Why Healthcare Is in a Death Spiral: Follow the Money

Executive Summary

Multiple conditions are aligning for a broad re-alignment of medical care delivery in the US, resulting in the development of a two-tiered delivery model: high-quality, efficient, innovating cash-pay for those who can pay and low-quality, wait-rationed care delivery for those who can’t.

If you can’t afford it, don’t get sick.

Health systems make their money through inflated commercial real estate (CRE), sale of patient health information (PHI), consolidation of supply chains, and kickbacks in exchange for redirecting federal dollars. Absent a tiny sliver of procedures, the delivery of healthcare itself is a loss leader. It is a requirement for entry, not a source of value. As such, care delivery managed to prevent loss, not promote innovation.

Most health system CEOs are financial engineers, not care delivery specialists, and compare the size of their real estate management infrastructure with their care delivery management infrastructure; the former is always much more robust than the latter.

Insurers have become utilities, administering government payment programs. Their ability to bear risk as a business model was discarded with the ACA; they no longer have the infrastructure or talent to do so. You might as well ask them to make shoes.

This monoculture, the corruption of monopoly and finally the response to the pandemic has crippled both.

Health systems faced a profound interruption in throughput which they dealt with by tapping reserves, inflating CRE further, pushing the boundaries of PHI sales, increasing their kickback programs, and, most importantly, becoming fully dependent on the now ending government bailouts.

Further consolidation and partnering with private money is their only path forward. Recent experience teaches that the private money will cut the delivery of healthcare to the bare minimum needed to maximize the other sources of value. A whole lot of administrators and c-suiters are also going to lose their jobs.

After the ACA, the Insurer’s only cash cow was the immensely overfunded and fraud-filled Value-Based Care (VBC) Medicare and Medicaid programs such as Medicare Advantage. The fraud is now being criminally prosecuted, the overpayments are gone, and the cost of care delayed during the pandemic and which the insurers now bear are being realized manifold.

Insurers simply have no path forward other than as payment administrators. Look for massive consolidation, starting with the individual Blues. The government has been resistant, but now it’s a choice of merger or bankruptcy. In 2028 probably only Coventry, United, and Centene will be left standing, no more blues.

The ACA itself is in a death spiral. Envisioned as a universal mandatory risk pool, so many exceptions have been made that only the sickest and those who have no choice get their care there, the former being subsidized by the latter, the government, and ever dwindling coverage. The pandemic subsidies masked it and without them the coverage is non-sensical. Non-participation will be its end.

In addition, government medical care programs have long been subsidized by suppressing payment for the resources used to obtain care delivery; clinicians, labor, administration, and even bedpans. Real wages for even the highest paying doctors working within the system haven’t increased since 2010, nursing wages have gone up only because so many have become free-lancing agency workers. I got offered a locums position for $145/hour, the same as I was offered 8 years ago.

All those resources are now worth more outside the system than inside. Thus, those resources are migrating to the cash-pay market. Used to be the huge government market and dependable payments was enough to overcome the difference in value between the two markets, cash vs third party. No longer.

The legacy costs, management/leadership expertise and business models of current Fee For Service (FFS) health systems preclude all but the most highly branded health systems from competing in the cash-pay model.

Access to the cash-pay market will vary based on jurisdiction: it’s illegal in some states, hamstrung by others, free in still more.

Look for policy to evolve into a high-dollar, deductible, roll-over Health Savings Account (HSA) with income-based subsidies paired with a government subsidized catastrophic care program. At least until the young and disaffected elect a socialist.

A $2,000 direct payment to beneficiaries such as being currently contemplated is completely ineffectual, especially since it has to be borrowed and will just increase inflation that much further.

True reform must include:

1.Invalidation of state and federal laws which restrict cash-pay.

2. Prohibition of not-for-profit (NFP) / Religious organizations from third-party payment programs. The competitive advantage of the tax-free business model and the inherent corruption it has engendered render their participation not in the public interest.

3. Removal of restrictions on clinician ownership in healthcare delivery.

4. Renewed criminal anti-trust enforcement in medical care delivery.

Others can be added, but if each of these is not a part of any ‘reform,’ than all that is being done is pouring money into a monopolizing cartel, just in a slightly different way.

No improvement will occur.

It’s not payments which need reform, it’s delivery.