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Equity Perspectives

For all the political rhetoric and legislative uncertainty, innovative managed-care companies have delivered significant alpha in the last year. Can that continue?

 

In Brief

  • Although the Affordable Care Act’s individual health insurance market is still losing money and state insurance exchanges have floundered, managed-care companies have performed quite well.
  • All this outperformance has been driven by lower healthcare utilization trends and rising employment; therefore, more insured members, and the combination of both factors, have driven upward revisions to earnings estimates.
  • Active managers equipped with astute research have benefited from growing patient consumerism, increasingly profitable Medicare Advantage programs, and increasingly prevalent Medicaid managed-care organizations, which are expanding across the nation.
  • With higher premiums and co-pays, not to mention a growing shortage of doctors and nurses, consumers are making greater use of urgent-care centers, retail clinics, specialized surgery centers, telemedicine, and remote monitoring.   
  • The key takeaway: The movement toward value-based care to control spiraling healthcare costs is likely to gain momentum.
 

Repeated attempts by the U.S. Congress to repeal (and replace) the increasingly expensive Affordable Care Act (ACA) may have failed, but consolidation, advanced technology, growing consumerism, and increased focus on outpatient care already have reshaped an ever complex system that accounts for 17% of America’s gross domestic product.  (See Chart 1.)

Evidence of such transformation is abundant. Declining insurance reimbursements and soaring drug prices have led doctors to sell their practices to hospitals. Hospitals have consolidated, expanded, and/or rented out space to leading cancer, heart, and orthopedic caregivers; some have even outsourced emergency room (ER) services to outside companies. Retail clinics have popped up in shopping centers. Pharmacies are poised to leverage their locations into other routine medical services. Urgent-care centers, a far less expensive alternative to lengthy ER visits, have proliferated. “Telehealth” is providing health care through videoconferencing, remote monitoring, electronic consults, and wireless communications. And with America in the throes of widespread depression and substance abuse, innovative behavioral health and addiction services have gained traction.

Managed-care companies appear well positioned to capitalize on such transformative innovation. Sure, the debate over the best (and most cost-efficient) way to deliver healthcare services and insure individuals may rage on for years, but the sector has benefited from the growing popularity of consumer-driven health plans (CDHP), increasingly profitable Medicare Advantage programs, and increasingly prevalent Medicaid managed-care organizations, which are expanding across the nation. (CDHPs, now offered by a majority of employers, are a type of medical insurance or plan that typically has a higher deductible and lower monthly premiums, as opposed to a traditional preferred provider organization or health maintenance organization. A high-deductible health plan, or HDHP, is a type of consumer-driven medical plan and it is also gaining favor.)

Although the ACA individual market is still losing money and state insurance exchanges have floundered, managed-care companies generally have outperformed the S&P 500® Index in the last year by a substantial margin, according to Bloomberg. One market leader, for example, was up nearly 48% as of August 9, 2017, compared to the S&P’s 12.68% gain, while another player was up 40.7%. All this outperformance has been driven by lower healthcare utilization trends and rising employment; therefore, more insured members, and the combination of both factors, have driven upward revisions of earnings estimates.

 

Chart 1. Health Care as a Share of GDP Totaled a Record 17.5% in 2014
Health care as a percentage of GDP, 1960–2014 



Source: Office of the Actuary, Centers for Medicare and Medicaid Services.

 

Costs versus Benefits 
Even with greater consumer choice, the United States still has the most expensive health care, and ranks last overall among 11 wealthy countries on measures of health system equity, access, administrative efficiency, care delivery, and healthcare outcomes, according to a recent study by The Commonwealth Fund.1

“While there is room for improvement in every country, the United States has the highest costs and lowest overall performance of the nations in the study, which included Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom,” the report said. “The United States spent $9,364 per person on health care in 2016, compared with $4,094 in the United Kingdom, which ranked first on performance overall.” 

Despite all that spending in the United States, Americans had worse healthcare outcomes than their international peers, the report added, citing data from the Organization for Economic Co-operation and Development (OECD). According to the OECD, the United States had the lowest life expectancy at birth of the countries studied, at 78.8 years in 2013, compared with the OECD median of 81.2 years. In addition, the United States had the highest infant mortality rate among the countries studied, at 6.1 deaths per 1,000 live births in 2011; the rate in the OECD median country was 3.5 deaths. (See Table 1.)

Of course, there are a number of things American health care does well. For example, it scores highly on preventative health measures, patient-centered care, and innovation, especially cancer care.2

The trouble is, demand for primary care services, particularly from physicians, is projected to outstrip supply, mostly due to population aging and growth. As a result, the number of primary-care nurse practitioners and physician assistants should grow far more rapidly than the physician supply, according to the U.S. Health Resources and Services Administration. 

All of which underscores why consumers are likely to make greater use of urgent-care centers, retail clinics, specialized surgery centers, telemedicine, and remote monitoring. Some of the largest managed-care companies already have invested heavily in these areas, and advanced technologies such as artificial intelligence should spur further innovation as cost pressures increase.

 

Table 1. Despite Much Higher Spending, U.S. Health Care Lags Other Wealthy Nations
Select population health outcomes and risk factors

a) Source: OECD Health Data 2015.
b) Source: Commonwealth Fund International Health Policy Survey of Older Adults, 2014. Includes hypertension or high blood pressure, heart disease, diabetes, lung problems, mental health problems, cancer, and arthritis/joint problems. 
c) Denmark, France, Netherlands, Norway, Sweden, and Switzerland based on self-reported data; all other countries based on measured data.
d) 2012.
e) 2011.

 

Medicaid Opportunities
While Congress was debating various ways to repeal Obamacare, investors may have overlooked how much risk-based managed-care organizations (MCOs) have benefited from the historical expansion of Medicaid, the joint federal and state insurance program for the poor. (Medicaid MCOs contract with state Medicaid programs to deliver comprehensive health care to enrollees.)

According to the Kaiser Family Foundation, MCO Medicaid spending totaled $236 billion in fiscal 2016—42.6% of total Medicaid spending. And a number of states would be loath to give up the federal portion of such funding, given how much it has helped their economies.

As one Kaiser report put it, “The infusion of federal dollars into the state’s economy results in a multiplier effect, directly affecting not only the providers who received Medicaid payments for the services they provide to beneficiaries but also indirectly affecting other businesses and industries as well. The multiplier effect Medicaid spending has on state economies is expected to grow in states that adopt the Medicaid expansion.”3

Unfortunately, Medicaid expansion also has contributed to the opioid epidemic, according to two recent studies4—hence, the rise of mental health/substance abuse treatment covered by that program. That helps to explain why managed-care companies are increasingly looking at dangerous combinations of medications—such as opioids with benzodiazepines—when they believe that the member is at risk for overdose or respiratory depression, said Kimberly Lenz, the clinical pharmacy manager for MassHealth, the Massachusetts Medicaid program.5

Some policymakers would prefer federal block grants to the states, which would help managed care become the more dominant payment model for Medicaid. And that could save the state-federal program tens of billions of dollars over the next decade, according to a recent report by The Menges Group for the Association for Community Affiliated Plans. 6

The report estimates that the savings from existing MCO programs could total $94.4 billion over the next 10 years.

At any rate, Medicaid managed care’s reliance on retail clinics to lower the cost of primary care treatment, screening, and diagnostic services in a variety of settings likely will grow at a substantial pace, particularly clinics that have formed partnerships with local health systems.

Medicare Challenges
Can Medicare lower costs and improve quality for a growing senior citizen population that will live longer than its creators ever imagined?

Much will depend on how healthcare providers comply with quality measures created by the Medicare Access and CHIP Reauthorization Act [MACRA] of 2015, which began January 1, 2017. The program will alter the way most physicians are reimbursed for services provided under Medicare Part B.

Physicians who already have been squeezed economically worry that the government’s reimbursement methodology could morph into a bureaucratic sinkhole, as if performance data they have to report electronically under MACRA will be compared against a national median score, which includes data from other providers in other specialties.

That scenario could be especially problematic for cancer care. As one doctor put it recently, “One of the main concerns oncologists and the American Society of Clinical Oncology have is that our cost attribution is going to be very high because our patient population requires drugs that are often single source, which can be very expensive. Oncologists cannot influence the drug price and should not have to bear the burden of penalty because they are treating the right patient with the right drug at the right time.”7

The Bottom Line
Clearly, more can be done to improve America’s byzantine healthcare system. Insurance premiums for commercial/employee-sponsored health plans covering 120 million Americans have soared since Obamacare was enacted seven years ago. Now, the federal government and states cover 70 million patients under Medicaid, and the federal government covers 50 million by Medicare.  An estimated 40–50 million individuals remain uninsured, which ultimately puts significant financial pressure on hospital emergency rooms.

Whether Congress (and, ultimately, the president) can agree on reforms that won’t strip millions of health care coverage is another matter.

In any event, with little chance of a single-payer system in the current political environment, the movement toward value-based care to control spiraling healthcare costs is likely to gain momentum.

As the CEO of one managed-care consortium put it, "At the end of the day, people are demanding value and people want more transparency about what's going on with the cost of care and the value that they are getting with the healthcare system around the country. That's going to continue."8  

 

The S&P 500® Index is widely regarded as the standard for measuring large cap U.S. stock market performance and includes a representative sample of leading companies in leading industries. Indexes are unmanaged, do not reflect the deduction of fees or expenses, and are not available for direct investment.

1 The Commonwealth Fund is a private foundation whose mission is to promote a high-performing healthcare system that achieves better access, improved quality, and greater efficiency, particularly for society's most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults.
2 “How to Compare Health-Care Systems,” The Economist,  June  30, 2014.
3 Laura Snyder and Robin Rudowitz, “Medicaid Financing: How Does It Work and What Are the Implications?” The Kaiser Commission on Medicaid and the Uninsured, May 2015.
4 “Medicaid’s Opioid Fix,” editorial, The Wall Street Journal, August 16, 2017.
“Managed Care Pushes for Safer Opioid Oversight,” Pharmacy Practice News, August 11, 2017.
6 “Potential Savings of Medicaid Capitated Care: National and State-by-State Estimates,” The Menges Group, July 2017.
7 “Q&A with Robin Zon, MD: It's Time to Start Reporting for MACRA,” Clinical Oncology News, August 4, 2017.
8 Shelby Livingston, “Kaiser CEO Tyson Says Value-Based Care Is Here to Stay, May Invest in New Growth,” Modern Healthcare, January 18, 2017.

The information provided is not directed at any investor or category of investors and is provided solely as general information about Lord Abbett’s products and services and to otherwise provide general investment education.  None of the information provided should be regarded as a suggestion to engage in or refrain from any investment-related course of action as neither Lord Abbett nor its affiliates are undertaking to provide impartial investment advice, act as an impartial adviser, or give advice in a fiduciary capacity.   If you are an individual retirement investor, contact your financial advisor or other fiduciary about whether any given investment idea, strategy, product or service may be appropriate for your circumstances.

Statements concerning financial market trends are based on current market conditions, which will fluctuate. All investments involve risk, including possible loss of principal. No investing strategy can overcome all market volatility or guarantee future results.

The opinions provided in this posting contains the current opinions of the author are as of the date of publication, are subject to change based on subsequent developments, and may not reflect the views of the firm as a whole. This commentary is not intended to be relied upon as a forecast, research, or investment advice regarding a particular investment or the markets in general. Nor is it intended to predict or depict performance of any investment. This commentary is prepared based on information Lord Abbett deems reliable; however, Lord Abbett does not warrant the accuracy and completeness of the information. Consult a financial advisor on the strategy best for you.

Past performance is not a guarantee or a reliable indicator of future results. All investments contain risk and may lose value.

Not FDIC-Insured. May lose value. Not guaranteed by any bank. Copyright © 2017 Lord, Abbett & Co. LLC. All rights reserved. 

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