Amitabh Chandra, Jonathan Holmes, Jonathan Skinner. Jeff. 2013. Is this time different? The slowdown in healthcare spending. Working Paper 19700. National Bureau of Economic Research
Abstract:Why have health care costs moderated in the last decade? Some have suggested the Great Recession alone was the cause, but health expenditure growth in the depths of the recession was nearly identical to growth prior to the recession. Nor can the Affordable Care Act (ACA) can take credit, since the slowdown began prior to its implementation. Instead, we identify three primary causes of the slowdown: the rise in high-deductible insurance plans, state-level efforts to control Medicaid costs, and a general slowdown in the diffusion of new technology, particularly in the Medicare population. A more difficult question is: Will this slowdown continue? Here we are more pessimistic, and not entirely because a similar (and temporary) slowdown occurred in the early 1990s. The primary determinant of long-term growth is the continued development of expensive technology, and there is little evidence of a permanent slowdown in the technology pipeline. Proton beam accelerators are on target to double between 2010 and 2014, while the market for heart-assist devices (costing more than $300,000) is projected to grow rapidly. Accountable care organizations (ACOs) and emboldened insurance companies may yet stifle health care cost growth, but our best estimate over the next two decades is that health care costs will grow at GDP plus 1.2 percent; lower than previous estimates but still on track to cause serious fiscal pain for taxpayers and workers who bear the costs of higher premiums.
摘要：为何医疗保健费用在过去十年减少了？一些人认为大萧条就是唯一的原因，但是大萧条期间的医疗支出和萧条之前的支出几乎完全相同。平价医保法案也不能在此居功，因为医疗支出的减少在其实行之前就已经开始了。然而，我们发现了放缓的三个主要原因：高免赔额保险计划的增加，州水平上努力控制医疗费用以及新技术扩散的普遍减慢，特别是在医保人口上。一个更困难的问题是：这种放缓会持续下去吗？我们对此较为悲观，这并不完全是因为上世纪90年代初的一个相似且暂时的放缓。长期增长的主要决定因素是昂贵技术的持续发展，而且也没有证据表明技术研发进程的永久减慢。质子束加速器的目标是在2010到2014年之间翻一倍，而心脏辅助装置的市场(花费超过30万美元)预计将快速增长。可信赖医疗组织和鼓励保险公司可能会抑制医疗费用的增长，但在未来20年内我们的最佳估计也是医疗费用的增长将高于GDP 1.2个百分点；这比以前的估计要低，但是仍可能给承担更高保险费成本的纳税人和工人造成严重的财政痛苦。
数据来源：
the CMS National Health Expenditures；
Dartmouth Atlas of Health；
Health Care Cost Institute；
Altarum Institute；
Macroeconomic Advisors；
Current Population Survey Merged Outgoing Rotation Groups Accounts；Kaiser HRET Survey；
Dartmouth Atlas of Health Care；
Particle Therapy Co-Operative Group；
New York Stock Exchange Index Services.
研究方法：文献综述和计量回归
Discussion and Conclusion :There has been considerable media and government attention to the question of whether health care costs have moderated. In this paper, we reconsider the existing evidence on this slowdown by considering a more disaggregated view of the health care sector. We first note that while all measures of health care spending and utilization point towards a recent slowdown, that this was not the first time; health care costs as a fraction of GDP had actually declined in the early 1990s, before resuming its strong upward trend in the latter 1990s. And certainly the remarkable stability in one measure of health care employment growth reinforces Victor Fuch’s (2013) caution against inferring too much about the next two decades from just a few years of data.
Second, we present evidence that aggregate health care spending growth may not exhibit a stable association with GDP growth in the medium-term. Unlike other types of consumption, health care in the United States is an aggregate of very different systems –private, Medicare, and Medicaid –whose dynamic paths of quantity and costs do not move in lock-step with one another, particularly during a recession or business cycle expansion. For this reason, we argue that researchers should consider a more disaggregated model of health care, complete with a specification of the factors such as reimbursement rates, prices, and technological developments for public and private services.
Third, in explaining the downturn in health care spending, we have placed a greater emphasis than previous researchers on the rise in cost-sharing in the private i nsurance market. While we consider these changes in a static framework –one can’t continue to raise copayment rates forever –there may also be dynamic effects arising from these changes. In Finkelstein (2007) and Clemens (2011), the rise of high-deductible health insurance will deliver both a short-run reduction in quantity demanded of services, and may also exert a longer-term impact on the incentive to adopt and pay for new innovations in an environment of high deductible health-plans. That said, we do not see evidence of such a long-term impact on innovation, at least based on the relative growth of health sector stock prices.
Fourth, we predict continued long-term growth in real per-capita health care spending that will exceed GDP; our best guess is GDP plus 1.2percent, which puts us in the middle of the pack between Medicare actuaries and the CBO, even if our own confidence intervals are wide. Even this modest estimate is not a cause for celebration; Roehrig (2012) has called attention to the “Triangle of Painful Choices”, which outlines the set of very unple asant options facing the U.S. even in the face of “moderate” GDP plus 1 percent growth rates in health care. The pain includes some combination of increases in tax rates or drastic cuts in non-health spending, and does not capture the additional unpleasantness of private health insurance premium hikes soaking up any real wage growth for the median worker (Auerbach and Kellermann, 2011).
Finally, and more optimistically, we also recognize that the structure and balance of power among providers and insurers may be undergoing fundamental changes. For example, private insurers emboldened by an increase in market share, from getting more patients from exchanges and the Medicare Advantage program, may begin to push back against the coverage of Category III treatments. Nascent signs of this are apparent in the isolated decisions by some private insurers to no longer cover proton-beam therapy.
Similarly, accountable care organizations in Medicare and the move towards bundled payments could encourage providers to switch from expensive and unproven therapies to cheaper ones. Many of these initiatives involve private partnerships with leading integrated delivery systems, such as Intermountain Healthcare’s collaboration with General Electric. Moreover, on both sides of the political aisle there is consensus that fee-for-service creates incentives for overuse. And while the exact solutions to this problem may differ on the spectrum of market versus regulatory approaches to technology management, a Republican-led Congress would continue the move towards payment reform. Yet ultimately, all these policy solutions must be concerned about the long-term technology pipeline that will continue to deliver new technology with large price-tags but with the potential for very modest health benefits.
讨论和结论：媒体和政府非常关注医疗保健费用是否减少的问题。这篇论文中，我们通过更加分解的视角来考虑医疗保健部门以重新思考这一放缓的现有证据。首先，我们注意到尽管所有对医疗保健支出和使用的测量都指向近期的放缓，但这并不是第一次；医疗保健支出作为GDP的一部分，在上世纪90年代后期恢复强劲上升趋势之前，实际上早在90年代初就已经开始下降了。当然在医疗保健就业增长上的显著稳定性加强了Victor Fuch’s (2013)对仅用几年的数据就过分推断未来20年情况的警惕。
第二，我们提出的证据表明，在中期内总医疗支出的增长可能不会和GDP增长之间呈现稳定的联系。与其他类型的消费不同，美国的医疗保健是不同体系的总和——个人、联邦医疗保险、医疗补助计划，它们在数量和费用上的运动轨迹并不彼此一致，尤其是在萧条或经济扩张的时候。正因如此，我们认为研究者应该考虑一个医疗保健的更分解的模型，包括对与公共和私人服务相关的因素如还款利率、价格和技术发展的说明。
第三，相对于之前的研究者，我们在解释医疗保健支出下降的时候更加强调私人保险市场上费用分担的上升。然而我们是在静态框架下考虑这些变化的—一个人不可能一直提高共同付费率—这些变化也有可能引发动态效应。在Finkelstein (2007) and Clemens (2011)的研究中，高免赔额医疗保险的增加既会产生服务需求量减少的短期效应，也可能对高免赔额医疗计划环境下接纳并购买新产品的动机产生长期影响。也就是说，我们并没有看到存在这样一个长期影响的证据，至少根据医疗部门股票价格的相对增长来说。
第四，我们预测持续长期增长的实际人均医疗保健支出将超过GDP；我们的最佳猜测是超出1.2%，这使我们置于医疗保险精算师和国会预算办公室之间的两难境地，即使我们自己的置信区间很宽。甚至这保守的估计也不是值得庆祝的；Roehrig (2012)已经唤起对“痛苦的三难选择”的注意，这概括出了美国面临的一系列艰难抉择，甚至面对医疗保健支出的增幅仅仅超过GDP 1%也是如此。这些疼痛包括税率的增加、非医疗支出的急剧削减以及不能处理由于私人医疗保险费上升吸收中产阶级工人实际工资增长的额外不愉快。
最后，更乐观的是，我们也意识到供应商和保险公司之间的结构和实力平衡可能发生根本性的变化。例如,私人保险公司受到市场份额增加的鼓舞从市场获得更多的病人，而且 “医疗特惠项目”可能会开始抵制第三类特殊护理的覆盖，这一现象的初期迹象是明显的，某些独立决策的私人保险公司的保险范围不再包含质子辐射治疗法。
相似地，联邦医疗保险的可信赖医疗组织和打包付费的趋向可能会鼓励供应商从昂贵且未经检验的疗法切换到更便宜的疗法上。许多积极的创始者包含拥有领先集成交付系统的私人合伙制企业，如美国山间医疗公司与通用电气公司的合作。此外，两党在按服务收费将导致过度使用这一事实上存在共识，虽然这个问题的解决方案可能不同于一般的市场与技术管理的监管方法，但共和党主导的国会将继续朝着支付改革的方向运动。但最终，所有这些政策解决方案都必须考虑到，长期中的技术研发进程无疑会继续生产出价格昂贵的新技术，但这给健康带来的的益处却可能非常有限。
（By 杨帆）
