00:00:00
December 4th, 2024.
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Midtown Manhattan.
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Early in the morning, Brian Thompson,
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the CEO of United Health
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Care, is gunned down.
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Inscribed into the bullets.
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Deny, depose and defend.
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A reference to the tactics
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used by health care companies
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to increase profits. To the media’s
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surprise
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Americans show little empathy
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towards the victim,
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and instead, a country wide
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discussion begins
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on the state of universal health care.
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Today, Americans spend more on health
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care than every country on Earth
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and by a wide margin.
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Worse yet,
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Americans spend more
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even though they see a doctor 50% less
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than other wealthy nations
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and the cherry on top?
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The average US life
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expectancy is three years
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lower than comparable countries.
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What went wrong?
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This is US health care,
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an American sickness.
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The US
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spends nearly $5
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trillion on health care every year.
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This represents almost 18% of GDP.
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However, for all of this money,
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the US gets very little.
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And ranks
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last among ten high income countries
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for health outcomes and access.
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Even when looking at it
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from a purely financial point of view.
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Improving the US health care system
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could save Americans
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nearly $2.5 trillion.
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That's enough
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to exceed the mandate of Doge
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in one year.
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To understand
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what's driving these high costs
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and poor outcomes,
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we need to break out
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the different components
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of the US health care system.
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Insurance, health care providers
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and pharma.
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Let's start off
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with health care insurance.
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92% of all Americans
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have some form of health insurance.
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Generally, it's
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broken down into employer
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sponsored programs.
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Government programs,
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and individual plans.
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Unlike most of the developed world,
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when Americans have insurance,
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they can select
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from multiple providers.
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This introduces choice,
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which some argue is nice
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and allows the consumer
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to decide what's best for them.
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However, it also introduces complexity.
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Each insurance payer can have different
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billing codes,
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payment processes,
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prior authorization protocols,
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service levels,
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doctor networks,
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pharmacy networks, PBMs, and more.
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The outcome
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providing care becomes
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a lot less about medicine
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and much more about
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administrative functions.
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According to the AHA, 40% of total expenses
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incurred by hospitals
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are related
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to administrative functions.
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Not medicine. Not care.
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Not surgery.
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No admin.
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In fact, when you compare the U.S.
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with other developed
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nations, 30% of the difference in cost
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is directly due
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to administrative overhead
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introduced by the insurance regime.
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But money isn't everything.
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To truly understand the impact.
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We need to look at patient outcomes.
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U.S.
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health insurance
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companies deny 16% of all claims,
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with companies
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like UnitedHealthCare and Medica
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denying 32 and 27%, respectively.
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This means that a doctor
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seeking to provide care
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is being rejected
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by an insurance company.
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nearly one out of every five times.
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Ultimately,
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this leads to patients
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having to make tough decisions
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of paying out of pocket
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or not pursuing care at all.
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For those paying out of pocket,
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it could mean taking on large
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sums of debt,
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often with costs so high that 67%
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of all US bankruptcies
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are healthcare related,
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or they can join the nearly 40%
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of Americans
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who have or know a family member
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who has delayed medical care
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due to cost,
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often paying the ultimate price.
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Health insurance
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companies argue
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that they do this
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to control costs for patients
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and ensure that hospitals
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aren't being overzealous,
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which is partially true.
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But these insurance companies
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are increasing
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the rate of denials over time
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and employing new technologies
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to quickly reject claims.
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From 2022 to 2023,
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care denials increased 20 and 56%
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for commercial
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and Medicare Advantage
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claims, respectively.
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They do this
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because less than 1% of
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all claims are appealed.
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This isn't because patients
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don't believe they need care,
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but appealing is costly.
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complicated and very time consuming.
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Remember, deny, depose and defend.
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To make matters worse, 75%
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of all Medicare Advantage
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denials were overturned.
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That's 216,000 denials.
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The misalignment of incentives
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is so clear and abundant
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that it is shocking
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that this continues.
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It is absolutely in the insurance
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company's best interest
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to deny as often as legally possible,
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regardless of the claim.
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But let's not forget
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this isn't a rejection
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of auto insurance.
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This is possibly preventing a human
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being in their most vulnerable state
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from receiving care that they need.
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But if we dig deeper,
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it continues to get worse.
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Prior
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authorizations are a form of approval
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that insurance companies must provide
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for certain types of care.
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This means that if a doctor requires
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a certain type of care
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for their patient
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before they can proceed,
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they must get approval
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from the insurance company.
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Again,
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insurance payers claim
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that this is to ensure
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that care being provided
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is actually needed, but often it leads
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to extremely negative consequences.
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For instance,
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30% of radiation oncologists
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have had a patient
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admitted into the emergency room
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or have permanent disability
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due to prior authorizations.
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This means that a patient was prevented
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from getting care in a timely manner
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because of the administrative burden
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of prior authorizations,
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and the outcome was life changing
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to receive authorization.
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These oncologists need to draft
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an explanation
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for the insurance companies
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that is reviewed by a doctor,
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referred to as a peer.
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However, 35%
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of these peers aren't oncologists,
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but this isn't solely an issue
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for oncology.
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Across all specialties, doctors claim
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that peers are only qualified
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15% of the time.
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One of the reasons
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the insurance companies
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are able to behave this way
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is because of market concentration.
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73% of commercial markets, 71%
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of Medicare Advantage
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markets, and 90% of ACA
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markets are considered
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highly concentrated.
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Some would argue this is a good thing,
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because theoretically it would mean
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that these insurance companies
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can negotiate
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better rates with hospitals,
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and a smaller
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number of payers
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would lower administrative burden.
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But in reality, this is just not true.
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Multiple mergers
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have been studied over the years,
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including Aetna and Prudential,
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UnitedHealth and Sierra and more.
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When studied, the results are almost
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always the same.
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Premiums rise
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as the market consolidates.
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Instead of passing on savings
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to customers,
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insurers take advantage
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of their market dominance
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and increase prices and profits.
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And this competitive positioning
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is very hard to usurp.
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The barrier
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to entry of launching
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a new paper
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is very high due
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to regulatory requirements.
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Anti-competitive practices and scale.
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These insurance companies
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have gone a step further
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and have begun to vertically integrate
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in 2010.
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The Affordable Care Act
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effectively capped insurance
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profit margins
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by requiring
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that insurers spend 80 to 85%
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of what they collect
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on medical services.
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While this sounds nice in theory,
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in practice
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it led to insurance
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companies seeking profits elsewhere.
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For example, UnitedHealth directly
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employs 10,000 physicians
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and has commercial ties
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to an additional 80,000, combined
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that is 10% of all American doctors.
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Again, this might sound nice,
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but as you concentrate more power
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into the hands of a few payers,
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the ability to increase prices
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and generate greater profits
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also rises.
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This again
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is at odds
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with the goal of achieving
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better health outcomes.
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The problem
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with the current US health
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care insurance regime is that success
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for insurance
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companies is not success
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for the patients.
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The unnecessary complexity
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of the regime,
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mixed with the consolidated power
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of the major players, has failed
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to lower costs
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or improve patient outcomes.
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Put simply, it is fundamentally broken.
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We've
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talked a lot about US
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health insurance companies,
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but they aren't
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the only reason
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the health care system is broken.
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Health care
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providers are also
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a part of the problem.
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Let's start off with doctors.
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This might be hard
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for some to believe,
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but US doctors are a major contributor
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to the overpriced healthcare system.
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Take a look at this chart.
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It shows the compensation for US
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doctors compared
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to doctors of other countries.
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There are many reasons
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why doctors in the US are paid more,
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but one of the primary drivers
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is the low supply of doctors.
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The US has 2.6 practicing physicians
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per 1000 people,
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compared to the OECD average of 3.7.
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But why are there so few doctors
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in the US? Simple.
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The American Medical Association
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artificially constrained supply.
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20 years ago,
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the AMA
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lobbied to reduce
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the number of medical schools,
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cap federal funding for residencies,
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and cut a quarter
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of all residency positions.
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Because, I quote, they were worried
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of an impending surplus of physicians.
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This disgusting
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move of regulatory capture,
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influenced by greed,
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meant
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the number of medical school
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graduates in 1980 was the same as 2005,
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even though the US population
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increased by 30%.
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Now it isn't all the doctor's fault.
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Hospital groups
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and investors are also a big problem.
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Similar to insurance, consolidation
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in hospitals
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and physician practices is very common.
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One of the key drivers
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for consolidation is the high
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administrative burden
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for physicians to remain independent.
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Managing all the complexity
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of a US
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healthcare system
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can not only be time consuming,
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but costly. By joining larger groups
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physicians are often able
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to avoid dealing
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with administrative headache
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that comes with a smaller practice.
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Over the past 20 years,
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there have been 1000 mergers
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among the country's
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5000 hospitals,
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and this extends beyond hospitals.
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Today, three out of every four doctors
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now works for a corporate group
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or hospital.
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Much of this has been executed
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by private equity firms.
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The one benefit of private equity
00:11:04
is that it
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generally lowers costs
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within practices,
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which should, in theory,
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lead to lower prices for patients.
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However, given patients
00:11:12
are captive customers,
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private equity groups
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are fully incentivized
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to increase prices.
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It's the perfect investment.
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Based on a recent study.
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When PE firms control
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more than 30% of a market.
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Prices rise meaningfully.
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Specifically, the study saw price
00:11:28
rises of 18%, 16%, and 13%
00:11:33
for Gastro
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OBGYN and dermatological practices,
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respectively.
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One of the most egregious
00:11:39
examples of price rises
00:11:41
was US Anesthesia Partners.
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After achieving
00:11:44
significant market
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concentration in Denver.
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USAP was noted as charging
00:11:49
reimbursement rates
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30 to 40% higher than competing groups.
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By acquiring a large
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share of anesthesiologists
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in the Denver area,
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payers and patients
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had little to no choice
00:12:02
but to pay whatever USAP asked.
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All of this
00:12:06
while USAP lowered their own costs.
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The saddest part?
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Quality of care doesn't increase
00:12:14
and might actually decrease.
00:12:16
A University of Chicago study
00:12:18
found that PE ownership
00:12:20
of nursing homes led to a 10% rise
00:12:23
in short term mortality rates.
00:12:25
Another Harvard study
00:12:27
found that quality of care
00:12:28
declined once
00:12:30
a hospital was acquired by PE firms.
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They noted a 25% increase
00:12:35
in hospital complications
00:12:36
and a 38% increase
00:12:38
in bloodstream infections.
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Although this may seem
00:12:41
surprising to some,
00:12:42
it makes perfect sense.
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To maximize profits,
00:12:46
the best course of action
00:12:47
is to increase the revenue
00:12:49
per patient, per doctor.
00:12:51
This operating leverage
00:12:52
will definitely increase margins,
00:12:54
but may compromise the quality of care.
00:12:57
And since most PE deals are financed
00:12:59
with large sums of debt,
00:13:01
investors are under pressure
00:13:02
to generate additional free cash flow
00:13:04
to pay down the debt.
00:13:06
This might mean cutting corners
00:13:08
to stay afloat,
00:13:09
but it isn't just private hospitals
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or PE back rooms
00:13:12
that are part of the problem.
00:13:14
Even nonprofits
00:13:15
hospitals are exemplifying
00:13:17
extreme greed.
00:13:19
For example, the former CEO of UPMC,
00:13:22
a nonprofit hospital, made nearly
00:13:24
$13 million in fiscal year 2022.
00:13:29
Yes, the head of a nonprofit
00:13:31
hospital made nearly $13 million.
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When asked about his compensation,
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this is what he had to say.
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Well, that's your judgment of it.
00:13:40
I think my board determines
00:13:43
what the appropriate
00:13:44
compensation is for me
00:13:45
and for all the other executives.
00:13:47
The conclusion for health care
00:13:48
providers, again, is simple
00:13:50
the pursuit of controlling supply
00:13:53
has led to the ability
00:13:54
to drive up price
00:13:55
without concerns for quality of care.
00:13:58
This applies to doctors
00:13:59
who have artificially lowered
00:14:01
their numbers, and clinic groups
00:14:02
who continue to consolidate
00:14:04
doctors and power.
00:14:08
The last element we
00:14:10
will explore is pharma.
00:14:11
The United States represents
00:14:13
approximately 44% of the world's
00:14:15
pharmaceutical market.
00:14:17
That's over
00:14:17
$600 billion on a per capita basis.
00:14:21
The US spends more on drugs
00:14:22
than anyone else, spending nearly 50%
00:14:25
more than the next highest
00:14:26
country, Germany.
00:14:28
But why? Is the US
00:14:29
just buying different,
00:14:30
better medicines?
00:14:32
No.
00:14:32
In fact,
00:14:33
they're buying
00:14:34
the exact same medicines.
00:14:36
But just paying a lot more.
00:14:39
When Bloomberg analyzed
00:14:40
eight of the best
00:14:41
selling drivers in the US,
00:14:42
even after applying discounts,
00:14:45
all but one or more expensive in the US
00:14:47
than any other major country,
00:14:50
and generally by a wide margin.
00:14:53
One of the more extreme
00:14:54
examples is for the chronic
00:14:56
myeloid leukemia pill Gleevec,
00:14:58
which costs $90,000 a year more
00:15:01
in the US
00:15:02
than the rest of the world, on average.
00:15:04
The craziest part about this, though?
00:15:06
The difference in
00:15:07
price is not just limited
00:15:08
to the US and other countries.
00:15:10
Even within states and counties,
00:15:12
people pay different prices.
00:15:15
Take a commonly used generic versions
00:15:17
of a prostate cancer treatment, Zytiga
00:15:20
they have more than 2200 prices
00:15:22
in Medicare plans.
00:15:24
For example, in Northern Michigan
00:15:26
you'll pay $815,
00:15:28
but hop around to Lake Michigan
00:15:31
and it jumps to nearly $3,400.
00:15:35
One of the reasons given
00:15:36
by pharmaceutical companies
00:15:37
as to the high price of drugs
00:15:39
is R&D costs.
00:15:40
R&D is often the largest expense
00:15:42
for pharma companies,
00:15:44
generally comprising
00:15:45
20 to 40% of revenues.
00:15:47
In addition,
00:15:48
the vast majority of all drug ideas
00:15:50
fail,
00:15:51
making the process
00:15:52
to identify and commercialize
00:15:53
a new drug
00:15:54
extremely time consuming and risky.
00:15:57
However, pharma
00:15:58
companies still generate
00:16:00
substantial margins
00:16:01
and returns on invested capital
00:16:03
as outside of R&D.
00:16:05
These pharma companies
00:16:06
are extremely capital efficient,
00:16:08
and clearly pharma companies
00:16:10
are charging less to other countries.
00:16:12
The main reason medicine in the US is
00:16:14
so expensive
00:16:15
is because,
00:16:16
unlike the rest of the developed world,
00:16:18
the US government does
00:16:19
not negotiate directly
00:16:21
with pharma companies.
00:16:22
In fact, they aren't even allowed to,
00:16:24
as per
00:16:25
the Medicare Noninterference clause,
00:16:28
by spreading the negotiating power
00:16:29
across payers.
00:16:31
The US is unable to realize the scale
00:16:33
benefits that it has.
00:16:35
This negotiating power
00:16:36
was further eroded
00:16:38
when the Medicaid drug
00:16:39
rebate program was put in place.
00:16:41
In essence, the program
00:16:42
set a maximum
00:16:43
price for drugs within Medicaid.
00:16:45
But in doing so,
00:16:46
pharma companies
00:16:47
made up for the lost
00:16:48
revenue with other payers.
00:16:50
The problem with pharma
00:16:52
is not only about prices,
00:16:53
but it's also about ethics.
00:16:55
In 2014,
00:16:56
the open Payments
00:16:57
Database was launched to disclose
00:16:59
financial relationships
00:17:01
between health care providers
00:17:02
and pharma companies.
00:17:04
Now, you might ask,
00:17:05
outside of employment,
00:17:06
why would pharma companies pay doctors?
00:17:09
Very simple.
00:17:10
Pharma companies
00:17:11
want people to use their medicines,
00:17:13
and the only thing in their way
00:17:15
is a doctor prescribing it.
00:17:17
To this end,
00:17:17
they offer illegal kickbacks
00:17:19
and other incentives
00:17:20
to ensure
00:17:21
that doctors recommend their drug
00:17:23
and not someone else's.
00:17:24
Sadly, this behavior is on the rise.
00:17:27
Since
00:17:27
2014, payments have grown from 6.5
00:17:30
billion to $12.8 billion.
00:17:34
Not all of this is illegal,
00:17:36
but in our view,
00:17:37
almost all of it is a gray area.
00:17:39
How can you be sure
00:17:40
that a doctor will be objective
00:17:42
if they have pharma companies
00:17:44
supporting their research,
00:17:45
giving them speaking fees,
00:17:47
hiring them as consultants?
00:17:48
And most atrocious
00:17:49
of all, paying them kickbacks.
00:17:52
There are dozens of examples
00:17:53
of bad behavior.
00:17:54
Novartis in 2010, Pfizer in 2014,
00:17:58
and then more recently, Purdue Pharma
00:18:00
with the opioid crisis.
00:18:02
This is not a financial crime.
00:18:04
Rather, it is a crime against humanity.
00:18:07
The pharma system is very, very broken.
00:18:10
Not only do Americans
00:18:11
pay exorbitant amounts
00:18:13
for the same drug,
00:18:14
but they can't even be sure
00:18:15
that they are being prescribed
00:18:16
the right medicines.
00:18:21
Now, that was a ton of information.
00:18:23
And frankly,
00:18:24
we cut out a lot,
00:18:25
including the impact of PBMs,
00:18:27
hidden fees, price transparency.
00:18:30
The problems with Medicare Advantage,
00:18:32
the destruction of rural hospitals,
00:18:34
and more.
00:18:35
Simply put,
00:18:36
the US health care
00:18:37
system is a behemoth,
00:18:38
and it is very complicated.
00:18:41
But from this complexity rises
00:18:43
extreme inefficiency
00:18:44
and the failure
00:18:45
to achieve the right health outcomes.
00:18:47
That said,
00:18:48
if you are wealthy
00:18:49
and financially stable,
00:18:51
the US health care system
00:18:52
is likely the best on Earth.
00:18:55
The US has the most advanced
00:18:56
technologies,
00:18:57
the most advanced facilities,
00:18:59
arguably the best doctors in the world.
00:19:02
The catch?
00:19:03
You must be able
00:19:04
and willing to pay for it.
00:19:06
The US health care
00:19:07
system is a Lamborghini.
00:19:09
Yes, it is capable, but at what cost?
00:19:12
Would we accept
00:19:13
a world
00:19:14
where the only car you can drive
00:19:16
was a luxury vehicle?
00:19:18
No.
00:19:19
Medicine is an enterprise.
00:19:20
Sure.
00:19:21
But it's different.
00:19:22
It's not about selling
00:19:24
the tastiest cheeseburger.
00:19:25
Nor is it about changing your car tire,
00:19:28
so you can get to work.
00:19:29
It is life or death.
00:19:31
It is as human as it gets.
00:19:33
And even if
00:19:34
you are opposed to a government run
00:19:36
health care model,
00:19:37
you have to admit that those models
00:19:40
are still better
00:19:41
than what the US has today.
00:19:43
Not only is the US
00:19:44
the most expensive in the world,
00:19:47
but it also has
00:19:48
some of the worst outcomes
00:19:50
in the developed world.
00:19:51
If you have watched our channel
00:19:52
for a while,
00:19:53
you might have ascertained
00:19:55
that we're not exactly socialist.
00:19:57
In fact,
00:19:58
you might argue
00:19:59
we are quite pro-business.
00:20:02
But don't let that fool you.
00:20:03
Above everything else,
00:20:04
we care about ethics and outcomes.
00:20:07
And to us, it doesn't matter
00:20:09
whether the US system is public
00:20:11
or private.
00:20:12
The fact of the matter is,
00:20:14
it is a disaster.
00:20:16
It is a system that would reject care
00:20:18
to a sick child
00:20:20
because of prior authorization.
00:20:22
It is a system
00:20:23
that would increase
00:20:24
emergency medicine fees
00:20:25
and surprise recovering patients
00:20:27
with an insurmountable bill.
00:20:29
It is a system where costs continue
00:20:32
to rise, outcomes continue to decline,
00:20:35
and nothing seems to improve.
00:20:37
So we must ask ourselves, is
00:20:39
greed always good?
00:20:42
Thank you for watching.
00:20:44
Subscribe to 2&20
00:20:45
for more on business, economics
00:20:48
and politics.
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