Sydney Williams'  Instablog

Dear CEO of Any Company:

Want in on a little secret? Here's what health care's brightest business people think about reform: whatever lawmakers accomplish this fall, it won't alter how the system works or move the needle on costs.

Now—more than ever—you need to understand health care's fundamental underpinnings. As the corporate leader, you aren't just managing health care costs. Even if your business is in a non-health care industry, you are likely seeing new revenue opportunities emerge in health care as it expands across the economy.

It's ironic, and perhaps telling, that a section of the economy as large as health care doesn't perform as a normal industry. At ground level, physicians provide services, but payment is received not from customers but from commercial health plans and government. Because supply does not actually transact with demand—unlike any other industry—there can be no market-determined price or consistent measure of quality and value.

What's more, physician service reimbursement occurs under a volume-based framework, called fee-for-service, where doctors submit claims based on specific inputs, not total care.

Medicare, for example, applies a complex reimbursement formula called the resource-based relative value scale ("RBRVS") to non-hospital rendered physician services—about 25% of total health care expenses. A 29-member committee, determines exactly how much Medicare will pay for these individualized services. Critically, it also serves, de facto, as the basis for commercial health plan reimbursement. This single committee, therefore, controls nearly $600 billion dollars in industry pricing.

Transparency is non-existent. And the medical value chain is left with cost control as its only profit lever.

2. Market forces also don't shape the drug supply chain. While in-patient and out-patient services exist outside standard economic practices, the other 20% of health care—the drug supply chain—does not follow the same framework, except for products that providers directly administer, such as infused and injected biologics. Commercial health plans and pharmacy benefit managers, instead, apply formularies to steer beneficiaries to more effective medication usage.

At least that's the intent. In reality, drug benefit managers also operate in their own opaque system, just not one controlled by a single committee. To optimize business margins, they negotiate directly with drugmakers on behalf of employers, their clients. Volume-driven rebates, pharmacy network spreads and mail service margins all affect formulary placement. Large margins, in particular, characterize generic drugs.

Drug manufacturers, meanwhile, have targeted physicians, directly and indirectly through consumer-directed advertising for branded products. Doctors, however, don't pay for the products. And those eagerly-courted erectile-dysfunctional consumers, happily forking out $30 co-pays, have no conception of actual prices.

Still, Caterpillar's recent effort with Walmart (and now Walgreens) attempts to alter this system by introducing a new competitive force: the retail channel. And unlike the medical side, the entire drug supply chain is publicly-traded, exposing it to shareholder demands and expectations.

The net effect of all this is that prescriptions are prescribed, purchased and paid for outside of anything resembling a normal supply/demand market framework.

3. Information is the most important commodity. In a system as complex as health care, knowing what someone else doesn't know can make all the difference in the world.

Here, there's an important parallel with the financial service industry. Broker-dealers, Wall Street's middlemen, have traditionally operated at the confluence of market data streams. Whether it's corporate news flow or clients orders, no other entity processes as much information. While so-called Chinese walls presumably deter misuse of this information, neither corporations nor institutions possess even a fraction of this information wedge.

In the late 1990s, things changed, as broadband Internet democratized information access. Suddenly, new tools allowed counterparties to know as much—or more than—the broker-dealer. At the same time, electronic share trading networks emerged, allowing institutions to transact directly with each other.

As a result, margins in traditional advisory services shrank, and broker-dealers began turning to high-margin proprietary trading and investment services.

Health records are still 90% paper-based. On the medical side, information is so fragmented that no one entity has a distinct advantage over another. Claims processing, for example, often takes weeks or months to adjudicate, as provider and payer bicker over codes, procedures and contract pricing.

On the pharmacy side, the pharmacy benefit manager functions similarly to the broker-dealer. No other entity controls as much information about manufacturers, payers, providers and consumers.

Just as the Internet revolution recast the financial services landscape, it could likewise upend the traditional flow of information in health care. For medical benefits, it could create new power centers as information is digitized. For the pharmacy side, it threatens to disintermediate existing channels.

4. New revenue opportunities exist across industries. So what if health care is 17% or 30% of GDP? If it's efficient, then it's creating jobs and contributing to economic growth.

Many different opportunities exist for non-health care companies to take advantage of the industry's growth. Take the affordability problem, for example. Why shouldn't bankers explore new lending channels to help consumers reduce the monthly premium burden? And what about information technology? Washington has already passed legislation that will provide incentives for electronic health record adoption. Like Sarbanes-Oxley, myriad rules will apply, a complex intertwining which creates opportunities for sophisticated software and service vendors.
Be proactive. How smartly you manage health care's various risks and opportunities will determine your company's success.

Disclosure: No Positions

Every now and then some data point comes along that completely disrupts the flow of a debate. In health care, this occurred in June, when the Congressional Budget Office (CBO) scored the first two health reform bills to emerge from the 111th Congress.

Then, the CBO starkly reminded us that large reductions in spending cannot occur without fundamental changes in the financing and delivery of care. And dollar savings attributed to comparative effectiveness, health IT and other "soft" initiatives vanished, as simple speculation.

With its scoring, the CBO established the ten year/ trillion dollar benchmark as a deciding legislative factor. Immediately, the debate shifted from concepts and theory to economic reality. This drew in the electorate, which arcane medical and insurance language and plain-old inertia had sidelined previously. (Remember, consumerism only factors into the health value chain on a limited basis.)

Now, a just-published survey could similarly disrupt the debate. It reveals just how the biggest payer of health care is thinking. And it's not positive.

This summer, the consultancy Towers Perrin surveyed 433 employers on health reform. Here are excerpts from its press release (published September 17th):


Pretty glum. What's important, though, is that the survey unifies the employer's voice. While different trade associations exist to represent them, politics distort opinion, which too often collides, diminishing what amounts to a potent and relevant stakeholder.

Recently, we've seen political dissonance muffle certain large employers sharing individual experience—Safeway, Walmart and Whole Foods. Rather than focusing on one company, however relevant its message, this survey reflects a cross-section of experience and opinion.

Towers Perrin, a consultancy, grinds no political ax. It makes a living advising employers on managing health benefits, which includes surveys and data collection.

This survey—its timing—provides as clear a window as we're likely to get into how 60% of the health care dollar is thinking.

And if employers are planning for higher capital costs and reduced head counts, then the bill we pay could be much higher than the CBO's current scoring, which measures direct tax revenue and government spending, not indirect economic consequences.

Anyway you cut it, the survey's results present a new twist and a new reality, not likely to disappear anytime soon.

Although it doesn't carry the same headline effect of the CBO suddenly grounding congress in financial responsibility, it does forecast an economic response we could feel for some time to come.

Disclosure: No Positions

Private enterprise is taking a beating. Whether in health care or the financial services industry, policy debates rarely feature the economics of supply and demand—much less self-correcting mechanisms. Instead policymakers have re-conceived market dynamics as a web of casual relationships.

Take, for example, these common lines of argument that advocate government intervention in the capital markets. Big Wall Street bonuses lead to excessive risk taking, which forces "bad behavior" in the capital markets. Likewise, improperly incentivized ratings agencies inflate the quality of securities, which bloats leverage ratios. Or, inconsistent regulation fails to curb market excess, which contributes to a moral hazard.

The fix, then, should be simple, right? Legislate—or mandate—bonus limits, new business models for ratings agencies and more comprehensive regulation.

Okay. Let's say we accomplish this and call it common-sense rules. (Read the text of President Obama's Wall Street speech here.)  Will it achieve the desired effect? Well, that depends what we mean by "desired effect" or "common-sense".

And here's the rub. The capital markets work as they do exactly because countless thousands (millions) of people interact with them daily, a few directly and many more indirectly, for many different purposes: investing, funding, speculation, arbitrage, price information, short-term needs, long-term needs, and more. Like Facebook or MySpace, the markets are a social network, except much bigger, much broader and much more unifying.

If it's control lawmakers want, then whatever they establish today risks obsolescence tomorrow—or, worse, some significant unintended consequence. Just look at the fallout from the short sale ban last fall. Market volatility elevated and the price discovery process deteriorated: the exact opposite of what the SEC and market participants intended, and needed, to take place.

Rules and regulation designed for control can never keep pace with market innovation. Nor would we necessarily ever want them to keep pace. Because if they ever were to match innovation, innovation could never occur, by definition.

Rules and regulation should, instead, support market innovation. Consider this in terms of Lehman's demise. Whether the Feds were correct in allowing the bank to shutter is secondary to the fact that the business model—Wall Street's business model—failed.

And let's not confuse the markets with Wall Street. The markets themselves didn't err. They got it right, punishing those who got it wrong. And we know government and regulators were far behind, having little clue that the Wall Street business model was failing as badly as it was.

Fast forward one year, and we're at the same place we were before the crisis. Nothing has really changed in terms of a new model taking root. The bulge bracket features new name plates, and one or two old ones. But if we view the landscape as a continuum of capital flows, then money is just as—or more—concentrated among these big guys as it was in September 2008.

In the name of 'Too Big to Fail', taxpayer money is effectively buttressing a broken model, and postponing its inevitable replacement.

The question should be: What's the opportunity cost of not allowing this transition process to take place? Weak economic growth, high unemployment, a diminished dollar, market uncertainty? Likely all four and more, as Wall Street fails to expand money flows between corporations and institutions.

Here are four expectations for the next Wall Street business model, in sequence.

A return to the partnership model. It should be no surprise that Goldman emerged on top because it embraces a model closest to a partnership than any of its competitors. In contrast to a shareholder controlled firm, a partnership ties the firm's capital directly to its manager, so that risk capital is their money, not other people's money.

A breakdown of concentrated capital. Empire building may be instinctive, but emperors will always define themselves by personal gain. It would be naive to expect that market participants would ever curtail their pursuit of personal fortune. That pursuit, though, could be much more lucrative in a different business model, even if the ultimate scale of the business is much smaller than, for example, Sandy Weill's Citigroup at its peak.

A greater sense of firm identity. An important byproduct of the partnership model is less employee turnover. The compensation format ties individuals to a firm. Wall Street had become a battlefield of mercenaries: analysts and bankers, for example, benchmarking themselves against external polls, instead of their own contribution to the firm's bottom line. Firms became faceless and amorphous, as employees sold themselves to the highest bidder.

A shift to longer-term planning. Goldman demonstrates that a partnership-like model can function within a publicly traded company. Other firms, however, may opt to proceed as private businesses. Either way, this shift will allow managers to plan longer-term and respond less to "best practices", which can often standardize quality. Firms may become more cautious, but they will likely become more specialized.

So, who's to say what's right and what's wrong? Definitely not government or regulators, or really anyone but the market itself. That's not to say there is no place for oversight or rules, just not the kind that impose control.

Capital is finite. It's an economic good. If there's one lesson we should take from the health care reform debate it's that we should never depend completely on the expectation that somebody will do something for us. The sooner that policymakers can trust markets, the better off we become, and the faster our economy will recover.

After all, the last thing we can afford is the restriction by non-market forces of a natural market transition.

Disclosure: No Positions

Pop quiz: who's missing at the health care reform discussion table? Is it: (a) government (b) patients (c) doctors (d) employers or (e) owners of health care companies?
The table below breaks down types of service by funding source.

Get ready for lots of news flow on "meaningful use" this fall. The government has set an ambitious yearend deadline for establishing a formal definition, a critical step in its effort to spur electronic health record (EHR) adoption.

"Meaningful use" refers to the way in which the government will expect providers to use electronic health record systems — whether in an appropriate manner or not.

At stake for the provider community are billions of dollars in incentive payments. Starting in 2015, the government expects providers to have adopted and be actively utilizing an EHR in compliance with the meaningful use definition or it will subject them to financial penalties under Medicare.

To defray the cost of EHRs — often tens of thousands of dollars — the government has promised big subsidies ($44,000 per physician), though not without strings attached. It will pay the first incentives in 2011 based on prior performance. A provider not following meaningful use of a certified EHR could risk not receiving any government funding. The American Recovery and Reinvestment Act of 2009 provided a minimum of $19 billion in funds to kick start EHR adoption. Media sources now report a funding level nearly twice the size at $36 billion.

According to the government's website, "The focus on meaningful use is a recognition that better health care does not come solely from the adoption of technology itself, but through the exchange and use of health information to best inform clinical decisions at the point of care." Broadly, meaningful use will encompass different parameters, including patient communication, diagnosis, device usage, patient encounters, specific patient information, laboratory tests, medication usage, physical exam findings, and procedures.

Just recently, the Obama administration announced it would provide $1.2 billion in grants to create 70 HIT centers around the country. David Blumenthal, the president's HIT czar and head of the national EHR effort for the Department of Health and Human Services, meanwhile, has stated that he expects a formal definition of meaningful use by the end of the year. The process began in June.

To put the cost savings opportunity in perspective, about half of health care expenditures constitute waste, whether dollars spent on preventable conditions, redundant tests or back office processing. About half of this waste relates to poor patient behavior: obesity, smoking, non-adherence. A quarter represents clinical inefficiency: readmissions, poorly managed care, medical errors, treatment variance, unnecessary ER visits — the primary target for EHRs.

The remaining quarter reflects operations, or the back office. Of this, claims processing accounts for about half, and ineffective IT a third, staff turnover and paper-based prescriptions the rest. (Note: We have sourced these estimates from a 2008 report by the consultancy PriceWaterhouseCoopers. Click here to view.)



If we exclude from this waste calculation patient behavior, the practice of defensive medicine (more a payment issue than an IT issue) and claims processing (not directly a clinical issue), then we would assume that EHRs would impact about a third of all wasted dollars spent.

In a $2.4 trillion dollar industry, where $1.2 trillion is waste, EHRs could theoretically address about $400 billion of this. A substantial number, it would roughly equal the entire prescription drug market at half this level.

Let’s not forget, too, that each of these numbers is growing at 10% per year. In seven years, $400 billion becomes $800 billion, although — presumably — effectively deployed EHRs would slow this growth rate.

With such a substantial business opportunity at hand, it's no wonder many different organizations are now targeting health IT, and EHRs specifically — including not just traditional technology vendors such as Intel, IBM and Microsoft, but also managed care organizations, plan sponsors, and dozens of venture-backed firms.

Despite this, many problems exist, ranging from cost to lack of a common standard. Even though, for example, several different EHR systems may operate within a single provider setting, one system does not necessarily communicate with another. And for small practices, implementation costs can be prohibitive.

While nearly 40% of physicians report using a full or partial EHR system, only 4% indicate they use a certified, fully functional system, according to a survey by the Centers for Disease Control and Prevention.

Enter the government, and Dr. Blumenthal's mandate to make everything work together. But for EHRs to recoup even the expenditure the federal government is prepared to make, all the different stakeholders must first agree on a definition of meaningful use.

No one anticipates an easy process.

What happens, for instance, if the government defines meaningful use too narrowly — or too broadly? How does the government change the definition? And when?

Providers will also need to submit data that qualifies them for incentives. What does this process entail? How much of a time burden does it create? Also, to what extent will provider inertia drag down future returns?

And none of this includes issues pertaining to the certification process and privacy concerns. Who, for example, owns the data?

In its scoring, the Congressional Budget Office has not allowed significant savings for EHRs simply because the opportunity, while massive, remains highly speculative. Even if the government adheres to its aggressive timeline, EHR savings on a national scale would not occur until well after 2015.

Stay tuned for a busy fall.

Disclosure: No Positions

Nobody wants a good thing to end, especially an historic run in the equity markets. Precedence, though, suggests that we're nearing a conclusion.

From its March 9th low through August 21st, the S&P 500 has rallied 51.7%, the index's best 117-trading-day performance since before 1950. In fact, five of the ten best continuous 117-day periods between June 1950 and August 2009 occurred this month, as the table below illustrates.



January 1983 featured three of these periods, and the end of May/beginning of June 1975 the remaining two. (Both of these periods come closest in showcasing the same type of performance.)

The market has been so strong that of the 14,890 continuous 117-day periods over this six decade time frame, just three periods posted gains over 45%: those ending August 19th, 20th and 21st.

And on only 89 occasions did the market gain more than 30%. That's less than 1% of total.  The market, moreover, only managed a 15%-or-more advance during less than 14% of this period.

82% of the time it ranged between -15% and +15%.



Clearly, the current race upwards marks a distinct reversal from the market's nosedive in the first days of March and in November last year. Too far, too fast? Statistically, at least, we've sprinted deep into outlier territory. If we go by our table above, then the more "normal" trend line for the S&P would be the 0% to 15% range.

Let's assume a flat market. It would take 39 trading days at the current 1026 level for the market to mean revert back into the sub 15% range.  Under a correction, this could happen more quickly.

On the other hand, for the market to sustain its record-setting 45%+ pace until yearend (for example), it would have to average daily gains of between 0.4% and 0.5%.  That would equal a closing level above 1500. Improbable, if not impossible.

While August 2009 showcases trading patterns similar to June 1975 and January 1983, it also features a much different backdrop. These two preceding months actually resemble each other much more closely than either one does August. 

In both months, the economy was three months into recovery, after severe, protracted downturns. In both cases, cyclical unemployment peaked exactly one month prior: in May 1975 at 9.0%, and in December 1982 at 10.8%. 10-year Treasurys were yielding 7.86% and 10.46%, respectively, while inflation soared at 8.5% and 6%.

Politically, the Democrats held both the house and senate in 1975, but not the White House. The Republicans under Reagan controlled the White House in 1983 and the senate, but not the house. Unlike today, free trade and capitalism energized a small minority of the world's population.

Tax policy varied, however. Rates sharply declined throughout the 80s. Gasoline prices also varied. In 1975, they were rising, and, in 1983, falling.

Market direction tracked differently, too. The S&P 500 after June 1975 closed the year 5% lower, and would not sustain higher levels for another three years. After January 1983, the market finished the year 14% higher, but had also gained 15% over the subsequent six-month period, equal to the same period-to-end-of-year time frame as 1975. Also, the nearly two-decade long bull run had just begun.

August 2009 is unique in many aspects: the global landscape, the point of time in the economic cycle, the credit and banking systems, the regulatory and legislative outlooks, to name a few.

Whether we're facing a lengthy flat market or a sharp pullback, don't expect the historic resurgence to continue.

Disclosure: No Positions