The Incidental Economist

The following originally appeared on The Upshot (copyright 2014, The New York Times Company).

Medicare Advantage plans — private plans that serve as alternatives to the traditional, public program — have been growing in popularity. One reason is that they offer additional benefits beyond those available in the traditional program but often at no additional cost to beneficiaries.

This is a great deal for beneficiaries, but a bad one for taxpayers, who have to cover the extra cost. If the program were reorganized to more closely resemble the Affordable Care Act’s exchanges, it could still provide good value to consumers at a lower cost to taxpayers.

The standard explanation for how Medicare Advantage plans are able to offer more has two parts, both problematic.

1) Private plans are more efficient than the public program; they can buy more care for fewer dollars and can manage care so patients use health services with less waste. This leaves more headroom to fund extra benefits.

2) Per person covered, plans are paid well above the average cost of providing the Medicare benefit; they can turn this payment surplus into additional benefits.

On the first point, the assertion that Medicare Advantage plans are, on average, more efficient than traditional Medicare has little support. According to the Medicare Payment Advisory Commission, which advises Congress on Medicare payment policy, in 2014 Medicare Advantage plans could provide the same benefits for 2 percent less than the cost of traditional Medicare.

But this analysis does not account for the fact that Medicare Advantage enrollees are at least a little bit healthier than traditional Medicare enrollees, as many studies have shown. Thus at least some of the difference in cost is due to the type of individuals drawn to Medicare Advantage, not to greater efficiency of private plans. When this is factored in, it’s unlikely that Medicare Advantage has an efficiency advantage over traditional Medicare, on average.

The second claim is true, up to a point: Medicare Advantage plans do turn some of the higher payments they receive into extra benefits.

But at least three studies suggest that for each dollar of these higher payments that plans receive, beneficiaries get only a fraction of a dollar of value. A study by Harvard scholars found that a $1 increase in payment translates to at most 50 cents in additional benefits. Another by researchers from the University of Pennsylvania found that only 20 cents of each additional dollar in plan payment is converted into better coverage. Finally,my own work with my colleagues Steven Pizer of Northeastern University and Roger Feldman of the University of Minnesota found that only 14 cents per dollar of additional payment benefits Medicare Advantage enrollees.

Whether it’s 14, 20 or 50 cents on the dollar, Medicare beneficiaries are not getting the full value of taxpayers’ largess. Sure, something is better than nothing, which is why many beneficiaries passionately defend the Medicare Advantage program. But could that deal be improved?

One way is to make Medicare Advantage plans (and traditional Medicare as well) compete more vigorously for enrollees. Today, plans receive a government subsidy according to an administratively set formula that does a poor job of matching payments to actual costs.

An alternative based on the Affordable Care Act’s structure could work something like this: Plans would submit bids for covering the Medicare benefit, as they do today. Then, instead of basically paying them what they bid in addition to some extra (which is more or less what happens today), the government would pick one of the cheaper bids (for example, the second lowest) and just pay that to all plans. [See analysis of such a plan by Roger Feldman, Robert Coulam, and Bryan Dowd.]

This is similar to how the Affordable Care Act, which bases subsidies on the cost of the second-cheapest silver plan, and the Medicare Part D prescription-drug plans work. Someone who wants a plan that costs more than the government payment must pay more out of pocket. Extra subsidies would be provided for low-income consumers, same as in the Affordable Care Act and Part D.

With such a structure in place, plans would compete more vigorously. Being the second-cheapest or cheapest plan would be a huge advantage. Other plans would have to charge a premium. Plans would not offer extra stuff beneficiaries might not value highly.

That’s a far cry from today’s Medicare Advantage, in which extra benefits are worth far less to beneficiaries than what taxpayers pay for them. It’s an inefficiency we know how to correct, but, to date, we’ve been unwilling to.

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In a prior post I described James Capretta’s plan that could replace Obamacare’s exchanges with lighter-touch regulations. I also wrote that his plan seemed to be identical to that offered by Yuval Levin and Ramesh Ponnuru. An essential, common feature of the approach offered by these gentlemen is that they do not include competitive bidding. That is, the premium subsidy for consumers in the individual and small-group markets would not be a function of market premiums; it’d be a flat tax credit.

To these authors, I presume this is a feature. By stepping away from the competitive bidding design of the Affordable Care Act’s (ACA’s) exchanges — in which subsidies are tied to to the premium of the second cheapest silver rated plan — their proposal does not require an administrator to take and manage bids from qualified plans. With this obviation, many regulations fall away. The market is unleashed! (To be fair, a few, other regulations would or could be put in their place.)

And yet, I think a flat tax credit is far from the most efficient design. One should not abandon competitive bidding and exchanges eagerly. The fundamental reason is that we do not know the right level of tax credit. It cannot be determined administratively. Capretta suggests starting levels “of about $5,000 [for families], and for individuals, about $2,500,” and then indexing them “to grow with some measure of inflation.” Is this exactly how much support should be offered individuals and families for purchase of health insurance? Why should it be identical across markets, which exhibit considerable variation in health care costs and premiums? To what measure of inflation should it be indexed?

Similar puzzles have arisen with respect to Medicare Advantage plans, for which subsidies are set administratively. We know what happened. They shot up well above what plans reported was necessary to provide the Medicare benefit. The ACA was supposed to change that, and to a large extent it did. But the administration also layered on a quality bonus program — the value of which has been questioned by MedPAC and the GAO — that helped keep payments above cost, providing yet another example of the difficulty of administratively setting and maintaining payments at an efficient level. Capretta’s argument against exchanges, which necessarily drove him away from competitive bidding, is that they invite price controls. The lesson from Medicare Advantage is that administratively set subsidies invite bureaucratic meddling too, which is no less damaging to the efficiency of markets.

Competitive bidding, which I’ve covered extensively, is an alternative to guessing the right subsidy level, as it ties that level to the actual cost of plans (or a plan) in a market. Moreover, if plan bidding is conducted on a market-by-market basis, it permits subsidies to vary with the geographic cost of care. This provides protections for consumers, as it keeps subsidies in line with their actual premium costs; and it provides protections for taxpayers, as it prevents subsidies from running amok, as they have for Medicare Advantage plans.

One might be concerned that competitive bidding implies a defined benefit, as opposed to a defined contribution (e.g., in the form of a pre-determined tax credit), but it need not. One can retain competitive bidding in a defined contribution regime, though possibly at the expense of the consumer protection I just described. My point is that if one’s interest in a pre-set tax credit, such as that Capretta proposed, is because it’s a defined contribution, one need not abandon competitive bidding to achieve that.

To be sure competitive bidding requires some additional regulations. Plans must bid their costs for some set of benefits. Thus, one needs to specify a minimum benefit standard and establish standardized plans for the purposes of bidding. But this also aids competition. Choice among many different options that vary in many different dimensions is difficult for consumers. Such an environment weakens competition, as consumers are forced to rely more heavily on inaccurate heuristics. This is the basic premise of a managed competition design, of which competitive bidding a one variant. Exchanges so designed are good for competition and consumers. One can always argue what the minimum benefit and standardized designs should be, of course.

Perhaps one might be reasonably pessimistic about exchanges, given the poor roll-out of healthcare.gov and some of those in specific states. There’s no denying this has been a disaster. And yet, we also have examples of well-functioning exchanges. Kentucky’s works well, for example. Enrollment in the California exchange has been brisk. Medicare has a perfectly fine, exchange-like environment on medicare.gov for Medicare Advantage and Part D drug plan selection. There are also private exchanges that serve businesses and individual markets. I’m no fan of a big bureaucracy screwing up a large IT project such as healthcare.gov, but I don’t think that condemns the exchange concept; it condemns the administration overseeing that bureaucracy.

My final concern about abandoning exchanges that harness a competitive bidding design is that I do not find doing so to be a conservative notion at all. For one, we know competitive bidding works. It’s a sound theory that has been tested. Capretta, Ponnuru, and Levin know this. Medicare’s drug benefit program — Part D — has a competitive bidding design that has performed well, and Capretta himself has praised it. The Federal Employees Health Benefits Program also has competitive bidding design elements and has been cited by conservatives, Capretta included, as a model.

Competitive bidding is also central to any Medicare premium support proposal worth considering. In this context, Levin once called it “the confident market solution.” I agree! With so much evidence of its soundness, and having expressed confidence in it, I’m surprised to see thought leaders for right-of-center policy abandon it. Have they lost the courage of their convictions? If there is a clear line of conservative logic from the confident market solution to an administratively set subsidy, I am not aware of it.

@afrakt

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I cracked open the latest MedPAC report to read its recommendations on hospital readmissions. There wasn’t much new in it beyond what I could infer about the Commissions’ thinking in March. Still, there’s a lot more detail. You’ll find it in Chapter 4 (PDF) and the accompanying appendix (also a PDF). Some of it was reported on by Jordan Rau. All of this is ungated, which is one reason I’m giving it short shrift here.

The other reason is that I was more surprised by what I found in Chapter 1 (PDF).

Consistent with the goal of encouraging beneficiaries to make cost-conscious choices, this chapter presents an overview of a model based on government contributions toward purchasing Medicare coverage—an approach we call competitively determined plan contributions (CPCs). The Commission uses the term CPC to broadly describe a federal contribution toward coverage of the Medicare benefit based on the cost of competing options for the coverage, including those offered by private plans and the traditional FFS program. Specifically, CPC has two defining principles: First, beneficiaries receive a competitively determined federal contribution to buy Medicare coverage; second, beneficiaries’ individual premiums vary depending on the option they choose.

As far as I know, this is the first time the Commission has considered Medicare plan competitive bidding (aka, premium support) — their CPC — in this way before. To be clear, it is not recommending CPCs. It’s merely exploring the idea. The chapter hits many of the issues related to competitive bidding that have been discussed on this blog (look here and here).

Competing private plans, however, do not necessarily lower the cost to the Medicare program if the rules defining how they get paid do not encourage them to compete based on cost or premiums. For example, the current Medicare Advantage (MA) program produces a higher cost to Medicare than the traditional FFS program. Therefore, whether a CPC approach can lower overall Medicare spending depends on the specific design of the model and how different components of the model interact. […]

Medicare Part D provides a working example of a CPC approach and illustrates the range of the detail and specificity of the rules that a CPC approach requires. […]

The Federal Employees Health Benefits (FEHB) Program also illustrates different applications of the CPC principles.

Again, you can read the chapter for details. There you’ll also find an exploration of these questions:

• Should the benefit package be standardized?
• Should a CPC model be based on competitive bidding?
• Should a CPC model include FFS Medicare?
• How should the federal contribution be determined?
  

These are just the “first-order” questions. A presumably high-order question, “How does the federal contribution grow over time?” was raised in the report but not addressed.

What’s interesting to me is not so much what MedPAC addressed or how they did so, since, again, I’ve covered it all here in some form. What’s interesting is that it has taken a small but significant step toward competitive bidding/premium support, not by endorsement, but just by consideration. It’s now clearly on the table for discussion by the Commission, though I don’t think this necessarily moves the political needle at all. Meanwhile, as far as I know, the Commission’s prior MA payment recommendation still stands: pay plans 100% of average fee-for-service cost.

UPDATE: MedPAC considered competitive bidding in a 2009 report. See Chapter 7 here.

@afrakt

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Sam Baker reports:

The Medicare agency had initially proposed a 2.2 percent cut in Medicare Advantage payments. But on Monday the agency said it had scrapped that cut and would instead offer a 3 percent payment increase next year. [Other reports say 3.3%.]

America’s Health Insurance Plans (AHIP), the industry’s top lobbying group, praised the reversal.

Is either price the right one? Theoretically, a competitive bidding regime would obviate this question.

@afrakt

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The JAMA paper by Song, Cutler, and Chernew on the consequences of a Wyden-Ryan type premium support plan is getting a lot of attention. However, I’ve not seen anyone notice the following two points:

1. Their 9% savings figure is an underestimate in the sense that it is measured relative to fee-for-service Medicare costs. Since Medicare Advantage plans are paid well above that level, the actual savings is more. I made this point in my post on the paper.
2. Their 9% savings figure is an overestimate in the sense that it is a simulation of what would have happened had Wyden-Ryan been in effect in 2009. Current law includes the ACA, and relative to that, the savings would be less. Feldman, Coulam, and Dowd also examine premium support in 2009 and, using different methodology, come up with a 9.5% savings figure. However, when they factor in the effect of the ACA, their figure is cut to 5.6%.

It’s tempting to say 1 and 2 cancel each other out, and to some extent they do. It’d be nice to see someone work out exactly what the Song, Cutler, Chernew estimate would be taking into account the Medicare Advantage overpayments and the effect of the ACA. In other words, it’d be nice to see it relative to a current law baseline. As far as I know, nobody has made that estimate.

UPDATE: And then there’s the insufficient risk adjustment issue.

We find that differential payments actually rise after risk adjustment and estimate that they totaled $30 billion in 2006, or nearly eight percent of total Medicare spending.

That just about cancels any 9% saving.

@afrakt 

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Below is my checklist for a complete Medicare premium support proposal. (I’ve never seen one in the wild.) It’s subject to change, and you can participate in changing it. Suggest additions in the comments.

1. Competitive bidding, of course (What’s that? More here.)
2. No cap on Medicare spending growth that isn’t somehow sensitive to spending growth of the entire health system (It is not credible to me that we will maintain a growing divergence between what Medicare can afford and what is standard in the rest of the market.)
3. FFS Medicare included among the competing plans (Why? See this. Apart from competitive effects, what’s the value of private plans anyway? Choice.)
4. Overseen by an IPAB-like board to minimize political meddling (more here) and to permit more rapid response by FFS Medicare to changes in consumer demand and the state of medical science (more here)
5. Income-sensitive subsidies and programs to protect the poor (as exist in Medicare today)
6. Risk-adjusted subsidies to protect the sick (advanced reading on this topic here)
7. Safeguards in case risk-adjustment is insufficient (more here)
8. Safeguards to (try to) ensure plans are accountable for good quality (more here)
9. Ample assistance to help beneficiaries select plans (more here)
10. Required minimum plan generosity, e.g. must include all current Medicare benefits (more here)
11. Adequate access to private plan data for research purposes (don’t get me started)
12. Doesn’t discard current Medicare experiments, which include promotion of bundled payments, ACOs, comparative effectiveness research, etc.  (Their success is no more or less certain than competitive bidding. They can all co-exist.)
13. Legal safe harbor for plans that shape benefits based on (somehow) sanctioned evidence (more here)
14. Legal safe harbor for providers that employ shared decision making (more here)
15. Rationalizing the role of Medicare supplements (or eliminating them entirely) so they don’t lead to increased taxpayer costs (more here)
16. Implemented gradually and with some delay. Near retirees should be afforded time to prepare. The market should be afforded time to adjust.
17. Does something sensible about the Medicare hospice benefit (more here)

They’re all important, and many are included in most proposals or at least widely recognized issues. But, numbers 2 and 4 are central to many of the problems Medicare faces and yet are often overlooked. It would be nice to see premium support advocates acknowledge the possible need for numbers 7, 8, and 9. Ignoring number 11 is how we lose any chance of accountability in and improvement of our health system. Number 12 is not widely understood, setting up the false dichotomy between left and right options. Number 13 is a huge deal that almost nobody discusses. Number 14 may seem not so relevant to a proposal that pertains to insurance. But if one of the motivating ideas of premium support is to encourage and harness choice and consumerism, then consumers ought to be more fully involved in all aspects of their care. Providers ought not be penalized for attempting to facilitate that.

For all that, I want to conclude with what is, perhaps, the most crucial point. Proponents of premium support proposals that do not include all of the elements listed above (and more) may say or suggest that it will solve Medicare’s problems. Same goes for those who advocate for the reforms in the ACA. Though both can help, I don’t believe either is the full solution that is often suggested. Here’s why:

Contrary to what some may claim, competition among private (and public) plans alone is not going to bend the cost curve. […] What matters is whether public and private insurers can serve as more than pass-through entities. What matters is whether we are going to continue to use public or collective funds to pay for any and every medical technology that clever minds can invent, whether more effective than cheaper alternatives or not. If [FFS Medicare] can broadly apply the results of scientific scrutiny of treatment types, we ought to embrace it and be thankful. We ought to preserve and protect it if it will actually lead us where we need to go. If it cannot, then it is not evident it deserves special treatment. But, [without additional legal and regulatory support], it is also not clear how private plans will perform any better. Either way, there is more work to be done.

In this sense, [many] premium support [proposals are] red herring[s]. It’s something reasonable to wrestle with in the near term, but shouldn’t distract us from the longer term challenge we face: either we dramatically reduce the rate of growth in Medicare and the broader health system by being smarter about what public and private plans cover or we ratchet up taxes and premiums (or some of both). Premium support or not, this challenge will likely be with us for a long time to come. It’s reasonable to believe that either private or public plans could meet this challenge, but not without substantial changes to law, culture, and politics. Until those are addressed, nobody on either side of the debate can stand up and credibly claim they have a complete solution.

@afrakt

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In JAMA, Zirui Song, David Cutler, and Michael Chernew estimate some of the consequences of the Ryan-Wyden premium support plan for Medicare.

Nationally, in 2009, the benchmark plan under the Ryan-Wyden framework (ie, the second-lowest plan) bid an average of 9% below traditional Medicare costs (traditional Medicare was equivalent to approximately the tenth-lowest bid). Since traditional Medicare is simply another plan option under the Ryan-Wyden plan, a beneficiary in 2009 would have paid an average of $64 per month (9% of $717) in additional premiums to stay in traditional Medicare. Across the United States, 68% of traditional Medicare beneficiaries in 2009 (approximately 24 million beneficiaries) lived in counties in which traditional Medicare spending was greater than the second–least expensive plan and would have paid more to keep their choice of coverage. [] Furthermore, more than 90% of MA [Medicare Advantage] beneficiaries (approximately 6.6 million seniors, excluding those dually eligible or in employer plans) would have also paid more for the plan they chose.

Translation: Had it been implemented in 2009, the Ryan-Wyden plan would have cut federal spending on Medicare by at least 9%. If every beneficiary had been enrolled in traditional Medicare in 2009, the estimated savings would have been exactly 9%. But almost one-quarter of beneficiaries were enrolled in a Medicare Advantage plan (pdf), which was paid 14% more than the cost of traditional Medicare at the time. So, under the Ryan-Wyden approach that brings payments to plans down to or below the cost of traditional Medicare, the savings would be higher than 9%.

Of course, holding all else equal, the full plan premiums must be paid by someone. The authors tell us what proportion of beneficiaries would have been stuck with a higher bill: 68% of traditional Medicare enrollees and 90% of MA enrollees. Don’t expect them to be happy.

On the other hand, it’s not likely all else would remain equal. Some beneficiaries would switch plans to avoid higher premiums. Perhaps plans would find ways to economize on costs, become more efficient. That’s the hope (claim) of competitive bidding/premium support advocates anyway.

What’s also true is that the future will not be exactly like 2009, at least under current law.

Affordable Care Act (ACA) reforms to traditional Medicare may change these estimates by moving traditional Medicare toward improved incentives for cost and quality through accountable care organizations, bundled payments, and strengthening primary care. The ACA also aims to slow the growth of traditional Medicare costs by reducing fee increases for some health care institutions. If traditional Medicare costs slow but do not close the 9% gap entirely, as currently projected, millions of beneficiaries will still have to pay more, although less than $64 per month, to maintain their choice of coverage—assuming the benchmark stays the same. However, if the ACA reduces traditional Medicare costs enough so that traditional Medicare becomes the benchmark, beneficiaries would no longer pay more to keep traditional Medicare; instead, MA plans would be costlier than traditional Medicare and require a premium.

That the ACA will make traditional Medicare more efficient and less costly is the hope (claim) of advocates of the law. Of course there is no way to know which advocates — those of a Ryan-Wyden type plan or those in favor of the ACA’s path — are correct about the future. Each is a bold experiment. One just happens to be law and in the process of implementation. The other is in a relatively vague stage of proposal with no certainty of becoming law.

Though I’m supportive of competitive bidding (of a type and with certain safeguards and conditions), I also think we should let the provisions of the ACA play out, to see what happens, with adjustments as warranted. Since few in power, let alone a majority of Congress, advocate running both experiments simultaneously (which is possible — they’re not incompatible), we may get only one or the other. Or we may get none. That is, in fact, precisely what would be achieved by repeal without replacement, a highly plausible political outcome.

Much more on competitive bidding and premium support in prior posts. Follow the links.

@afrakt

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Austin is on vacation, but I feel compelled to give him a victory lap nonetheless:

The Obama administration said Wednesday that it would vastly expand the use of competitive bidding to buy medical equipment for Medicare beneficiaries after a one-year experiment saved money for taxpayers and patients without harming the quality of care.

The experiment represented a sharp break from the usual fee-for-service Medicare program, under which beneficiaries can choose any supplier or provider of goods and services. In the experiment, Medicare officials invited bids and awarded contracts to 356 suppliers of medical equipment in nine metropolitan areas, including Cleveland, Dallas, Miami-Fort Lauderdale and Riverside, Calif.

Kathleen Sebelius, the secretary of health and human services, said the pilot program had reduced Medicare costs by 42 percent, or $202 million, by securing lower prices and curbing “inappropriate utilization” of personal medical equipment in the nine markets.

Granted, I’m biased. But few have been beating the drums for the potential of competitive bidding like this blog has.

UPDATE: Merrill Goozner had the goods a month ago.

@aaronecarroll

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This post has an unfair title. I’m writing this to say that I’m not going to be writing about Paul Ryan’s new plan for Medicare, which is to be released as part of the House GOP budget today at 10AM. I have five papers in process (i.e., too much paid work to do), so I have no time to write new blog posts.

However, we can crowd source this. If you see analysis and commentary on the plan, feel free to drop links in the comments. I might be able to swing back later or tomorrow and pull them into the following list. Just to get us started, here are some background materials:

• My premium support series
• My NEJM Perspective with Henry Aaron
• TIE’s FAQ on health plan competitive bidding
• KFF’s side-by-side comparison of premium support proposals (pdf)

@afrakt

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Roger Feldman, Robert Coulam, and Bryan Dowd* previously had estimated that a competitive bidding premium support program for Medicare could save 8 percent of Medicare spending (pdf). Their new estimate, described in a recently published AEI paper (pdf), incorporates increased enrollment into Medicare Advantage (MA) as well as revisions in MA payment policy embedded in the ACA. (Technical point: Due the nature of the plan bid data available to the researchers, the new estimate is based on comparing the 25th percentile of MA bids of per enrollee costs (not the lowest or second lowest) to traditional per beneficiary Medicare spending. See the paper for details.)

The bottom line from Feldman, Coulam, and Dowd:

Using data from 2009, we estimate that fully-implemented competitive bidding would save 9.5 percent of Medicare spending, which is more than our previous estimate. However, the Affordable Care Act of 2010 (ACA) is estimated to save 4.2 percent if it is implemented as the law requires, and so competitive bidding would save 5.6 percent more than the ACA legislation.

That’s a one-time savings or shift in the spending curve. It’s a large shift, so I’m not dismissing it as unimportant. Far from it. We should keep options of this type on the table for discussion. But other things should be on the table too. Beyond the scope of their work is the question of how a competitive bidding premium support would alter the rate of growth in Medicare spending. Though it would clearly shift the curve, would it bend it? This is a crucial question.

Not all curve bending (or shifting) is the same. What we should want is bending/shifting driven by increases in efficiency in the delivery of health care and health. It’s not a big leap from this ambition to consideration of comparative effectiveness. After all, it’s the very definition of inefficient to employ a treatment or mode of delivery that costs more for no more health than another. Comparative effectiveness research (CER) is intended to discover just when, where, and for whom this occurs. Big money is at stake and substantial growth. For instance, ten percent of the growth in Medicare since the mid-1990s is due to percutaneous coronary intervention (coronary angioplasty) a procedure known to be employed in many cases for which a cheaper medical therapy would do. We know this from CER, the COURAGE trial.

An important feature of CER is that it’s a public good. Consequently, it will be (and is) underprovided by the market. The infrastructure to support and translate it into practice is a proper role for government. Funding for such an infrastructure is provided by the Affordable Care Act. The key question, again well beyond the scope of Feldman et al.’s work, is what a premium support program — or the legislation in which it is embedded — would do to that nascent public infrastructure.

It’s this question, among a few others, that gives me pause about premium support. It’s not that it isn’t a worthy idea, yet no idea is perfect. It’s that other ideas are worthy too and some of them are already written into law and are just being implemented. Often, proponents of premium support also support repeal of that law, suggesting it’s one or the other. It’s actually a false choice. Our problems in health care are broad. We ought not discard potential solutions before they’re even attempted.

More in my series on premium support, in the FAQ, and my NEJM paper with Henry Aaron.

* FULL DISCLOSURE: I work or have worked with all of the authors.

AF

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