requirements that already exist. John Cochrane worries about gaming of the rules as well. Competition and price discipline are better prescriptions for price transparency and might be better addressed by eliminating the incentives for third-party payment arrangements, like the unbalanced tax deductibility of health insurance premiums, but that kind of reform isn’t on the horizon. Goodman concedes that many procedures are “shoppable”, and he does not minimize the extent to which pricing varies within local hospital markets.

Conclusion

The most insane thing about hospital revenue generation is its reliance on fictitious losses. And hospitals, profit and non-profit, have a tendency to spend excess cash in ways that fuel additional growth in cost and prices. Sadly, beyond their opacity, hospital prices do not reflect the true value of the resources used by those institutions.

In my view, the value of price transparency does not hinge on whether the average health care consumer is sensitive to hospital prices, but on whether the marginal consumer is sensitive. That includes those willing to pay for services out-of-pocket, such as those who seek care at the Surgery Center of Oklahoma. Third-party payers lacking significant market power would undoubtedly prefer to have more information on pricing as well. Mandated price transparency won’t fix all of the dysfunctions in the delivery and payment for health care. That would require more substantial free-market reforms to the insurance and health care industries, which ideally would involve replacing price subsidies with direct payments to the uninsured. The transparency mandate itself might or might not intrude on domains over which privacy is protected by the Constitution, a question that has already been brought before the courts. Nonetheless, transparency would lead to better market information for all participants, which might help rationalize pricing and encourage competitive forces.

 

You’re Welcome: Charitable Gifts Prompt Statist Ire

14 Friday Dec 2018

Posted by in Central Planning, Charity, Uncategorized

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Charitable acts are sometimes motivated by a desire to cultivate a favorable reputation, or even to project intelligence. Perhaps certain charitable acts are motivated by guilt of one kind or another. Tax deduction are nice, too. But sometimes a charitable gift is prompted by no more than a desire to help others less fortunate. It’s likely a combination of motives in many cases, but to gainsay the purity of anyone’s charitable motives is rather unseemly. Yet Gaby Del Valle does just that in Vox, casting a skeptical eye at Jeff Bezos’ efforts to help the homeless through his Day 1 Fund.

“Last week, Amazon founder and CEO Jeff Bezos announced that he and his wife, MacKenzie Bezos, were donating $97.5 million to 24 organizations that provide homeless services across the country. The donation is part of Bezos’s $2 billion ‘Day 1 Fund, a philanthropic endeavor … that, according to Bezos, focuses on establishing ‘a network of new, non-profit, tier-one preschools in low-income communities’ and funding existing nonprofits that provide homeless services.”

Del Valle says Bezos deserves little credit for his big gift for several reasons. First, Amazon very publicly opposed a recent initiative for a $275 per employee tax on large employers in Seattle. The proceeds would have been used to fund public programs for the homeless. This allegation suggests that Bezos feels guilty, or that the gift is a cynical attempt to buy-off critics. That might have an element of truth, but the tax was well worthy of opposition on economic grounds — almost as if it was designed to stunt employment and economic growth in the city.

Second, because Amazon has been an engine of growth for Seattle, Del Valle intimates that the company and other large employers are responsible for the city’s high cost of housing and therefore homelessness. Of course, growth in a region’s economy is likely to lead to higher housing prices if the supply of housing does not keep pace, but forsaking economic growth is not a solution. Furthermore, every large city in the country suffers from some degree of homelessness. And not all of those homeless individuals have been “displaced”, as Del Valle would have it. Some have relocated voluntarily without any guarantee or even desire for employment. As for the housing stock, government environmental regulations, zoning policies and rent control (in some markets) restrains expansion, leading to higher costs.

Finally, Del Valle implies that private efforts to help the homeless are somehow inferior to “leadership by elected officials”. Further, she seems to regard these charitable acts as threatening to “public” objectives and government control. At least she doesn’t disguise her authoritarian impulses. Del Valle also quotes a vague allegation that one of the charities beholden to Amazon is less than a paragon of charitable virtue. Well, I have heard similar allegations that government isn’t celebrated for rectitude in fulfilling its duties. Like all statists, Del Valle imagines that government technocrats possess the best vision of how to design aid programs. That attitude is an extension of the scientism and delusions of efficacy typical of central planners. Anyone with the slightest awareness of the government’s poor track record in low-income housing would approach such a question with trepidation. In contrast, private efforts often serve as laboratories in which to test innovative programs that can later be adopted on a broader scale.

While selfishness might motivate private acts of charity in some cases, only voluntary, private charity can ever qualify as real charity. Government benefits for the homeless are funded by taxes, which are compulsory. Such public programs might be justifiable as an extension of social insurance, but it is not charity in any pure sense; neither are it advocates engaged in promoting real charity, despite their conveniently moralistic positioning. And unlike private charity, government redistribution programs can be restrained only through a political process in which substantial payers are a distinct minority of the voting population.

Public aid and private charity have worked alongside each other for many years in the U.S. According to Russ Roberts, private giving to the poor began to be “crowded-out” during the Great Depression by a dramatic increase in public assistance programs. (Also see Doug Bandow’s “War On Charity“.) It’s certainly more difficult to make a case for gifts to the poor when donors are taxed by the government in order to redistribute income.

The statist war on private charity can take other forms. The regulatory apparatus can crowd-out private efforts to extend a helping hand. Chloe Anagnos of the American Institute for Economic Research (AIER) writes of a charity in Kansas City that wanted to provide home-cooked soup to the homeless, but health officials intervened, pouring bleach into the soup. I am aware of similar but less drastic actions in St. Louis, where organizations attempting to hand-out sandwiches to the poor were recently prohibited by health authorities.

Private charity has drawn criticism because its source has driven economic growth, its source has opposed policies that stunt comic growth, and because it might interfere with the remote possibility that government would do it better. But private charity plays a critical role in meeting the needs of the disadvantaged, whether as a substitute for public aid where it falls short, or as a supplement. It can also play a productive role in identifying the most effective designs for aid programs. Of course, there are corrupt organizations and individuals purporting to do charitable work, which argues for a degree of public supervision over private charities. But unfortunately, common sense is too often lost to overzealous enforcement. In general, the public sector should not stand in the way of private charities and charitable acts, but real generosity has little value to those who press for domination by the state.

Climbing Up: Economic Mobility In the U.S.

29 Monday Oct 2018

Posted by in Inequality, Markets, Redistribution

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One of the great sacred cows of current economic discourse is that U.S. living standards have been stagnant for decades, coincident with a severe lack of economic mobility (I know, those are goats!). These assertions have been made by people with the training to know better, and by members of the commentariat who certainly would not know better. But Russ Roberts has a great article on the proper measurement of these trends and how poorly that case stacks up. I have made some of the same points in the past (and here), but Roberts’ synthesis is excellent.

Those who insist that income growth has languished or even declined in real terms over the past 40 years have erred in several ways. They usually ignore non-wage benefits (for which workers often receive favorable tax treatment) and other forms of income. Roberts notes that income tax returns leave about 40% of income unreported, and a lot of it goes to individuals in lower income strata. In addition, the studies often use flawed inflation gauges, fail to adjust correctly for various demographic trends in the identification of “households”, and most importantly, fail to follow the same individuals over time. The practice of taking “snapshots” of the income distribution at two different points in time, and then comparing the same percentiles from those snapshots, is inappropriate for addressing the question of income mobility. Instead, the question is how specific individuals or cohorts have migrated across time. Generally incomes grow as people age through their working lives.

Roberts discusses some studies that follow individuals over time, rather than percentiles, to see how they have fared:

From a study comparing the 1960s and the early 2000s:

“… 84% earned more than their parents, corrected for inflation. But 93% of the children in the poorest households, the bottom 20% surpassed their parents. Only 70% of those raised in the top quintile exceeded their parent’s income.”

 In another study compared children born in 1980:

“… 70% of children born in 1980 into the bottom decile exceed their parents’ income in 2014. For those born in the top 10%, only 33% exceed their parents’ income.”

Another study finds:

“The children from the poorest families ended up twice as well-off as their parents when they became adults. The children from the poorest families had the largest absolute gains as well. Children raised in the top quintile did no better or worse than their parents once those children became adults.”

The next study cited by Roberts compares adults at two stages of life:

“The study looks at people who were 35–40 in 1987 and then looks at how they were doing 20 years later, when they are 55–60. The median income of the people in the top 20% in 1987 ended up 5% lower twenty years later. The people in the middle 20% ended up with median income that was 27% higher. And if you started in the bottom 20%, your income doubled. If you were in the top 1% in 1987, 20 years later, median income was 29% lower.”

And here’s one more:

“… when you follow the same people, the biggest gains go to the poorest people. The richest people in 1980 actually ended up poorer, on average, in 2014. Like the top 20%, the top 1% in 1980 were also poorer on average 34 years later in 2014.”

These studies show impressive mobility across the income distribution, but is it still true that overall incomes have been flat? No, for reasons mentioned earlier: growth in benefits and unreported income have been dramatic, and inflation measures used to “deflate” nominal income income gains are notoriously poor. When the prices of many goods are expressed in terms of labor hours, there is no doubt that living standards have advanced tremendously. It is all the more impressive in view of the quality improvements that have occurred over the years.

The purported income stagnation and lack of mobility are also said to be associated with an increasingly unequal distribution of income. The OECD reports that the distribution of income in the U.S. is relatively unequal compared to other large, developed countries, but the definitions and accuracy of these comparisons are not without controversy. A more accurate accounting for incomes after redistribution via taxes and transfer payments would place the U.S. in the middle of the pack. And while measures of income inequality have trended upward, consumption inequality has not, which suggests that the income comparisons may be distorted.

Contrary to the oft-repeated narrative, U.S. living standards have not stagnated since the 1970s, nor have U.S. households been plagued by a lack of economic mobility. It’s easy to understand the confusion suffered by journalists on these points, but it’s horrifying to realize that such mistaken interpretations of data are actually issued by economists. Even more disappointing is that these misguided narratives are favorite talking points of class warriors and redistributionists, whose policy recommendations would bring-on real stagnation and immobility. That’s the subject of a future post, or posts. For now, I’ll let it suffice to say that it is the best guarantee of mobility is the preservation of economic freedom and opportunity by limiting the size and scope of government, creating a more neutral tax code, and encouraging markets to flourish.

Embracing the Robots

03 Friday Mar 2017

Posted by in Automation, Labor Markets, Technology

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Machines have always been regarded with suspicion as a potential threat to the livelihood of workers. That is still the case, despite the demonstrated power of machines make life easier and goods cheaper. Today, the automation of jobs in manufacturing and even service jobs has raised new alarm about the future of human labor, and the prospect of a broad deployment of artificial intelligence (AI) has made the situation seem much scarier. Even the technologists of Silicon Valley have taken a keen interest in promoting policies like the Universal Basic Income (UBI) to cushion the loss of jobs they expect their inventions to precipitate. The UBI is an idea discussed in last Sunday’s post on Sacred Cow Chips. In addition to the reasons for rejecting that policy cited in that post, however, we should question the premise that automation and AI are unambiguously job killing.

The same stories of future joblessness have been told for over two centuries, and they have been wrong every time. The vulnerability in our popular psyche with respect to automation is four-fold: 1) the belief that we compete with machines, rather than collaborate with them; 2) our perpetual inability to anticipate the new and unforeseeable opportunities that arise as technology is deployed; 3) our tendency to undervalue new technologies for the freedoms they create for higher-order pursuits; and 4) the heavy discount we apply to the ability of workers and markets to anticipate and adjust to changes in market conditions.

Despite the technological upheavals of the past, employment has not only risen over time, but real wages have as well. Matt Ridley writes of just how wrong the dire predictions of machine-for-human substitution have been. He also disputes the notion that “this time it’s different”:

“The argument that artificial intelligence will cause mass unemployment is as unpersuasive as the argument that threshing machines, machine tools, dishwashers or computers would cause mass unemployment. These technologies simply free people to do other things and fulfill other needs. And they make people more productive, which increases their ability to buy other forms of labour. ‘The bogeyman of automation consumes worrying capacity that should be saved for real problems,’ scoffed the economist Herbert Simon in the 1960s.“

As Ridley notes, the process of substituting capital for labor has been more or less continuous over the past 250 years, and there are now more jobs, and at far higher wages, than ever. Automation has generally involved replacement of strictly manual labor, but it has always required collaboration with human labor to one degree or another.

The tools and machines we use in performing all kinds of manual tasks become ever-more sophisticated, and while they change the human role in performing those tasks, the tasks themselves largely remain or are replaced by new, higher-order tasks. Will the combination of automation and AI change that? Will it make human labor obsolete? Call me an AI skeptic, but I do not believe it will have broad enough applicability to obviate a human role in the production of goods and services. We will perform tasks much better and faster, and AI will create new and more rewarding forms of human-machine collaboration.

Tyler Cowen believes that AI and  automation will bring powerful benefits in the long run, but he raises the specter of a transition to widespread automation involving a lengthy period of high unemployment and depressed wages. Cowen points to a 70-year period for England, beginning in 1760, covering the start of the industrial revolution. He reports one estimate that real wages rose just 22% during this transition, and that gains in real wages were not sustained until the 1830s. Evidently, Cowen views more recent automation of factories as another stage of the “great stagnation” phenomenon he has emphasized. Some commenters on Cowen’s blog, Marginal Revolution, insist that estimates of real wages from the early stages of the industrial revolution are basically junk. Others note that the population of England doubled during that period, which likely depressed wages.

David Henderson does not buy into Cowans’ pessimism about transition costs. For one thing, a longer perspective on the industrial revolution would undoubtedly show that average growth in the income of workers was dismal or nonexistent prior to 1760. Henderson also notes that Cowen hedges his description of the evidence of wage stagnation during that era. It should also be mentioned the share of the U.S. work force engaged in agricultural production was 40% in 1900, but is only 2% today, and the rapid transition away from farm jobs in the first half of the 20th century did not itself lead to mass unemployment nor declining wages (HT: Russ Roberts). Cowen cites more recent data on stagnant median income, but Henderson warns that even recent inflation adjustments are fraught with difficulties, that average household size has changed, and that immigration, by adding households and bringing labor market competition, has had at least some depressing effect on the U.S. median wage.

Even positive long-run effects and a smooth transition in the aggregate won’t matter much to any individual whose job is easily automated. There is no doubt that some individuals will fall on hard times, and finding new work might require a lengthy search, accepting lower pay, or retraining. Can something be done to ease the transition? This point is addressed by Don Boudreaux in another context in “Transition Problems and Costs“. Specifically, Boudreaux’s post is about transitions made necessary by changing patterns of international trade, but his points are relevant to this discussion. Most fundamentally, we should not assume that the state must have a role in easing those transitions. We don’t reflexively call for aid when workers of a particular firm lose their jobs because a competitor captures a greater share of the market, nor when consumers decide they don’t like their product. In the end, these are private problems that can and should be solved privately. However, the state certainly should take a role in improving the function of markets such that unemployed resources are absorbed more readily:

“Getting rid of, or at least reducing, occupational licensing will certainly help laid-off workers transition to new jobs. Ditto for reducing taxes, regulations, and zoning restrictions – many of which discourage entrepreneurs from starting new firms and from expanding existing ones. While much ‘worker transitioning’ involves workers moving to where jobs are, much of it also involves – and could involve even more – businesses and jobs moving to where available workers are.“

Boudreaux also notes that workers should never be treated as passive victims. They are quite capable of acting on their own behalf. They often act out of risk avoidance to save their funds against the advent of a job loss, invest in retraining, and seek out new opportunities. There is no question, however, that many workers will need new skills in an economy shaped by increasing automation and AI. This article discusses some private initiatives that can help close the so-called “skills gap”.

Crucially, government should not accelerate the process of automation beyond its natural pace. That means markets and prices must be allowed to play their natural role in directing resources to their highest-valued uses. Unfortunately, government often interferes with that process by imposing employment regulations and wage controls — i.e., the minimum wage. Increasingly, we are seeing that many jobs performed by low-skilled workers can be automated, and the expense of automation becomes more worthwhile as the cost of labor is inflated to artificial levels by government mandate. That point was emphasized in a 2015 post on Sacred Cow Chips entitled “Automate No Job Before Its Time“.

Another past post on Sacred Cow Chips called “Robots and Tradeoffs” covered several ways in which we will adjust to a more automated economy, none of which will require the intrusive hand of government. One certainty is that humans will always value human service, even when a robot is more efficient, so there will be always be opportunities for work. There will also be ways in which humans can compete with machines (or collaborate more effectively) via human augmentation. Moreover, we should not discount the potential for the ownership of machines to become more widely dispersed over time, mitigating the feared impact of automation on the distribution of income. The diffusion of specific technologies become more widespread as their costs decline. That phenomenon has unfolded rapidly with wireless technology, particularly the hardware and software necessary to make productive use of the wireless internet. The same is likely to occur with 3-D printing and other advances. For example, robots are increasingly entering consumer markets, and there is no reason to believe that the same downward cost pressures won’t allow them to be used in home production or small-scale business applications. The ability to leverage technology will require learning, but web-enabled instruction is becoming increasingly accessible as well.

Can the ownership of productive technologies become sufficiently widespread to assure a broad distribution of rewards? It’s possible that cost reductions will allow that to happen, but broadening the ownership of capital might require new saving constructs as well. That might involve cooperative ownership of capital by associations of private parties engaged in diverse lines of business. Stable family structures can also play a role in promoting saving.

It is often said that automation and AI will mean an end to scarcity. If that were the case, the implications for labor would be beside the point. Why would anyone care about jobs in a world without want? Of course, work might be done purely for pleasure, but that would make “labor” economically indistinguishable from leisure. Reaching that point would mean a prolonged process of falling prices, lifting real wages on a pace matching increases in productivity. But in a world without scarcity, prices must be zero, and that will never happen. Human wants are unlimited and resources are finite. We’ll use resources more productively, but we will always find new wants. And if prices are positive, including the cost of capital, it is certain that demands for labor will remain.