Chaos Theory in Financial Markets: The Fiasco of Bankruptcy Reform

Capitalism at a Crossroads

The Fiasco of Bankruptcy Reform: Finding the Butterfly

PREFACE

The Great Recession is a rolling disaster that the world economy seemingly stumbled into in the spring of 2008 and continues most colorfully today with the slow motion train wreck of monetary policy in the EU. This rolling economic Verdun was born many years before in a series of ill-conceived and poorly understood policy initiatives championed by consumer advocates and industry groups alike. These reforms – generally characterized as deregulation – were targeted at the seemingly laudable targets of risk mitigation and fairness, and categorically achieved just the opposite.

Each of these examples is a terrific case study of chaos theory at work. In chaos theory, a small action/change in a complex/dynamic system can have enormously disproportionate impact in the future. The classic example is posited by Lorenzo in his 1972 paper, Predictability: Does the Flap of a Butterfly’s Wings in Brazil set off a Tornado in Texas? What is most important to remember here is that chaos theory is very sensitive to initial conditions, and unpredictable beyond very short periods of time. For those making economic policy this requires a constant vigilance for the undesirable unintended consequences of policy changes – clearly the butterfly did not intend the tornado.

It is to the quest of finding Lorenzo’s butterfly that I dedicate this series of articles.

The first such reform considered in this series is Bankruptcy Reform – the singular achievement of financial lobbyists of the last two decades.

Bankruptcy – An American Perspective

Colonial America utilized the standard debt collection/remediation practices of Great Britain, the debtor paid or the creditor had him jailed and or enslaved through indentured servitude. Some great and notable Americans from this era spent some time in debtors prison including three signatories to the Declaration of Independence – Robert Morris, James Wilson and Henry Lee III (the father of Robert E. Lee and former Governor of Virginia). The debtors prisons in both Europe and the Americas were hotbeds of corruption by the jailers – sort of the company store on steroids. Inmates paid for their own accommodations, and bribes to the jailers were a necessary component of daily existence.

The unhappy circumstance of an English debtors prison – a family affair

The English practice of indentured servitude was really enslavement to work off debts, and has precedents back into Roman business practice. Indentured servitude was a common practice in colonial America, and accounted for many of the English immigrants arriving on our shores – and tied to the land to work off their debt of passage.

In such a system, the niceties and exact rules of bankruptcy were largely irrelevant – either pay or 1) you go to prison, or 2) you become my slave.

The entire system stunk of privilege, and clearly went against the revolutionary concepts of liberty championed by the “populist wing” of the Founding Fathers. Andrew Jackson literally rode a horse into the White House as part of inaugural celebration, and symbolically started a second revolution – this one aimed at financial institutions. He shut down the National Bank, paid off the National Debt, and shut down all Federal Debtors prisons – permanently separating private legitimate debts from the criminal justice system. In 1833 Federal debtors prisons were outlawed and closed, as were most state’s. By the 1850’s, most states had explicitly included a prohibition on debtors prisons in their constitutions.

The message in this was clear, the lender was responsible for prudent lending practices, and could not resort to the tools of state based criminal justice for the resolution of legitimate (not fraudulently incurred) debt. Without a doubt this reduced both the propensity to lend as well as the availability of credit. As a corollary, this increased the requirement for savings and equity based financing. Within 60 years the US was the leading industrial power in the world.
Can you hear the butterfly’s wings flapping?

The Bankruptcy Abuse Prevention and Consumer Protection Act of 2005

This Act, commonly referred to as The Bankruptcy Reform Act (BRA) was initially passed by both houses of Congress in 2000, but was pocket vetoed by President Clinton, and was subject to endless congressional squabbling until it was ultimately passed in 2005, in legislation sponsored by Chuck Grassley (R-IA). The thesis behind the legislation was that the unscrupulous use of the bankruptcy system by consumers was having a material and negative impact on the availability of credit, and dramatically increasing its cost.

Specifically, BRA would limit the availability of Chapter 7 filings for individuals, and dramatically expand the use of Chapter 13. In general terms Chapter 7 is available for individuals who are really broke – and it discharges their debts and starts them with a fresh slate. Chapter 13 provides for a reduction of some of an individual’s debts, but puts in place a required repayment plan by which creditors are treated fairly relative to the individual’s ability to repay. Chapter 13 is generally used by people who have means to pay some debts, but who have imprudently or through bad luck – e.g. medical bills – accumulated more debt than they can possibly service. In general, BRA was designed to prevent consumers from ducking unsecured credit through bankruptcy – it was as simple as that. As Congressman F. James Sensenbrenner Jr. (R-WI), one of the bill’s key supporters in the House, argued, “This bill will help restore responsibility and integrity to the bankruptcy system by cracking down on fraudulent, abusive, and opportunistic bankruptcy claims.”

As can be seen in the chart above, passage of the BRA did not change the trajectory of consumer loan growth, but it probably continued the growth of consumer credit well beyond what was prudent. The declining quality of consumer lending can be noted by the immediate increase in the charge-off rate of consumer credit after the passage of BRA, as shown below. Charge-offs are seen to spike at the end of 2005, just prior to the passage of the BRA, and then climb steadily through 2010. After 2010, the dramatic reduction in credit availability through the banking system in response to the Great Recession began to reduce charge-offs, as non-credit worthy borrowers were removed from the system.

Charge-Off Rates

All Banks, NSA: Consumer Credit

       Period                All         Credit Card    Other
2011:3
3.52%
5.63%
1.26%
2011:2
3.51
5.58
1.29
2011:1
4.46
6.96
1.70
2010:4
4.90
7.70
1.93
2010:3
5.28
8.55
1.81
2010:2
6.70
10.97
2.05
2010:1
6.62
10.16
2.45
2009:4
5.73
10.11
3.03
2009:3
5.74
10.10
3.07
2009:2
5.67
9.77
3.10
2009:1
4.83
7.62
2.98
2008:4
4.30
6.30
3.03
2008:3
3.56
5.62
2.37
2008:2
3.27
5.47
2.02
2008:1
2.98
4.70
1.96
2007:4
2.85
4.18
2.03
2007:3
2.48
4.05
1.54
2007:2
2.29
3.85
1.35
2007:1
2.36
3.93
1.38
2006:4
2.41
4.03
1.39
2006:3
2.16
3.87
1.09
2006:2
3.52
0.87
0.09
2006:1
3.12
0.90
0.19
2005:4
6.05
1.35
0.77

The second material change that BRA provided was to exclude certain types of derivative financing from the normal “preference payment” requirements of bankruptcy. Preference payments allow a bankruptcy trustee to unwind virtually all transactions outside of the ordinary course of business occurring 90 days prior to filing. Until BRA, the overnight “reverse – repo” derivative type of financing would have been subject to a bankruptcy based haircut of up to 100%. After BRA, it was not subject to material bankruptcy risks and lenders were more than happy to make it available to the shakiest of credits. This change allowed firms such as Lehman Brothers and Bear Stearns to gorge on short term financing, enormously inflating their balance sheets, and ultimately leading to their failure. No lender ever would have provided such financing until the BRA created this special class of financing which lies outside the law as applied to all other types of funding. Can you hear the butterfly’s wings flapping yet?

The final element of massive failure in the BRA was the prohibition of discharge in bankruptcy of certain types of student loans. Student loans have an awful history of default, but frequently enjoy Federal guarantees, making them a desirable credit class. Largely due to the Federal guarantees, and the immunity from bankruptcy, these loans have exploded in recent years, increasing by 511% in the last decade alone.

Default rates, on the other hand, reversed their downward trend in 2005, exactly contemporaneous with the passage of the BRA and began increasing again. This increase in defaults is despite the bankruptcy proof status that these loans gained in 2005. Better yet, Federal government recently enacted a plan by which student borrowers could agree to dedicate 10-15% of their after-tax disposable income to student loan repayment – regardless of the amount earned – and be fully in compliance. After 10-20 years the debt is discharged – whether or not the principal is repaid. Such are the luxuries afforded the youth.

No one talks about the BRA when talking about the origins of the Great Recession, or how we get out of it. It is a historical butterfly, whose wing beats “sowed the wind and reaped the whirlwind”. The message here is pretty simple, by attempting to limit credit risk, lenders have sponsored legislation to limit borrowers access to bankruptcy – both individual and corporate. Feeling greatly comforted that recalcitrant borrowers would be compelled to repay, lenders threw credit standards to the wind and went on a lending spree – more loans meant more money. Credit risk had been banned by effective – if punitive – legislation. Or so they thought.

This ill-conceived legislation flew in the face of 160 years of wildly successful reform – reform sponsored by Andrew Jackson and directed at making lenders accountable for their own actions. Imagine, Jackson promulgated and passed his program before the “too big to fail doctrine” truly insulated lenders from their own folly.

In reality, this legislative attempt at credit enhancement only served to drive lenders into the arms of the least prudent and credit worthy borrowers. The amazing outcome was the universal failure of every single element of the financial system touched by this legislation. This is chaos theory at its best – an obscure piece of largely forgotten legislation wreaks havoc on the financial system, and so distant is the causal event that nobody can connect the dots.Can you hear the butterfly’s wings flapping?

Thanksgiving on Moosilauke

Mt. Moosilauke
A Windy & Snowy Day for Kilimanjaro Preparation
The Prouty Mountaineering Program
(the first Prouty Challenge Event benefitting Dartmouth-Hitchcock Norris Cotton Cancer Center)
Prep Hike #4
11 miles, 4,802 feet
November 24, 2011
Wes Chapman
Mt. Moosilauke – a Bald Place
Mt. Moosilauke is an English language adaptation of the Abenaki Indian name for the hill – mosi (bald) auke (place). This was altered into Moose Hillock, and then finally into Moosilauke. Moosilauke is an interesting hill, in that it is considerably wilder today than it was in 1860, when the Pinnacle House opened on July 4th, to a crowd of over 1,000 people – right at the top of the Hill. Moosilauke was home to Dartmouth skiing through the ‘40’s, and the national skiing championship was held there in the ‘30’s.
I must have climbed Moosilauke well over 100 times, but my first Thanksgiving Day climb was today, with my young friend and climbing companion Jon Morse, and his two dogs Liz and Ted (aka The Menace).
Jon Morse on the road to the base
Jon is training for Kilimanjaro, Hood and Rainier, and so enjoyed a chance to bust out into the fresh snow for a day of tough trail breaking up Moosilauke. We were the first tracks up the Hill as of 8:30 on Thanksgiving morning, and 10-18 inches of fresh, heavy snow really changes the degree of difficulty from a normal summer hike.
The Gorge Brook trail was at least partially washed out in Hurricane Irene, and currently involves a fair amount of rock hopping/wading. As wet dogs and fresh snow mix very poorly, we headed up the Snapper Trail to the Carriage Trail. The best thing about fresh snow is fresh animal tracks, and we saw plenty – 2 deer, a bear, and a couple of moose – one of which we followed almost to the top. The mis-applied moniker of Moose Hillock was accurate at least for today.
Plenty of fresh snow
Mountain climbing on Holidays is a particularly risky business, as failure to show up on time for Thanksgiving dinner will invariably result in several tons of malodorous excrement being immediately dumped on your head, with no way of removing the odor for weeks. Speed is essential at such times, and we climbed like men possessed all day.
        The Menace in the Snow 
Liz at lunch
The temperature at the top was about 10 degrees, blowing a full gale, and a white out. The drifts were waist deep, and the going was awfully slow. It was not the clear and cloudless skies promised by the weather channel. By the time we got back to the bottom we were really beat, and the dogs were encrusted in snow several inches thick. We made it back on time, made dinner without issue, and all ate massively –man and beast alike. Without a doubt, a day well spent.

Perverse Incentives, Clumsy Laws, and the Value/Volume & RVU Conundrum in Medical Quality

By Wes Chapman; Charles Hutchinson, PhD; & Michael Choukas, MBA

Preface

This is the second of four articles regarding quality issues in the delivery of clinical healthcare. The first looked at the popular methods for quality improvement in healthcare, and their applications and limitations. This second article examines the alignment/quality issues and system design considerations regarding high volume procedures and high Relative Value Units. The third article will propose recommendations on system design for optimized protocol-based care in delivery systems involving small and large hospital systems. The fourth article looks at the development and utilization of process and outcome metrics, and how metrics can help in the development and continuous improvement of medical care protocols.

Summary

The largest single problem with flow-based quality concepts in medicine is that neither patients nor providers consider process quality measures to be relevant to their personal concept of quality. Instead, they focus on the practical concepts of provider skill and experience – the results of constant training and procedure volume. On the other hand, doctors and hospitals are paid according to Relative Value Units (RVUs), which have nothing to do with volume, experience, or the resulting improvements in quality. Instead, RVUs create a system where specialized procedures are paid far more highly than primary care. This lures many struggling hospitals into offering high RVU procedures, regardless of their ability to attract sufficient patient volume to develop the experience and skill required for a high quality outcome. Legal restrictions on referrals compact the problem by blocking the ability of smaller hospitals to direct patients to high-volume centers without losing all of the potential revenue. To achieve an acceptable level of quality improvement in healthcare, we must first find a solution to this value/volume conundrum.

Divergent Views on Medical Quality

There has been a tremendous amount of work in clinical and academic circles addressing medical quality as a process-related function. As we addressed in our August paper, Medical Quality Systems: the Elusive Goal of Quality in Complex Systems, there are considerable practical problems with this approach, mostly centered on the non-linear process flow in the vast majority of medical clinical systems. The largest single problem with flow-based quality concepts in medicine, however, is that neither patients nor providers really consider process quality measures to be at all relevant to their personal concept of quality.

Patients and doctors focus on the practical concepts of provider skill and experience as the key determinants of quality, and with good reason. The literature is very clear that, more than any other single factor, experience – of both the provider and the medical center – determines the success or failure of a medical procedure (Birkmeyer et al). Specifically, in their seminal paper Hospital Volume and Surgical Mortality in the United States, the authors conclude, “In the absence of other information about the quality of the surgery at the hospitals near them, Medicare patients undergoing selected cardiovascular or cancer procedures can significantly reduce their risk of operative death by selecting a high-volume hospital.” (N Engl J Med 2002;346:1128-37)

This is pretty strong stuff, and published in a top journal. Staying on the same theme, Birkmeyer et al concluded in a paper in the New England Journal of Medicine the following year, “For many procedures, the observed associations between hospital volume and operative mortality are largely mediated by surgeon volume. Patients can often improve their chances of survival substantially, even at high-volume hospitals, by selecting surgeons who perform the operations frequently.” (N Engl J Med 2003;349:2117-27)

The racetrack metaphor that pops to mind is, if the horses are all pretty much the same, bet on the jockey. Clearly patients are encouraged by the academic literature to select busy jockeys at busy tracks.

The academic literature about this subject is voluminous, straightforward, and unassailable: practice makes perfect. The Leap Frog Group is a Washington advocacy group sponsored by major corporate employers; the kind who have great (and very expensive) healthcare plans for their employees. These folks are uninhibited by the limitations of peer reviewed publication and state with no mistaken purpose:

Tens of thousands of Americans die every year undergoing elective surgery. For many high-risk procedures, surgical patients can reduce their risks considerably by having their procedures performed at hospitals with low risk-adjusted mortality rates and/or sufficient experience with those procedures.

For some procedures, the right surgeon may be even more important. In particular, high-volume surgeons often have markedly lower mortality rates than surgeons who perform those procedures infrequently.

Dr. Atul Gawande is perhaps the most prolific and successful advocate for process control from the active ranks of medical professionals. Dr. Gawande is an endocrine surgeon at Brigham and Women’s Hospital in Boston, an associate professor at Harvard, and author of the enormously popular book (at least among quality wonks) The Checklist Manifesto, in which he analyzes the impact of checklists on process control and quality outcomes in medical applications. Dr. Gawande put an exclamation mark on the concept of the duality of quality in medicine with his recent New Yorker article, Personal Best (October 3, 2011), in which he describes how and why he decided to hire a personal coach to help improve his surgical skills. He addressed head-on the importance that technical skills and technique mean for the practicing surgeon. Clearly process control is necessary but not sufficient for a quality outcome. Constant practice and skill refinement are at least as important as any process refinement in achieving quality outcomes in medical procedures.

The message for healthcare system design is clear: Specialization, volume, and constant training are key determinants of outcomes in healthcare. From a practical perspective, a move to increase specialization and volume always tends to increase linearity in a production system, which directly addresses the issues of complexity inherent in medical delivery systems. 

RVUs and the Centrifugal Forces of Procedure Venue

The Fairfax Medical Dictionary defines Relative Value Unit as a comparable service measure used by hospitals to permit comparison of the amounts of resources required to perform various services within a single department or between departments. It is determined by assigning weight to such factors as personnel time, level of skill, and sophistication of equipment required to render patient services. RVUs are a common method of physician bonus plans based partially on productivity. RVUs were adopted in 1989 as part of Omnibus Budget Reconciliation Bill of that year, and replaced the overly vague and wickedly expensive “reasonable and necessary” language that was part of the original Medicare payment method.

“…all RVUs are created equal…the person who performs 100 procedures per year gets paid the same as a provider who does just one…”

As of 2010, about 7,000 different procedures are paid by RVUs, which are based around the Current Procedural Terminology Codes (CPT Codes) owned and controlled by the American Medical Association (AMA). All RVUs are determined by the AMA’s closely controlled Specialty Society Relative Value Scale Update Committee (RUC) and are comprised of compensation for three components: physician work, practice expense, and malpractice insurance. (For a detailed description of how RVUs are calculated, see www.acro.org/washington/RVU.pdf.)

From a practical perspective, all RVUs are created equal, with no specific differentiation for the volume practiced by a hospital or physician. In the same geographic region and type of facility, the person who performs 100 procedures per year gets paid the same as a provider who does just one. This creates a system with enormous incentive for struggling hospitals to try to fix their fiscal woes by undertaking new lines of business that have high RVUs, whether or not the hospitals have the potential to become high volume – and therefore high quality – centers for that procedure.

Another important consideration is that not all procedures are created equal in the eyes of the RUC. As Dr. Pauline W. Chen put it in her recent New York Times article on the subject (Sept. 22, 2011):

Put simply, our payment system pays more for procedures performed by specialists. Specialists, therefore, have greater earning power, so more doctors choose to train to be specialists. Careers in specialties like radiology, dermatology, and neurosurgery offer lifetime earnings several million dollars higher than those in primary care. It is no surprise that medical students emerging from the educational mole hole saddled with hundreds of thousands of dollars of debt choose more lucrative fields.

The fact is that the RUC is dominated by specialty medical societies (23 of 29 seats) and operates with all the openness of England’s notorious Star Chamber, yet it directly controls the relative disbursement of $60 billion paid by Medicare to physicians, and effectively directs another $60 billion from private payers who use Medicare standards.

There is a Logical Solution, but…

Barring a coup d’etat in the RUC, disproportionate incentives for specialty procedures are here to stay. The current RVU/RUC system will continue to provide incentives for dispersion of care that work to the detriment of quality in every case delivered in a low-volume environment. Higher volumes produce better physician skills and better teams, along with delivery systems that become more linear and easier to monitor and control. Low-volume environments inhibit physician skill development, preclude specialty team formation, and are always more expensive to operate.

The logical solution to this situation is to:

  1. Direct procedures to centralized facilities for execution.
  2. Allow RVU-based definitions of clinical care delivery to begin with screening and end with rehabilitative/home healthcare.
  3. Treat the episode of care across both time and venue.
  4. Require all parties to the care to share in the revenue, so all can benefit financially from patient-centric collaboration and good outcomes.

Unfortunately, until very recently what is most logical has also been illegal.

Logic and Reality Collide at the Federal Anti-Kickback & Stark Laws

From a practical point-of-view, the Anti-Kickback and Self-Referral legislation is referred to today as part of the Stark Laws; although they are different legislative undertakings, they are directed at the same sorts of problems. The Stark Laws are named for their sponsor, Rep. Peter Stark of California, and are really targeted at the issues surrounding self-referral. The Federal Anti-Kickback laws were first passed in 1972, prohibiting the payment for referrals. As the Office of the Inspector General states in its fact sheet, first published in November of 1999:

… the federal anti-kickback law’s main purpose is to protect patients and the federal health care programs from fraud and abuse by curtailing the corrupting influence of money on health care decisions. Straightforward but broad, the law states that anyone who knowingly and willfully receives or pays anything of value to influence the referral of federal health care program business, including Medicare and Medicaid, can be held accountable for a felony. Violations of the law are punishable by up to five years in prison, criminal fines up to $25,000, administrative civil money penalties up to $50,000, and exclusion from participation in federal health care programs.

Because the law is broad on its face, concerns arose among health care providers that some relatively innocuous – and in some cases even beneficial – commercial arrangements are prohibited by the anti-kickback law. Responding to these concerns, Congress in 1987 authorized the Department to issue regulations designating specific “safe harbors” for various payment and business practices that, while potentially prohibited by the law, would not be prosecuted.

Like so many things in Federal Legislation, the law of unintended consequences came to play full force in this case. The implications of volume and quality were not understood at the time the legislation was passed, and the legislation has not kept up with the reality of medical practice. None of the 13 Safe Harbors address the concepts of optimized care based on quality/volume. On the face of it, the law makes the concept impossible. This misdirected impact of the Stark Laws has created a value/volume conundrum that must be deciphered if we are to achieve an acceptable level of improvement in medical quality.

Bundled Payments: A Viable Alternative for High-Volume Care Delivery

 

“…here at last is a way to implement the four-part solution to the value/volume conundrum…”

The recent Bundled Payment Initiative (BPI) launched by the Centers for Medicare & Medicaid Services (CMS) in August of 2011 offers a unique and direct opportunity to address the perverse financial incentives that disperse high-RVU procedures to low-volume facilities. In this initiative, groups of providers can share the provision of services and fees related to specified medical procedures. Here at last is a way to implement the four-part solution to the value/volume conundrum, allowing best practices and patient-centric care to bridge the legal chasm created by the inhibiting Stark Laws.

In rural environments with large numbers of critical access hospitals (CAHs), this is a particularly interesting alternative. CAHs are limited to 25 beds or less, and are designated as critical to care in geographically isolated communities. In return for the limitations on size, the CAHs are allowed to charge Medicare “cost plus” for the rendering of services to Medicare beneficiaries. These hospitals tend to be the effective “medical home” for their patients, providing primary care and related services. Depending upon specialist availability, these small facilities sometimes enter into the delivery of specialized (i.e., high RVU) medical procedures – almost always in a low-volume environment. This makes it virtually impossible to achieve the high procedural volumes necessary for high-quality outcomes.

In the Bundled Payment Initiative, these facilities can team up with larger high-volume acute care hospitals (ACHs). They can direct specialty procedures to those facilities, while sharing in the diagnostic, patient prep, and post-procedure care. They can also share in the fees associated with the procedure. This allows the patient to receive care close to home for as long as possible, and vastly improves the potential for integrated care between the primary care physician (PCP) and the specialist performing the procedure. Importantly, it eliminates the need to have a surgeon at the CAH perform the procedure in order for the CAH to benefit financially.

Still One Stumbling Block

The greatest problem with the implementation of the CAH–ACH pairing is the fact that the existing BPI plan is limited to expenses incurred under the Prospective Payment System (PPS) for CMS. The PPS establishes rates for payments to most hospitals, but does not include the cost-plus payments made to CAHs. To be truly cost effective and patient centric, the BPI must be modified to include historical levels of cost incurred at the CAH related to a single episode of care for a patient, when those costs can be tied directly to an integrated episode of care.

Consider, for example, patient John Doe (or JD), who presents at his CAH medical home for a diagnosis of hip pain. His PCP, in conjunction with the hospital staff, does a series of radiographic images – including an X-Ray and MRI – and determines that a hip replacement is called for. Accordingly, the PCP makes a referral to an ACH to perform the surgery. The ACH performs exactly the same radiographic examination in deriving its diagnosis and surgical plan.

In an ideal bundled payment, the duplicate imaging would be eliminated, and the savings would accrue to the participants. This would require some coordination and protocol adherence, but it would be better for JD and would save several thousand dollars in redundant tests. In order to accomplish this, however, the BPI package must be expanded to include the cost-plus payments from the CAH, as well as the PPS payments from the ACH. It would seem that the immediate improvement in patient care (through reduction in exposure to radiation) and the savings of thousands of dollars per case would make this well worth the additional effort.

New Hampshire and Vermont as a Case Study

On November 4th of 2011, a group of 15 healthcare providers, including acute care hospitals, critical access hospitals, and home health/visiting nurse groups from the states of Vermont and New Hampshire, submitted a letter of intent to Medicare to start the data analysis necessary to develop a BPI that would include all of the parties. Our firm, PCD Partners, Inc., acted as convener in the process, arranging the data analysis, program design, and implementation.

New Hampshire and Vermont are known locally as the Twin States. While they are quite similar in size and history, they have quite different approaches to state government and healthcare. Vermont has had a long commitment to state-directed control of healthcare payment and planning, while New Hampshire has had a very hands-off policy, with little state involvement. Summary statistics for the two states are shown below.

New Hampshire and Vermont have relatively large and geographically isolated rural populations. In both states, the rural populations are older and poorer than in urban areas. These rural populations depend on their local  CAHs for the delivery of the preponderance of their medical care, but they tend to migrate to higher volume, larger ACHs for specialty procedures – amounting to an estimated 20-40% of the total annual service provided to the served populations. This is a critical loss of revenue for these small facilities, and there have been attempts over the years to provide some of these services locally. Unfortunately, with their small size and a difficulty in recruiting physicians, this has not proved to be a viable alternative in most cases.

The Bundled Payment Initiative for the CAHs in New Hampshire and Vermont offers a unique opportunity, both to improve care for their patients and to improve their own financial circumstances. Any reasonable level of revenue participation should ensure long-term financial improvement, and the integration of care back to the medical home will greatly facilitate post procedure care. Finally, the cases could be referred to ACHs in such a manner as to maximize the case loading of those facilities and physicians. The increased volumes would clearly improve care and lower the cost per procedure.

Conclusion

Directing patients who require specialized procedures to high volume facilities is the only way to improve care and lower cost in those procedures. Smaller hospitals, such as the critical access hospitals in New Hampshire and Vermont, have never had an alternative that allowed them to do this legally and still participate in the patient care and the financial benefits. The Bundled Payment Initiative, though not yet perfect, is a unique opportunity for small hospitals in New Hampshire and Vermont – and anywhere else in the country – to resolve the conundrum of high RVU financial benefits and high volume quality.

Next

There is an old management saw (incorrectly attributed to Edwards Deming) that states, “you can’t manage what you can’t measure.” Measurement is a critical part of any management system – both of the process and the outcome. In the effort to improve quality in healthcare, regulators, practitioners, payers, and patient advocates have all agreed on one thing: you must have some way to measure the effects of what you are doing, and the results. The CMS,  AHRQ, NCI, and a long list of other acronymic agencies have specified thousands of metrics to measure quality in healthcare. Almost all of these – and certainly all of the metrics and measures accepted by regulatory agencies and payers – are process measures. There is a certain logic to this: in the confusion of procedures and protocols currently implemented in the nation’s hospitals and clinics, it is impossible to compare outcome measures in any meaningful way. You must define the process before you can understand the outcomes. Over the past decade, literally thousands of these process metrics – normally associated with the concept of best clinical practice – have been promulgated by these groups. Making sense of who has been doing this, what the metrics are, which really matter, and why is quite a puzzle to sort out and will be the objective of most of our analysis. Not too surprisingly, outcome metrics have lagged behind process metric development, as they depend frequently on idiosyncratic patient interpretation. A patient’s own measure of satisfaction can be so entirely subjective as to be anecdotal, and is very dangerous as a comparative metric on which to base either claims of healthcare quality or claims for payment. Unfortunately, all healthcare providers, from the largest acute care hospital to the smallest walk-in clinic, must do both in order to stay certified, attract patients, and get paid. How then do we choose the best metrics and measures to satisfy the regulators and payers, and still get the data we need to improve processes and achieve a level of quality that will also satisfy the patient?

Sources
  1. http://medical-dictionary.thefreedictionary.com/RVU
  2. http://en.wikipedia.org/wiki/Relative_Value_Units
  3. http:// www.acro.org/washington/RVU.pdf
  4. http://well.blogs.nytimes.com/2011/09/22/how-one-small-group-sets-doctors-pay/
  5. http://oig.hhs.gov/fraud/docs/safeharborregulations/safefs.htm
  6. High Volume and Surgical Mortality in the United States, Birkmeyer et al, N Engl J Med, Vol. 346, No 15, April 11, 2002
  7. Surgeon Volume and Operative Mortality in the United States, Birkmeyer et al, N Engl J Med, Vol. 349, No. 22, Nov. 27, 2003
  8. Trends in Hospital Volume and Operative Mortality for High-Risk Surgery, Finks et al, N Engl J Med 364, No. 22, June 2, 2011
  9. Outlier Payments for Cardiac Surgery and Hospital Quality, Baser et al, Health Affairs, 2009; 28(4), 1154-1160
  10. Operative Mortality and Procedure Volume as Predictors of Subsequent Hospital Performance, Birkmeyer et al, Annals of Surgery, 243, No. 3, March 2006
  11. United States rural hospital quality in the Hospital Compare database – Accounting for hospital characteristics, Goldman et al, Health Policy, 87(2008), 112-127
Find a glossary of terms on our Resources page.

Phelps Mt. – Prouty Mountaineeering Prep Hike #4

Phelps Mountain
The Prouty Mountaineering Program – Kilimanjaro Preparation
(the first Prouty Challenge Event benefitting Dartmouth-Hitchcock Norris Cotton Cancer Center)
Prep Hike #3
8 miles, 4,160 feet
November 13, 2011
Wes Chapman
Phelps Mountain – named for a legend
Phelps Mountain is the closest 4,000 foot mountain to Adirondack Loj, and was named for the legendary Orson Schofield “Old Mountain” Phelps (1817–1905) who cut the first trail up Marcy, and many of the trails in the Adirondack Park. Its proximity and size make it a favorite for weekend hikers, and I had left it for either a nice day in the late season or a ski trip in the winter.
Mt. Marcy from the summit of Phelps
My companion for the day was Rick Morse, an old friend and cancer survivor, who drew the short straw and had to pick up the slack when Pete Volanakis went AWOL after our Mt. Colden expedition. Rick is a Vermont native, and had spent 8 years looking across the Lake at these Hills from Burlington where he went to College and Medical School. But he had never come over to climb – that was until today.
Dr.Richard Morse (AKA Rick Morse) enjoying a chance to come climbing
A steep and icy path to the top
A new slide on the back of Mt. Wright – a product of Hurricane Irene
Sunrise over Lake Champlain – highlighting our targets for the day
The day was warm and breezy, and really quite windy on top – blowing over 40 mph. The trail up was steep, icy and quite eroded. These trails were cut many years ago – right up the fall-line of the mountain. They are terribly eroded today, and could really use a major re-routing through a switchback layout. In any event, the going was slow, but the views from the top were well worth the effort.
Mt. Colden from the summit of Phelps
Dining al fresco near the summit
This is probably the last warm hike of the season, and I hope that soon we’ll have some snow for some skiing soon. Kilimanjaro training will switch to AT gear soon. If you want to do a little training for the Prouty Kilimanjaro trip give me a call – I’m sure that we’ll be heading out into the Hills.

The 7% Solution: A Trigger for Fiscal Collapse?

A Curious Relationship between Addictions to Cocaine and Cheap Money

Sherlock Holmes Meets Silvio Berlusconi & George Papandreou

I have long likened the flood of cheap money released into the world economy over the last twenty years to drugs for an addict. Our financial system craves more and cheaper money to feed our ever growing addiction to asset inflation as a substitute for real economic growth. The collapse of the Italian government this week – putatively due to interest rates hitting 7% – brought to mind the great fictional collapse of Sherlock Holmes due to abuse of a 7% solution of cocaine. The metaphor of addiction intertwined with the mysteriously recurring 7% was simply irresistible.

Three Titans Laid Low by a 7% Solution

Sherlock Holmes

Berlusconi 

Papandreou

Listening to and reading the popular financial media over the last week, I was struck by the new standard of failure in international finance – a 7% rate on a 10 year government bonds. The financial world was bloviating endlessly about the abject failure of Italy – as evidenced by a 7% plus rate demanded for its “full faith and credit” financial instruments. For those of us who came of age in the early ‘80’s, 7% is an interest rate for Euro-wimps. We grew and flourished in short term US Government rates of over 15% – and they were difficult to sell at that price.

But the media got it right; Greece also started to fail when its interest rates hit 7%, as did Ireland and Portugal. What made all of the pundits so agitated was the fact that given the enormous levels of debt to GDP – at or near 100% in all of these countries (as well as the US) – at 7% interest rates, the cumulative interest burdens become simply unsupportable.

Consider the Durability of the Characters

Silvio Berlusconi enjoys a reputation as perhaps the most notorious national leader in the Western World. His eight years in office have been marked by unrelenting scandal and barely dodged jail sentences – this was the guy who introduced bunga-bunga parties into popular parlance.  Papandreou on the other hand is a Minnesota born Greek patriarch, the third member of his family to hold the position of Greek Prime Minister. Yet both of these characters succumbed to the fury of the Euro Bond market – the fatal potency of the 7% solution.

All of the leaders of the Euro Zone should consider the words of European Central Bank policymaker Juergen Stark who warned European governments on Wednesday against asking the ECB for support in dealing with the region’s sovereign debt crisis, saying this would put the central bank’s independence at risk. “We are not the lender of last resort (to governments) and I do not advise European governments to ask the ECB to become lender of last resort,” Stark, a member of the ECB’s executive board, said at a business conference. “This will mean that the ECB immediately will lose its independence.”

Fabulous – it sounds just like the US Fed during the Great Depression. If a central bank is not the lender of last resort, then who is? Central banks really only have one crisis oriented function – lender of last resort. Their role is not to act as deflation fighter, employment agency or investment advisor. The Central Bank is exactly the lender of last resort – lest chaos ensue. Take comfort Silvio and George, other European leaders will be joining you soon.

The rolling fiasco in Europe has raised an immediate series of questions for me regarding the US:

  1. How much Federal Government debt do we currently have in the US, and where will it be in the next two years or so?
  2. What part of our deficit is currently interest, and at what average interest rate?
  3. What would happen to our deficit if our debt went to 7% interest rates, and what would that do to the work of the Congressional Super Committee (finding a minimum of $1.5 Trillion in expenditure reductions/tax increases over the next 10 years)?
Question 1 – How Much Debt Are we talking about?

 

Total US Government debt = $13.5 T

Digging around it appears pretty clear that the total debt of the US Federal Government is currently around $13.5 T. The next question is this stable, or should we expect continued growth over the next 2 years – the period of our analysis.

Current deficits – $1.25 T per year

Looking at current growth rates, tax rates, and expenditures, it seems pretty clear that we will be doing pretty well to hold US budget deficits to $1.25 T for each of the next couple of years. The government projects getting under $1.0 T, but they have missed all of their projections since the Great Recession began, and I have no reason to believe that it will get any better. For prudence, we’ll figure that total debt will be $16 T by the end of 2013, and we will base our calculations on the $16.0 T figure.

Base Case Federal Debt

$13.5+ (1.25*2) = $16.0 T by the of 2013

Question 2 – How much interest are we talking about?

First, let’s take a look at current interest rates on Federal Debt.

Average Interest Rates on US Government Debt

Clearly, the weighted average cost of US debt is 2.859%, and has been falling pretty rapidly since the beginning of the fiasco in Europe this summer. Calculating the cost of the US debt as of today:

Total Interest Expense, and as % of the deficit

1. Current:
Total interest: $13.5 T * 2.859% = $386 B
Interest as a % of Deficit = $386/$1,250 B = 30.9%
Interest as a % of total budget = $386/$3,456 B = 11.2%

2) End of 2013:
Total Interest: $16.0 T * 2.859% = $ 457B
Interest as a % of Deficit = $457/$1,250 B = 36.6 %
Interest as a % of total budget = 447/$3,336 = 13.4% (1)

(1) Assumes target budget reductions are met reducing annual budget by $120 B

It is important to note that historically there has been widespread reporting of net interest – net of the interest paid on the debt held by the Social Security Trust Fund. While historically this may have made sense – the combination of the scale of interest now paid to foreign entities (over 50%) and the huge reductions in collections by social security over the last several years due to suspension of payroll tax collection and increase in unemployment make a gross level much more relevant.

Question 3 – What happens if Interest rates rise?

First, it’s worth taking a look at historical levels of interest rates. The market seems to have chosen 7% as the level of mortal peril. Let’s take a look and see if this was simply arbitrary, or perhaps is something more tangible. We’ll take a look at both long term and short term interest rates, with a simple objective – determine if 7% is a reasonable level of interest rates for long and short term instruments.

7% interest rates may be high for short term rates

7% seems historically reasonable for longer rates

Looking at the historical interest rate levels, it seems perfectly plausible that rates could hit the magical 7% level. The real question is what would be the impact if they did?

Outcome from 7% interest rates and above
1.  Interest Rates  rise to 7% for the existing Federal Debt
Total interest: .07* $13.5 T = $945 B
% of total budget = $945/$3,456 =27.3%
Increase in budget deficit = $559 B, 44.7 % increase in deficit
2.  Interest Rates rise to 9% for the existing Federal Debt
Total interest: .09* $13.5 T = $1.22 T
% of total budget = $1,220/$3,456 =35.3%
Increase in budget deficit = $834 B, 66.7 % increase in deficit

 

The key factors for future interest rates

The key factors influencing sovereign interest rates are classically given as inflation, credit quality, liquidity, and alternative investments. In the real world the factors are fear and greed. The final determinant is always more buyers than sellers. Consider the application of the real world portion of these factors to the current Euro Bond market. People are scared, the governments need huge amounts of money and there are no buyers. The ECB has stated that they are not the buyer of last resort – so there is none. The sovereign states members of the Euro have given up their ability to print money – and they are consequently in big trouble.

So what does this mean for the US – if rates were to hit 7% to 9%, our deficit would increase by 45-65%. This is about 4.5-7.0X the total amount of “doomsday” deficit reduction targeted by the so-called Super Committee.

A 7% Solution for the US ?

It is a perverse feature of highly indebted borrowers – raising interest rates to adequately compensate for credit risk results increases the risk of default. Sovereign borrowers frequently (and unfortunately) adjust to higher rates by increasing the monetary base and inflation, resulting in the demand for higher rates – entering into a death spiral leading to currency recalibration – typically through the practical expedient of dropping three to six zeros. What could be easier?

The US has enormous borrowing needs over the next three years – at least $2.5 T in deficit funding, and 2.5 T in refinancing – for a total of $5.0 T. This compares to around $14 T in total value for all US stocks – while the comparison is imperfect, it does give a good idea as to how much of our financial resources will be needed for funding the federal debt. In short, the federal government will need to borrow an amount equal to 36% of total US stocks – and that is just to keep going with no increase in interest rates. Increasing interest rates to 7% would increase the total amount needed to around $6.1 T, or around 43% of total equities. Another way to put the enormous growth in demand for government debt, is that in the first 200 years of the republic we accumulated $1 T in debt. We will need to borrow 5-6 X that in the next two years just to stay even.

In order to sell this much debt there will have to be buyers, and the buyers will want to be compensated for risk. The easy solution has been to stuff money into the Fed’s balance sheet and pawn it off on the Chinese, but after a while even these sources will dry up – we are talking about $5-6 T. We may well see the day in the next year or two when the US will need to sell its obligations to real buyers, and even 7% may look too cheap.

In summary, there is no magic number at which sovereign credits become unsustainable. Too much is dependent on exogenous factors – the principle factor being the willingness of people to keep on lending. One thing is certain, however, the US needs to borrow a tremendous amount of money over the next three years, and will consume enormous amounts of liquidity doing so. There are a lot of things that will need to go right to pull this off, and interest rate increases are only one of many factors that can cause a fiscal train-wreck.

Mt. Cube – Prouty Mountaineering Prep Hike # 2

Mighty Mt. Cube
A Beautiful Day for Kilimanjaro Preparation
Prep Hike #2
4 miles, 2909 feet
November 7, 2011
Wes Chapman
View of Smarts and the Dartmouth Skiway from the Summit
November 6, 2011
Kilimanjaro Preparation with the Sirens of Hanover
Pete and I returned to Hanover to find a house full of people – all of whom wanted to go climbing the next day – desperate to prepare for Kilimanjaro next year. It was dark, we were tired and we agreed, so long as the hike was local and easy. The ladies were violently opposed to doing anything too easy, but we talked them out of doing Franconia Ridge, and into Cube – about 2,000 vertical feet of hiking – with the best ROC (return on climb) in the Upper Valley.
Andrea, Martha and Christie – the Sirens of Mt. Cube
We headed up the Cross Rivendale trail, which replaces the Appalachian Trail, which used to start in the same place, but was moved several years ago. The local volunteers do a great job with this trail, which is well laid-out and maintained. Cube is a giant hunk of quartzite, which is very hard and resistant to both chemical and physical erosion. The rock was polished smooth by the glacier, and still bears the glacial striations ground into the rock over 10,000 years ago.  
Mt. Cube NH

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Smarts Mt from the summit of Cube Oct. 30, with a lot of snow
Cube is one of my favorite hikes, and was the first hike that I did in 1973 when I arrived at Dartmouth. I’ve climbed it in all kinds of weather, every time of day and every month of the year. The last two weeks have had some of the best weather and views that I’ve ever had from the summit, and Sunday’s climb was about the biggest and most raucous crowd that I’ve ever climbed with. It was one continuous laugh from the bottom to the top and back.
There was just a little ice on the trail, and only a few minor spills. The lunch at the top was quick and just enough to whet appetites for something more substantial back in the valley. This was a great way to spend a Sunday getting ready for Kilimanjaro in 2012.
Lunch including Rick Morse 
Rick Morse and Pete Volanakis preparing to descend
This is the second in a series of preparatory hikes for the Prouty climb of Kilimanjaro in December of ’12. These hikes happen sporadically, depending on weather, demands of work, the venue of the author and simple ambition. If you have any interest in joining us, drop me a line.