Tag Archives: policy

More on the Widely Varying Charges for Common Health Procedures: Price Variation for Standard Blood Tests

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Blood Test Prices in California - Lipid Panel

A.  Widely Varying Prices Charged Even for Standard Blood Tests

This post is an addition to an earlier post on this blog that looked at the widely varying prices being charged in the US for common health procedures.  As that post noted, such differences in prices for what are fundamentally the same services are a clear indication that the market is not working.  The prices would be similar if the market was working, with differences that are relatively small and explainable by factors such as geography.  But that is not the case.

That post looked at data from a number of studies (including my own simple research on the prices that I would be charged in the Washington, DC, area, for a common surgical procedure).  Prices could vary by a factor of 10, and indeed often even more.  And as that post showed in a series of charts, the prices actually paid in the US (at the rates negotiated by insurers) are not only widely varying, but also consistently far higher than the prices paid for the same procedures in other countries.

A criticism of studies that examine the prices being charged for health care procedures is that individual cases can differ, with some more complex than others.  Thus prices might vary for that reason.  Even though it is difficult to see how costs can vary by a factor of ten or more even with differing levels of complexity for some standard procedure (such as a hip or knee replacement, for example), one can recognize that differing degrees of complexity might explain at least some of the price differences.

Thus a study published last week in the BMJOpen, an open-access on-line journal affiliated with the British Medical Journal, is of interest as it addresses the question of whether such price variation is found also for procedures where case complexity does not enter.  The lead author is Dr. Renee Hsia, of the Department of Emergency Medicine at the University of California – San Francisco.  In an earlier study, summarized in the blog post cited above on health care price variation, Dr. Hsia had looked at the prices charged by hospitals in California for an uncomplicated but urgent appendectomy.  She found that the prices varied by a factor of 120, between the lowest rate charged and the highest.

In the current study, Dr. Hsia with her colleagues looked at the prices charged by California hospitals for ten common blood tests.  The prices reviewed are the so-called “chargemaster” rates, or the list prices at the hospitals for the tests.  The actual price paid will then normally be a lower rate negotiated with the hospital by your insurer (if you have insurance), but the chargemaster rate is the starting point.  Why this matters will be discussed below.

Dr. Hsia was able to obtain the data for California because hospitals there are required to report to state authorities the average prices they charged for a number of common procedures.  Since routine blood tests are standard, and are not more or less complicated for one patient vs. another (the blood is drawn, brought to a standard machine, and the results then read), one cannot argue that the price variation observed might be a consequence of different degrees of case complexity.

The results from one of the blood tests examined, that of a standard lipid test (which measures blood cholesterol levels), is shown graphically at the top of this post.  Data was available from 178 hospitals, and each hospital reported the average price it charged for this test over the course of 2011.  The price charged at one hospital was only $10 per test.  The average price charged at a different hospital, for the exact same blood test, was $10,169 per test, or over 1,000 times as much.  Such variation is absurd.

These are, of course, the extremes.  But even if one focusses on observations in the middle of the distribution, it is impossible to see how such variation in prices charged can be justified.  The price at the 5th percentile (meaning 5% of the hospitals charged this price or less) was $76.  The price charged at the 95th percentile (meaning 5% charged this price or more) was $602.  This is almost 8 times higher than the price at the 5th percentile.  The results for the other nine blood tests examined were broadly similar (with ratios between the prices at the 95th and 5th percentiles varying from a high of 12 times and a low of 6.8 times).

B.  Chargemaster Rates Matter

What can justify such a spread?  Nothing that I can see.  The tests are standard, use standard machines, and all use similarly drawn blood.  The response of a spokeswoman for the California Hospital Association was that the prices reviewed in the study are “meaningless”, since virtually no one (she states) pay these rates.  As noted above, the rates reviewed in the study, as in the earlier study of the prices charged for appendectomies, are the chargemaster rates of the hospitals.  These are the regular list prices for the procedures, which are then typically discounted in negotiations with individual insurers.

But there are still several problems with this, including:

1)  How much the prices are negotiated down will vary according to the bargaining strength of the patient’s individual insurer in the region.  In the bargaining process discussed in an earlier post in this series on health reform, insurers will bargain with hospitals on what the rates will be.  Their relative bargaining strength will depend on how concentrated the local market is in terms of hospitals (if there is only one hospital, or one chain of hospitals all owned by the same entity, but a number of insurers, the bargaining power of the hospital will be great) versus insurers (in one insurer dominates in the market, while there are many hospitals, that insurer will have great bargaining power).  If you have insurance with an insurer who does not command great market share in the region, the price you will have to pay may be close to the chargemaster rate.

2)  If you do not have insurance (and many could not get health insurance, prior to the reforms of Obamacare), you will be charged the chargemaster rate.  You might then try to bargain individually with the hospital, but the starting point will be the chargemaster rate.  And many hospitals will insist, unless you are poor, that you have to pay that chargemaster rate.

3)  You may well have insurance, but if the particular hospital you are in is not in your insurance network (perhaps because you were brought by an ambulance to the nearest hospital in an emergency), you will be charged the chargemaster rate.  Your insurance company might pay a portion of this at what they consider to be a “reasonable rate”, but this is likely to be close to what your insurer has negotiated with others, and as we have discussed in the earlier blog posts cited above, this might be only one-tenth of the chargemaster rate.  You will then still be responsible for the other 90%.  This can be a lot, if you are at the hospital where a simple lipid panel blood test is charged at over $10,000.

4)  You may well again have insurance, and be in a facility that is in-network for your insurer, but your insurer might disagree on whether some standard blood or other test ordered by your doctor was really needed.  Your insurer will then refuse to cover the cost of that test, and you will be charged the chargemaster rate.

I am personally facing a case of that right now.  While the amounts are small in absolute terms, the issue is the same.  My doctor ordered a set of routine blood tests for me earlier this year, and my insurer covered all except one.  For that one, the insurer asserted that there had not been a need (even though both my doctor, and research I found on the web, made clear that the test was in fact needed).  The lab therefore charged me the full chargemaster rate (which in this case was $213.98), even though the negotiated rate Aetna would have paid, had they agreed it should be covered, was only $16.23.  That is, the full billed rate was 13.2 times the negotiated rate.  I would have been glad to pay the negotiated rate in full, and the $16.23 the lab has negotiated with Aetna is evidently a rate sufficient to provide an adequate profit to the lab.  But find it absurd that I should have to pay over 13 times more.  I am appealing, but do not know yet the outcome.

5)  Finally, it is worth noting that the chargemaster rates can matter for other issues as well. For example, hospitals are typically required to provide a certain amount of “charity care” (care provided to the poor without health insurance for free or at discounted rates) in order to benefit from certain tax breaks.  This is especially important and valuable for private, profit-making, hospitals.  Valuing such services at the chargemaster rates, when these rates are 1000 times higher than what someone else might charge, will make it look as if the hospital is providing a good deal of charity care.

C.  Conclusion

This new study should put to rest the argument that price variation in health care services is principally due to variation in the degree of complexity of individual cases.  Common blood tests are standard, and they show price variation which is huge as well as similar in degree to that seen for standard health care procedures (see the review in the earlier post).  The prices vary not principally due to case complexity, but rather due to a grossly misfunctioning market for health care services, where there are strong forces keeping out effective competition and any pressure to converge on low prices from efficient providers.

America’s Underinvestment in Public Infrastructure

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Real per Capita Public Investment vs. GDP, 1950-2013

Public infrastructure in the United States is an embarrassment.  This is clear even to ordinary travelers.  Countries in Europe and in much of East Asia enjoy far better roads, highways, public transit, and other forms of public infrastructure than the US does, even though the real per capita incomes of these countries are lower than that of the US.  And this is backed up by more systematic global comparisons, such as in the Global Competitiveness Report of the World Economic Forum.  The most recent report ranked the US as only number 15 in the world in terms of its infrastructure (transport, power, and telecom).  This put the US behind Canada, the major countries of Western Europe, and such countries as Japan, Korea, Hong Kong, Singapore, and Taiwan in East Asia.

The poor quality of public infrastructure in the US should not, however, be a surprise.  As the chart at the top of this post shows, the US is spending no more now, in real per capita terms, than it did over a half century ago in 1960, in the last year of the Eisenhower administration.  The chart draws on data issued in the standard GDP (NIPA) accounts of the BEA of the US Department of Commerce.  Infrastructure investment is taken to be total government investment (at all levels of government – Federal, State, and Local) in structures, excluding such spending by the military.  Most government infrastructure spending in the US is for transport (primarily roads and associated bridges, but also including investment in mass transit, ports, and airports), with a significant amount also for water and wastewater treatment.

Public infrastructure spending in real per capita terms rose during the Eisenhower administration in the 1950s (when the Interstate Highway system was started) and continued rising during the Kennedy and Johnson administrations in the 1960s.  Indeed, during this period, such spending rose at a somewhat faster pace than real per capita GDP, the blue line in the chart.  But starting in 1969, the year Nixon took office, public infrastructure spending was cut.  By the mid-1970s it was down close to the level seen at the end of the Eisenhower administration (in real per capita terms), and then was cut even further at the start of the Reagan administration.  It then began to increase from 1984 with this continuing to a peak in 2002, after which it fell again.  By 2013 it was 2% lower than it was in 1960.  Over this same period, real per capita GDP almost tripled.

In dollar terms, real per capita spending on public infrastructure (in terms of 2009 prices, the base now used in the GDP accounts) was $793 in 1960 and was 2% lower, at $776, in 2013 (about 1.6% of GDP).  Over this same period, per capita real GDP rose from $17,159 in 1960 to $49,852 in 2013.  The increment in real per capita GDP was $32,693 over this period.  None of this growth went to increased investment in public infrastructure.

It is this stagnation in real per capita spending, and huge lag behind income growth, that has led to bridges and highways that are both congested and in poor condition.  People drive more, fly more, and import and export more goods, as their real incomes grow.  Public infrastructure has not kept up.  A 2009 report issued by the American Association of State Highway and Transportation Officials (AASTO) notes that vehicle miles driven between 1990 and 2007 rose by 41%, about double the increase in the US population over this 17-year period (of 20.6%).  Based on the figures in the chart above (which however covers all public infrastructure, not just highways), spending to build or maintain such infrastructure per mile driven fell by over 20% over that period.

The AASTO report also found (based on an analysis of US Federal Highway Administration data) that one-third (33%) of the nation’s major highways was classified as being only in poor or mediocre condition (as of 2007).   Thirteen percent was classified to be in poor condition, with this rising to over 60% poor in some major urban areas.   And roads in poor or mediocre condition deteriorate quickly, leading to much higher costs when the road eventually has to be repaired.  The AASTO report notes that the cost per mile over 25 years is three times higher if roads are left to be reconstructed, instead of maintained on the regular recommended schedule.

This stagnation in real per capita spending on public infrastructure over more than a half century may be surprising to some.  While many might be aware that infrastructure spending has not kept up with real per capita GDP (which has almost tripled), most people would assume that there has been at least some increase in per capita infrastructure spending.  But that is not the case.

Part of the reason for this mis-conception is that when measured as a share of GDP, it might not appear that public infrastructure spending has fallen so far behind.  As a share of GDP, public infrastructure spending (using the figures cited above for public investment in non-Defense structures, from the BEA accounts) was 39% less in 2013 than it was in 1960.  Put another way, public infrastructure spending would have had to increase by 64% (=1/(1-.39)) between 1960 and 2013, to match the GDP share it had in 1960.  But the figures shown above in the chart indicate that public infrastructure spending would have had to triple over this period to match the increase in GDP.

Why this big difference?  The reason is Baumol’s Cost Disease, which was discussed in an earlier post on this blog.  If the price index for public infrastructure spending over this period had matched the price index for overall GDP, then an increase in infrastructure spending of 64% would suffice to bring it into line with the increase in real GDP over the period.  But the cost of building infrastructure has risen at a faster pace than the cost of making goods generally.  This is not because of increased waste, but rather because building infrastructure is by nature labor intensive and hard to automate.  The relative cost of infrastructure will therefore increase over time relative to the cost of goods whose production can be increasingly automated.

The importance of this is huge, but is often ignored in the debates.  As the chart above shows, investment in public infrastructure has stagnated in real per capita terms over more than a half century, and would need to almost triple at this point to catch up with how much real per capita GDP has grown.  This is far greater than the 64% increase (which is itself not small) that one might assume would be necessary by simply focussing on GDP shares.

The fundamental cause of this stagnation in real spending on public infrastructure has been an unwillingness in Congress to pay for it.  The most important source of funding for highway expenditures has been the gasoline tax, which supports the Highway Trust Fund. But as was discussed in an earlier post on this blog, gasoline taxes have been set as so many cents per gallon and are not adjusted regularly for inflation.  The last time the tax was raised (in nominal terms) was in 1993, over 20 years ago.  Since then, even general inflation has eroded this by over 50%.  If one took into account that prices for infrastructure investments rise at a substantially faster pace than general prices (due to Baumol’s Cost Disease, discussed above), the real erosion has been much greater.  As a result, funds in the Highway Trust Fund are far from adequate.

The result has been repeated crises as the Congress passes one short term patch after another to allow even the overly low on-going highway investments to continue.  One such crisis is underway now, where expenditures would need to be slashed on August 1 if nothing is done.  The Senate is currently expected to vote this week on an extension, although it would only be for a few months at best.  If passed and can then be reconciled with a similar House passed measure (passed two weeks ago), spending on highway investment will be able to continue for a few more months.

To provide the needed funds, given that the Highway Trust Fund is far from sufficient (due to the failure to adjust the tax to reflect inflation), Congress has included again an especially stupid provision in the draft bills.  As it did in an earlier authorization in 2012 (see the blog post cited above), Congress would allow corporations to make assumptions on their pension obligations which will in effect allow them to underfund their pension obligations by even more than currently.  The corporations will then show (on their balance sheets) higher profits, which will generate somewhat higher corporate income tax obligations.  These higher tax obligations will be counted as government revenues.  But those reliant on corporate pensions will be at greater risk of not receiving the pensions they are owed.  Ultimately the government may be obliged to cover these pension obligations (through the Pension Benefit Guarantee Corporation).  But these costs latter costs are being ignored.

The Continued Fall in Government Spending Under Obama

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Govt Spending on Goods & Services by Presidential Term, Quarterly

A.  Introduction

Government spending continues to fall under Obama.  As this blog has noted in earlier posts, the fiscal drag from this reduction in demand for the goods and services that unemployed workers could have been producing can fully explain why the recovery from the 2008 has been so slow.  As another blog post noted, if government spending had merely been allowed to grow under Obama at the same pace as it had historically, the economy would by now be back at full employment.  The public debt to GDP ratio would also be lower, as GDP would be higher.  And if government spending had been allowed to grow as it had under Reagan, we would likely have returned to full employment by 2011.

Fiscal drag is therefore important.  Yet it is still not yet commonly recognized that government spending has been falling in real absolute terms for the last several years (and even more so when measured as a share of GDP).  Earlier blog posts have reviewed this.  The trends have unfortunately continued and indeed strengthened over the last year.  Whether this will now change with government spending finally leveling off, and perhaps even start to recover, remains to be seen.  The budget compromise for fiscal years 2014 and 2015 reached by Senator Patty Murray and Congressman Paul Ryan in December, and passed by Congress in January, will reverse part of the impact of the budget sequester.  According to calculations by the Committee for a Responsible Federal Budget (fiscal hawks in favor of budget cuts), the agreement for FY2014 will lead to a small (1.8%) rise in nominal terms in budget authority compared to the FY2013 post-sequester levels.  This would still be flat to negative in real terms, based on inflation of about 2%.  And the FY2014 sum would still represent a 3.7% fall compared to what the FY2013 pre-sequester levels would have been.

Possibly more important would be government spending at the state and local level.  This was cut back as a result of the 2008 collapse and slow recovery, due to lower revenues and the requirement in many states and localities of a balanced budget.  While expenditures were still falling in 2013, revenues have started to grow (due to the positive, though still slow, recovery of GDP) and state and local budgets as a result can now start to recover as well.  But it also remains to be seen if that will happen.

This blog post will update the government spending figures during the Obama term through the fifth year of his administration.  And it will present the figures from a different perspective than before, by tracing the paths during the course of each presidential term (going back to Carter’s) relative to what the spending was at the start of their respective presidencies.

[Note that all the government spending figures used in this post will be in real, inflation-adjusted, terms.]

B.  Government Spending on Consumption and Investment

The graph at the top of this post shows the tracks of real government spending on consumption and investment during each presidential term going back to Carter, as a ratio to what it was at the start of their terms.  The base period is always taken as the last quarter before their inauguration (i.e. in the fourth quarter of the calendar year preceding their January 20 inauguration).  The data is computed from the figures in the standard National Income and Product Accounts (NIPA accounts, also commonly referred to as the GDP accounts) of the Bureau of Economic Analysis (BEA) of the US Department of Commerce, and are seasonally adjusted.  Note that all levels of government are included here – federal, state, and local.  We will examine below spending at the federal level only, as well as spending including transfer payments.

This government spending has fallen by 5 1/2% in real terms by the end of the fifth year (the 20th quarter) of Obama’s term in office.  It rose by 2 1/2% during Obama’s first year, which one might note is similar to the increases seen by that point under Carter, Reagan, and Bush I, and with a significantly greater increase by that point under Bush II.  Spending during Obama’s term has since been falling steadily, leading to the fiscal drag referred to above, to a point where it is now 8% lower in real terms than it was in his first year, or a net 5 1/2% fall from when he took office.

There has been no such fall in government spending under any other presidential term since Carter.  The closest was spending during the Clinton period, but there was still a 3% rise by the end of his fifth year in office.  The increases by the end of the fourth year under Carter and Bush I (single term presidencies) were 8% and 6 1/2% respectively.  And the increases by the end of the fifth year in office were 13% during the term of Bush II, and by a full 21% in real terms under Reagan.  Government spending also continued to grow under Bush II and Reagan, reaching increases of 21% and 33% respectively by the end of their eight years in office.

Yet Reagan and Bush II are seen as small government conservatives, while Obama is deemed by conservatives to be a big spending liberal.  The facts simply do not support this.

C.  Government Spending Including Transfers

Government spending for the direct purchase of goods and services (used for consumption or investment), reviewed above, is a direct component of GDP demand.  When there are substantial unemployed resources (as now), such government spending will have a significant positive impact in spurring economic expansion.  As was discussed in an Econ 101 post on this blog, under such circumstances the fiscal multiplier will be positive and high.  Hence the fiscal drag from the cut-back in government spending during Obama’s term in office has kept the recovery below what it would have been.

But there is also government spending on transfers to households (such as for Social Security, food stamps, or unemployment insurance).  Such transfers are ultimately spent by households for their consumption of goods and services (or will in part be saved, including through the pay-down of debt such as mortgage debt).  It will enter into GDP demand by way of the spending of households for consumption, and the impact on GDP will depend on the behavior of households in deciding what share of those transfers they will spend or save.

Such spending rose more sharply during Obama’s first year in office, as he faced an economy in free fall as he was taking his inaugural oath:

Govt Spending, Total incl Transfers, by Presidential Term, Quarterly

The economy was losing 800,000 jobs per month at that time, pushing the unemployment roles up rapidly and plunging the incomes of many in the population to levels where they qualified for food stamps.  Government spending including transfers therefore rose by almost 9% by the third quarter of 2009, and reached a peak of 9.8% in the third quarter of 2010.  Since then, however, total government spending including transfers has been modestly falling, and is now 7 1/2% above where it was when Obama took office.

[Note all figures are in real terms.  The personal consumption expenditures deflator in the NIPA accounts was used to adjust transfer payments for inflation.]

Only during the Clinton period did one see a modestly smaller increase, of about 6 1/2%.  But there was a 16 1/2% increase in such spending at the same point in the term of Bush II, and an increase of over 22% under Reagan.  It was also higher by the end of their fourth years in office for both Carter and Bush I.

The differences are not small.

D.  Federal Government Spending on Consumption and Investment

What matters to the economy when demand is inadequate and unemployment is high is spending at all levels of government.  Yet while we commonly blame the president in office for the performance of the economy, they at best can only influence the federal budget (and influence it only partially, as Congress decides on the budget).  Hence it may be of interest also to examine the paths of only federal government spending.

Such federal spending on direct consumption and investment at first rose during the Obama term, reaching a peak 8% increase in the third quarter of his second year in office.  It then fell sharply, to a point where it is now 5 1/2% below where it was when Obama took office:

Federal Govt Spending on Goods & Services by Presidential Term, Quarterly

The initial increase in federal spending was in part due to the stimulus package that served to restart the economy (GDP was falling from 2008 through the first half of 2009; it then began to recover).  Note that while federal spending rose by 8% by the third quarter of 2010, overall government spending (including state and local) rose only by 2 1/2% at that point.  State and local government was cutting back, as they were forced to do by the balanced budget requirements of many of them, so federal spending and the stimulus it could provide was partially being offset by their cut-backs.

But after this initial increase in the first two years of the Obama presidency, federal spending has been cut substantially, to the point where it is now 5 1/2% below in real absolute terms where it was when Obama took office.  Federal spending also fell during the Clinton term, by 11% at the same point in his term.  In contrast, federal spending rose sharply under Bush II (by 27% at the same point) and especially under Reagan (by over 31%).

E.  Federal Government Spending Including Transfers

Finally, federal government spending including transfers:

Fed Govt Spending, Total incl Transfers, Quarterly

[Technical Note:  Federal government transfers in the NIPA accounts include transfers to individuals as well as transfers to the states or localities for all purposes, including road construction, for example.  Such intra-government transfers are netted out in the accounts when government as a whole – federal, state, and local – is examined, so that remaining government transfers are then solely transfers to individuals, such as for Social Security.]

Such spending is now lower under Obama than under any of the presidencies examined, including Clinton.  Federal spending including transfers rose to a peak in 2010 of 10% above where it was when Obama took office, but has since declined to just 1% above that level.  It was 4% higher at that point in Clinton’s term, 23% higher at the point in the term of Bush II, and 25 1/2% higher at that point in the term of Reagan.

F.  Conclusion

Republicans in Congress and conservatives generally continue to criticize Obama as being responsible for runaway government spending.  But after an initial modest increase in the first two years of his term, as he sought to stop the economic free fall he inherited on taking office (and succeeded), government spending has come down under any measure one takes.  The resulting fiscal drag has held back the economy, leading to an only slow recovery.  And the fiscal drag during Obama’s term in office is in sharp contrast to the large increases in government spending observed during the terms of George W. Bush and especially Ronald Reagan. Yet they have been viewed as small government conservatives.