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Health Tracking

TRENDS

National Health Spending In 2004: Recent Slowdown Led By Prescription Drug Spending

Abstract

 
U.S. health care spending rose 7.9 percent to $1.9 trillion in 2004, or $6,280 per person. Health spending accounted for 16 percent of gross domestic product (GDP), nearly the same as in 2003. The pace of health spending growth has slowed, compared with the 2000–2002 period, for both public and private payers. Hospital spending accounted for 30 percent of the aggregate increase between 2002 and 2004, and prescription drugs accounted for an 11 percent share—smaller than its share of the increase in recent years and much slower in absolute terms.

Private payers played a greater role in slowing spending than public payers in 2004, although drug spending grew more slowly for all payers. Private spending growth slowed to 7.6 percent in 2004, compared with 8.6 percent in 2003. Out-of-pocket payments grew 5.5 percent in 2004; this resulted in a lower share of aggregate and private spending. Private health insurance premiums also exhibited slower growth in 2004, while private health insurance benefits stabilized as slowing drug spending offset faster hospital and physician spending growth (Exhibit 2). The net cost of private health insurance grew much more slowly in 2004, as premium and benefit growth rates converged.

The sources of growth in overall health spending have changed in recent years. The share of personal health care (PHC) spending growth associated with hospital services rose sharply after 2000, coincident with a drop in the prescription drugs’ share. The spread of managed care coupled with the effects of the Balanced Budget Act (BBA) of 1997 held down hospital spending growth in the mid- to late 1990s, reflected in slower overall growth and hospitals’ smaller contribution to net PHC spending growth in 1997–2000. Drug spending had accounted for a 23 percent share of net personal health care spending growth in 1997–2000, but by 2002–2004 it accounted for only 14 percent.³ Thus, much of the slowing in overall health spending since 2000 can be attributed to drug spending, while both hospital and physician spending have picked up larger shares (Exhibit 3).

View larger version (23K): [in this window] [in a new window]   EXHIBIT 3 Services’ Contribution To Personal Health Care Spending Growth, Selected Periods, 1997–2004

Sources Of Funds

Top Sources Of Funds Types Of Services Concluding Comments NOTES

 
Medicare. Medicare spending rose 8.9 percent to $309 billion in 2004, more than its 6.6 percent increase in 2003. In part, this acceleration reflects MMA’s legislative impacts on payment rates. Although the Part D drug benefit will have a major impact starting in 2006, the principal changes in MMA that immediately affected Medicare spending were higher payments to rural providers, $440 million in subsidies for low- income beneficiaries of the Medicare drug discount card transitional assistance program, and increases in rates for managed care plans. The latter allowed plans to expand their benefits in 2004, prompting a 1 percent gain in enrollment following several years of declines. This contributed to an 11.7 percent increase in Medicare managed care spending for PHC, up from 0.4 percent in 2003.

Increases in Medicare home health and physician spending in 2004 were driven in part by increases in use. Growth in spending for physician services ($8 billion) accounted for nearly 35 percent of the 2004 increase in Medicare PHC spending as the volume and intensity of services rose. For physician spending this was disproportionately larger than its 26 percent share in 2003. Growth in Medicare spending for home health services (19 percent) in 2004 was nearly four times its 2000 rate, reflecting both higher payments and usage under the prospective payment system (PPS) along with growing use of home health–based hospice services.

Accompanying the growth in Medicare spending has been an increased reliance on general revenue taxes to fund this spending. In 1987, designated funds from payroll taxes and premiums funded 79 percent of Medicare spending, but by 2004 that share had fallen to 63 percent. At the same time, the share funded by general tax revenues increased from 21 percent to 35 percent. This shift reflects legislation and faster growth in Part B services, which are financed by general revenues, than in Part A services, which are financed by payroll taxes. The result is a greater obligation on general tax revenues that are competing with other government spending (Exhibit 4).⁵

Historically one of the fastest-growing Medicaid services, drug spending slowed significantly in 2004. States have been intensifying efforts to contain the rise in drug spending by instituting prior authorization policies; imposing quantity limits on drugs dispensed; requiring use of generics; negotiating higher rebates, including supplemental rebates; and joining multistate purchasing pools.⁷ Even though Medicaid drug spending slowed, it continued to outpace trends for other Medicaid services, so that drug spending rose from 11.2 percent of all Medicaid spending in 2000 to 12.5 percent in 2004.

Private insurance spending. Private health insurance premiums amounted to $658.5 billion in 2004, compared with $563.5 billion in benefits paid. Premium growth decelerated for the second year in a row. The trend primarily reflects slowing per enrollee health costs, as enrollment held steady in 2004 instead of declining, for the first time since 2000. Payments for private benefits rose 8.4 percent in 2004, compared with average annual growth of 9.4 percent during 2000–2002. The net cost ratio (the difference between premiums and benefits) increased slightly to 14.4 percent of premiums in 2004 (up from 14.2 percent in 2003).

Households pay for slightly less than 30 percent of private health insurance premiums. The employee share of employer-sponsored and individually purchased coverage rose to $206.4 billion in 2004, while out-of-pocket spending for copayments and deductibles and for noncovered goods and services reached $235.7 billion. When payroll taxes and premiums associated with government-subsidized care such as Medicare and Medicaid are added in, aggregate household spending totaled $557.2 billion—more than one-third of PHC spending in 2004. Aggregate private business spending was $448.3 billion (Exhibit 5).

Private insurance premium growth for private and government employers and employees slowed from 10.8 percent in 2002 to 8.9 percent in 2004.⁸ Wage growth in these sectors accelerated but stayed below premium growth (from 0.4 percent in 2002 to 5.4 percent in 2004).⁹ The decelerating growth in premiums reflects slowing underlying health cost trends, changes in the types of insurance plans offered, and employees’ switching to lower-cost plans to guard against premium costs consuming more of their wages, among other factors. (Even so, as noted above, total out-of-pocket costs have grown more slowly than premiums.) While employers offer, and employees are choosing, health savings accounts (HSAs) and high-deductible plans in greater numbers, only 2.4 million people were covered by these plans by spring 2005—a minority of the nearly 195 million people with private health insurance.¹⁰

As insurers have focused their attention on the management of fast-growing drug spending, drugs have accounted for a smaller share of annual private health insurance growth in recent years. Drug spending, which had accounted for 24 percent of the growth in private benefits in 2000–2002, accounted for only 13 percent in 2004.¹¹ Hospital and physician spending accounted for larger shares of growth in 2004—40 and 38 percent, respectively, compared with 35 and 33 percent in 2000–2002.

Types Of Services

Top Sources Of Funds Types Of Services Concluding Comments NOTES

 
Prescription drugs. Across all payers, growth in retail drug sales continued to decelerate in 2004, increasing 8.2 percent (Exhibit 6). This was the first year of single-digit growth in the retail market in ten years; as a result, drug spending held steady at about 11 percent of aggregate health spending and 12 percent of all PHC spending. Contributing to this slowing trend were rapid growth in use of lower-price generic drugs through tiered benefit plans, increased over-the-counter (OTC) use of anti-ulcerants and antihistamines, a shift toward greater mail-order dispensing, and reduced consumption of certain drugs as a result of concerns about their safety.

Moreover, plans have encouraged consumers to purchase OTC drugs by moving the prescription form of comparable drugs to the third copayment tier, mailing coupons to members for the OTC product, or no longer covering certain prescription drugs.¹³ All of these factors have contributed to a slowdown in the rate of private health insurance spending for drugs to 6.5 percent in 2004, much slower than its 13.3 percent average growth in 2000–2002.

Another source of slowing drug spending growth is linked to changes in distribution channels. Mail order grew 13.6 percent in 2004, compared with retail growth of just 2 percent, to account for approximately 17 percent of total prescription drug sales.¹⁴ In the past three years, growth in drugs dispensed through the mail accelerated, while growth in drugs dispensed through retail outlets decelerated. In mail-order settings, pharmacists have more time to switch to lower-cost drugs and to those generating larger rebates, which sometimes leads to larger rebates in turn.¹⁵ The lower copays required in mail order also serve as an enticement to consumers.

Hospitals. Hospital spending growth has averaged 8.2 percent since 2000, following an average of 3.7 percent from 1993 to 1999. By 2004 the 8.6 percent increase in hospital spending accounted for 33 percent of the overall spending increase, greater than its 30 percent share of aggregate spending. Public spending for hospital care increased 7.9 percent, up from 6.2 percent in 2003. Medicaid hospital spending growth accelerated to 9.9 percent, in part because of an enhanced federal match rate and increased disproportionate-share hospital (DSH) payments. Medicare hospital spending growth also accelerated; in contrast, that by private payers remained relatively stable, at around 9.5 percent.

Hospital spending growth can be disaggregated into population, price, and residual components (the latter includes changes in quantity and intensity of services used).¹⁶ Of the 8.6 percent increase in hospital spending in 2004, prices were responsible for 5.0 percentage points—more than the average 4.1 percent during 2000–2002. The residual component increased 2.6 percentage points in 2004, compared with average 3.1 percent growth in 2000–2002. Population growth accounted for the remaining share.

A large share of hospital-specific price inflation can be tied to payroll and other input costs. In the hospital sector, compensation accounts for an estimated 60 percent of operating expenses.¹⁷ While growth in compensation costs for civilian hospital employees (4.0 percent) slowed slightly in 2004 compared with annual growth of 4.9 percent during 2000–2003, it remains faster than during 1995–1999.¹⁸ Rising wages associated with the nurse shortage and rising input costs including higher professional liability costs incurred by hospitals have also contributed to price growth during the past few years.

Stronger growth in hospital volume as measured by admissions contributed to faster hospital spending growth between 2000 and 2002. However, growth in admissions and out-patient visits slowed in 2003, as did spending growth.¹⁹ Hospital employment, a more current indicator of demand for hospital services, grew more slowly in 2004 at 1.2 percent, compared with average annual growth of 2.4 percent between 2001 and 2003.²⁰

Physician services. Spending for physician services increased 9.0 percent in 2004 to $399.9 billion, nearly the same as the 8.6 percent increase in 2003. The share contributed by physician services to PHC spending increases has risen since 2002, similar to hospital spending (Exhibit 3). Spending for physician services accounted for 29 percent of the total growth in PHC spending in 2004, up from an average of 25 percent in 2000–2002.

Public spending growth for physician services gained momentum in 2004: It rose 9.9 percent, compared with 8.9 percent in 2003. Medicare spending for physician services increased 11.1 percent in 2004, up from 8.8 percent in 2003. Because the physician fee schedule update in 2004 was similar to that of 2003, the acceleration is the result of increasing volume and intensity of services per beneficiary. For 2004, MMA mandated a minimum rate increase of 1.5 percent (1.6 percent was applied in 2003).

Home health services. Spending for freestanding home health agencies rose more rapidly in 2003 and 2004 than any other service category (11.1 percent and 13.3 percent, respectively). Home health spending has remained a small but growing portion of PHC spending (2 percent in 2004). In 2004, public spending rose 17.6 percent and accounted for 74 percent of home health spending. The largest payer, Medicare, accounted for 38 percent of home health spending in 2004, up from just 26 percent in 1999, a year influenced by BBA-imposed payment cuts. Double-digit growth in Medicare spending for home health services in recent years, including a 19.3 percent increase in 2004, stems in part from rapid growth in home-based hospice services, which grew an average of 27 percent per year between 2000 and 2004. In 2000 these services accounted for 29 percent of Medicare spending for home health, but by 2004 they had reached 39 percent, or $6.5 billion. Medicare spending for freestanding home health services (excluding hospice) has grown an average of 12.5 percent since the PPS began in 2000.

Nursing homes. Spending for services provided by freestanding skilled nursing facilities (SNFs) rose 4.3 percent in 2004 to $115.0 billion, more slowly than its peak growth of 6.6 percent in 2001 and nearly unchanged from its increase in 2003.

Medicaid is the largest public source of funding for SNFs and accounts for nearly 40 percent of such spending (Exhibit 5). Medicaid nursing home spending growth decelerated from 5.3 percent in 2003 to 3.0 percent in 2004. Spending was influenced by the upper payment limit (UPL) financing methods that had greatly affected Medicaid spending in 2000–2002. Since then, use of UPL funds has been restricted, slowing Medicaid spending for nursing homes from an average 5.9 percent annual growth during 2000–2002 to growth in 2004 that is close to the average 3.2 percent growth experienced in 1994–1999. As treating patients in noninstitutional settings has become a policy imperative, use of home and community-based waivers has grown at double-digit rates since 1998.²¹

In contrast to the deceleration in Medicaid spending for nursing home care, Medicare spending for this sector increased 7.4 percent in 2004, following 5.7 percent growth in 2003. Lower Medicare payment rates were in effect in 2003 following the expiration of temporary add-ons to Medicare funding, which contributed to the double-digit growth in 2000–2002.²² Medicare spending has outpaced other payers’ spending growth for nursing homes for the past several years. Thus, Medicare accounted for 14 percent of nursing home spending in 2004, up from 10 percent in 1999.

Concluding Comments

Top Sources Of Funds Types Of Services Concluding Comments NOTES

 
U.S. health care spending grew more slowly in 2004 than in the three previous years. Hospital spending was a principal source of tempered spending growth in the mid- to late 1990s, but prescription drug spending has been the strongest factor in the slowdown in recent years. The rate of drug spending had nearly converged with that of other health services by 2004.

The trajectory of health care spending continues to be driven by new medical treatments, rising prices, and growing utilization. Medical progress has improved health care for many families, but rising costs are also a growing burden for households, businesses, and governments. Medical spending continues to rise faster than wages and faster than economic growth, and workers are paying much more in health care premiums than just a few years ago. As costs rise, the efficiency of health care spending is increasingly scrutinized, which has led to greater interest in paying for improved quality or outcomes, disease management, and consumer-directed health care. Although much of health spending may be highly valued, continued spending growth will require difficult trade-offs for businesses, households, and governments as other spending also rises. These trade-offs are more stringent for those with fewer resources.²³

Editor's Notes

 
The authors are in the National Health Statistics Group, Office of the Actuary, Centers for Medicare and Medicaid Services, in Baltimore, Maryland. Cynthia Smith (Dnhs{at}cms.hhs.gov), Cathy Cowan, and Aaron Catlin are economists; Stephen Heffler is director of the group. The members of the National Health Accounts Team are named in an acknowledgment at the end of the paper.

The authors thank the National Health Accounts Team: Mary Carol Barron, Micah Hartman, Anna Long, Anne Martin, Art Sensenig, Nate Singer, Andrea Sisko, Ben Washington, and Lekha Whittle. The opinions expressed here are the authors’ and not necessarily those of the Centers for Medicare and Medicaid Services. The authors also thank Richard Foster, Mark Freeland, Katie Levit, and the anonymous peer reviewers for their helpful comments.

NOTES

Top Sources Of Funds Types Of Services Concluding Comments NOTES

 

1. National health spending estimates periodically undergo comprehensive revisions to incorporate new concepts, methods, and data sources. Updated definitions and methodology are available at http://www.cms.hhs.gov/stats/stats.htm.
2. An expansion of the definition of structures raised total spending by $11.7 billion in 2003. Medical-sector investment in equipment adds an additional $44.3 billion; together, the revised estimates of structures and equipment (including software) accounts for $56 billion of the $62 billion revision in 2003. For historical estimates through 2003, see C. Smith et al., "Health Spending Growth Slows in 2003," Health Affairs 24, no. 1 (2005): 185–194.
3. The share is calculated by dividing cumulative growth for prescription drugs by the cumulative net growth in personal health care spending.
4. Authors’ calculations. Despite recent improvements, questions remain about whether existing measures can accurately distinguish between changes in prices and changes in intensity, as when a new medical technology is introduced.
5. This analysis has been available in C. Cowan et al., "Burden of Health Care Costs: Businesses, Households, and Governments, 1987–2000," Health Care Financing Review (Spring 2002): 131–159, http://www.cms.hhs.gov/review/02spring/02springpg137.pdf (accessed 16 November 2005).See also CMS, "Methodology Burden of Health Care Costs: Businesses, Households, and Governments, 1987–2000," 17 September 2004, http://www.cms.hhs.gov/statistics/burden-of-health-care-costs (accessed 27 October 2005)
6. National Association of State Budget Officers, The Fiscal Survey of States: June 2005, June 2005, http://www.nasbo.org/Publications/fiscalsurvey/fsspring2005.pdf (accessed 27 October 2005).
7. P. Cunningham, "Medicaid Cost Containment and Access to Prescription Drugs," Health Affairs 24, no. 3 (2005): 780–789.[Abstract/Free Full Text]
8. Excludes individually purchased policies.
9. Bureau of Labor Statistics, Quarterly Census of Employment and Wages (total wages), http://www.bls.gov/cew/home.htm (accessed 21 November 2005).
10. Enrollment figures are estimated by the Office of the Actuary using data from the Census Bureau’s Current Population Survey and the Centers for Disease Control and Prevention’s National Health Interview Survey.
11. Benefits are calculated by subtracting the personal health care spending growth on the private health insurance table.
12. A.M. Zaugg, "IMS Health Report: Pressure Zone," Medical Marketing and Media (May 2005): 36–50.Regarding increasing supplies of generic drugs, see Generic Pharmaceutical Association, "Generic Pharmaceutical Facts at a Glance," http://gphaonline.org/aboutgenerics/factsabout.html (accessed 27 October 2005).
13. Coupon programs were popular with Prilosec OTC, which entered the top-ten list of OTC drugs by sales in 2004. Drug Topics, "Top 200 OTC/HBC Brands in 2004," April 2005, http://www.drugtopics.com/drugtopics/article/articleDetail.jsp?id=156502 (accessed 27 October 2005).
14. With our comprehensive revision, Department of Veterans Affairs (VA) and Department of Defense (DoD) mail-order spending was transferred from hospital services (where such drugs were historically dispensed) to prescription drugs. Explicitly estimating mail-order drug spending for the first time also lowered the total out-of-pocket share of drug spending.
15. M. Wosinska and R.S. Huckman, "Generic Dispensing and Substitution in Mail and Retail Pharmacies," Health Affairs 23 (2004): w409–w416 (published online 28 July 2004; 10.1377/hlthaff.w4.409).[Abstract/Free Full Text]
16. The residual includes changes in service mix, in technology used to deliver services, and in the age/sex mix of the population and any miscalculations in measuring overall spending and prices.
17. CMS, "Quarterly Index Levels in the CMS Prospective Payment System Hospital Index using Global Insight Inc. Forecast Assumptions, by Expense Category: 1990–2015," http://www.cms.hhs.gov/statistics/market-basket/mktbskt-pps-hospital-2002.pdf (accessed 16 November 2005).
18. Bureau of Labor Statistics, Employment Cost Index (civilian hospital workers), http://bls.gov/ncs/ect/home.htm (accessed 12 September 2005).
19. American Hospital Association, Hospital Statistics, 2005 Edition (Chicago: AHA, 2005).
20. BLS, Current Employment Statistics Survey.
21. This spending is categorized within "other PHC."
22. CMS, "CMS Health Care Industry Market Update, Nursing Facilities" (Baltimore: CMS, May 2003), 9.
23. Henry J. Kaiser Family Foundation/Health Research and Educational Trust, Challenges and Trade-offs in Low-Income Family Budgets: Implications for Health Coverage (Menlo Park, Calif.: Kaiser/HRET, 2004).

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