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Health Tracking

TRENDS

National Health Spending In 2005: The Slowdown Continues

Abstract

 
In 2005, U.S. health care spending increased 6.9 percent to almost $2.0 trillion, or $6,697 per person. The health care portion of gross domestic product (GDP) was 16.0 percent, slightly higher than the 15.9 percent share in 2004. This third consecutive year of slower health spending growth was largely driven by prescription drug expenditures. Spending for hospital and physician and clinical services grew at similar rates as they did in 2004.

View larger version (16K): [in this window] [in a new window]   EXHIBIT 3 Growth In National Health Expenditures (NHE) And Gross Domestic Product (GDP), 1981–2005

The slight slowdown in overall health spending growth in 2005 was largely driven by weaker growth in prescription drug spending: 5.8 percent compared with 8.6 percent in 2004 (Exhibit 2). Major factors contributing to this trend include increased use of generic drugs, changes in the therapy mix, and a dramatic slowdown in Medicaid prescription drug spending.⁶ In contrast, hospital spending continued to grow relatively quickly at 7.9 percent in both 2004 and 2005 (Exhibit 2) and accounted for the largest share of the overall spending increase in both years. The recent hospital spending trend was attributable to faster increases in both inpatient and outpatient use, which more than offset slower growth in prices.⁷

Public-sector spending on health care ($902.7 billion in 2005) increased 7.7 percent in 2005, compared with 7.8 percent in 2004 (Exhibit 4). Public spending growth averaged 9.3 percent during 2000–2003, compared with 8.1 percent for private spending. The impacts of the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act (BBRA) of 1999; the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act (BIPA) of 2000; and the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 kept the rate of growth in public spending on health care relatively high during this period. The trend continued in 2005 as this growth outpaced growth in private spending by 1.4 percentage points (Exhibit 4).

Health spending can also be analyzed by sponsor—businesses, households, and governments—to better understand who pays the health care bill and what burden these costs are placing on each sponsor.⁹ Analyzing spending by sponsor is particularly relevant as a baseline before the effects of Medicare Part D (which began full operation in 2006) are reflected in these estimates. In 2005, governments financed 40 percent ($736.3 billion) of all health services and supplies (Exhibit 5).¹⁰ This spending increased 7.8 percent from 2004 to 2005, outpacing the 6.2 percent growth in household spending and the 7.0 percent growth in business spending (data not shown).¹¹

The 2005 hurricane season was regionally devastating and disrupted economic activity across many sectors, including health; however, it is difficult to isolate the full impact of Hurricanes Katrina and Rita on U.S. health spending. To the extent that services were not obtained in the affected region that normally would have been, these events would have contributed to the overall health spending slowdown in 2005. However, potentially offsetting increases in public health activity as a result of local, state, and federal health responses and use of services in other areas would have had the opposite effect. The Deficit Reduction Act of 2005 authorized disaster relief payments of $2.0 billion for health care related to Hurricane Katrina. These payments were disbursed through Medicaid, and even though the bill was not passed until 2006, a portion of the funding paid for expenses incurred in 2005.

Sources Of Funds

Top Sources Of Funds Types Of Services Concluding Comments NOTES

 
Medicare. Medicare spending reached $342.0 billion in 2005, growing 9.3 percent after increasing 10.3 percent in 2004 (Exhibit 4). Despite this modest deceleration, Medicare spending growth was faster than the average annual growth rate of 6.4 percent during 1994–2004 (data not shown). The deceleration in 2005 was driven primarily by slower growth in spending for hospital care, physician and clinical services, and nursing home and home health care.

Medicare hospital spending grew at a rate of 8.1 percent in 2005, slightly slower than the 8.4 percent growth in 2004, as the use of hospital services remained robust (data not shown). Likewise, strong growth in Medicare spending for physician and clinical services, albeit slower than in 2004, was the result of rapid increases in the volume and intensity of services.¹³ The deceleration in Medicare nursing home spending growth reflects a slowdown in discharges, covered days, and average reimbursement per day following several years of more significant increases in use.¹⁴ Medicare spending for home health care marked its fifth consecutive year of double-digit growth following implementation of the prospective payment system (PPS) in 2000, which replaced an interim payment system that had greatly reduced spending. However, Medicare home health care spending growth decelerated in 2005—to 10.7 percent from 17.9 percent the previous year—in part because of a slowdown in home health–based hospice spending (data not shown).

Although growth in Medicare spending for prescription drugs in 2005 (19.7 percent) outpaced growth in overall Medicare spending, it represented only a 1.2 percent share of total Medicare spending and does not include the full Medicare Part D prescription drug benefit, which did not begin until 1 January 2006. The trend in Medicare drug spending through 2005 was driven primarily by managed care plan spending and the temporary Medicare transitional assistance benefit.

Unlike traditional Medicare fee-for-service (FFS) spending growth, which slowed to 7.8 percent in 2005 after growing 10.1 percent in 2004, Medicare Advantage (MA) spending increased rapidly in 2005 (19.8 percent), following growth of 11.7 percent in 2004 and –0.2 percent in 2003 (data not shown). After declining for four consecutive years, enrollment in MA (formerly Medicare+Choice) turned around in 2004 by increasing 1.0 percent, followed by more rapid growth in 2005 of 7.0 percent. These recent increases were largely due to MMA provisions that implemented MA, raised managed care payments, provided expanded coverage (in turn attracting more beneficiaries), and established regional preferred provider organizations (PPOs).

Medicare is financed by a combination of payroll taxes, premiums, Medicaid buy-ins for dual eligibles, income taxation of Social Security benefits, general revenues, and interest income.¹⁵ The portion of Medicare that is financed by the federal government is 30 percent of the federal government’s spending on health (calculated from data in Exhibit 5). As Part D provisions begin to take full effect, the part financed by nondedicated funds will increase.

Medicaid. Medicaid spending increased 7.2 percent in 2005—the fourth consecutive year of decelerating growth, as states implemented cost containment initiatives between 2002 and 2005.¹⁶ Some of these initiatives include provider payment cuts or freezes, pharmacy cost and usage controls, increased fraud-and-abuse control activities, and greater use of disease or case management programs.¹⁷ Also, as the economy recovered from the 2001 recession, Medicaid enrollment growth slowed. Growth in Medicaid spending for physician and clinical services, prescription drugs, home health care, and other professional services was slower in 2005 than in 2004 (data not shown).

Public funds accounted for 27.2 percent of all spending on prescription drugs in 2005; more than two-thirds of this spending came from Medicaid. Medicaid drug spending growth slowed sharply in 2005, increasing just 2.8 percent, much lower than its 11.6 percent growth in 2004 and the average annual growth rate of 15.4 percent between 1994 and 2004 (data not shown). This dramatic slowdown occurred as states continued to undertake aggressive cost control initiatives, successfully secured higher rebates resulting from increased use of multistate purchasing pools, and changed their formularies to shift beneficiaries to drugs that offered higher rebates.¹⁸ Forty-two states showed slower growth in Medicaid prescription drug spending in 2005 than in 2004.

Medicaid spending for physician and clinical services also slowed significantly, decelerating 2.3 percentage points in 2005 to 7.3 percent, in part as a result of reduced or frozen reimbursement rates in some states.¹⁹ Hospital care, the largest share of Medicaid spending, accelerated in 2005, growing 9.2 percent following growth of 7.2 percent in 2004 (data not shown). Much of this acceleration was driven by recent attempts to ensure that all Medicaid financing was used to provide health care services and not for states’ other needs.

Although Medicaid spending growth slowed recently, it continued to put pressure on state budgets, as just over one-third of states experienced Medicaid budget shortfalls in fiscal year 2005.²⁰ Changes in the Federal Medical Assistance Percentage (federal match rate) enacted in the Jobs and Growth Tax Relief Reconciliation Act of 2003 relieved some of the pressures facing states as federal payments were increased in FY 2003 and FY 2004. Because this assistance expired, federal Medicaid spending increased just 3.8 percent in 2005, while state and local Medicaid spending increased 12.0 percent. When private health insurance premiums and Medicare payroll taxes for state and local government employees are combined with state Medicaid payments and other state- and locally sponsored health programs, they account for about 24 percent of state and local governments’ revenue over the past three years, up from around 19 percent in the mid-to-late 1990s.²¹

Private spending. Private health insurance premium growth also slowed in 2005, increasing 6.6 percent to $694.4 billion, compared with 7.9 percent in 2004 (Exhibit 4). This was the third straight year that this premium growth decelerated and the slowest rate of growth since 1997. Factors include slower growth in underlying benefit payments, a relative stabilization in the net cost of insurance (difference between premiums and benefits), and changes in benefit packages. Private health insurance benefit payments increased 6.9 percent in 2005, down from 7.4 percent in 2004 (data not shown). The 2005 slowdown was broadly based across most services. Most notably, private health insurance payments for prescription drugs grew 5.8 percent in 2005, well below the annual average of 16.7 percent during 1994–2004. In addition, the underwriting cycle appeared to hit its peak in 2004 as the net cost ratio (net cost divided by premiums) declined from 14.3 percent in 2004 to 14.1 percent in 2005 (data not shown).

Most private health insurance premiums originate from employer-sponsored health insurance (94 percent in 2005), including purchases by governments on behalf of their employees. The employer share of private health insurance was 74.4 percent in 2005, with employees paying the remaining 25.6 percent. The employer share grew slightly in 2005 but remains below the share that employers were funding in 1999 at the peak of health maintenance organization (HMO) enrollment (data not shown).

Rather than increasing employees’ share of insurance premiums, employers continue to seek cost savings by increasing the use of coinsurance, adding deductibles, and eliminating coverage for specific treatments or prescription drugs.²² These actions might slow premium growth for employees, but they ultimately increase the burden on individuals as their direct out-of-pocket costs increase.

Out-of-pocket spending for health care reached $249.4 billion in 2005 (Exhibit 4).²³ Payments for prescription drugs ($50.9 billion in 2005; Exhibit 6) represent the largest share of out-of-pocket spending at 20.4 percent, followed by physician and clinical services at 17.0 percent and dental services at 15.4 percent. Growth in household spending, which is out-of-pocket spending combined with households’ premium payments for health insurance (public and private) and Medicare payroll taxes, slowed to 6.2 percent in 2005 from 6.5 percent in 2004. However, the share of household personal income devoted to health care grew from 5.4 percent in 2001 to 6.0 percent in 2005 (data not shown).²⁴

Types Of Services

Top Sources Of Funds Types Of Services Concluding Comments NOTES

 
Prescription drugs. In 2005, U.S. prescription drug spending increased just 5.8 percent to $200.7 billion, or $676 per person (Exhibits 1 and 2). The drug spending slowdown in 2005 continued a dramatic deceleration from a peak of 18.2 percent in 1999. The 2005 trend is due in part to a sharp deceleration in Medicaid drug spending (discussed in the Medicaid section) and a shift in use toward generic drugs. The broader slowdown between 2000 and 2005 was driven by the proliferation of tiered-copayment benefit plans, which slowed growth in brand-name drug use, and a decrease in the number of new drug introductions.

Private sources paid for nearly 73 percent of prescription drug spending in 2005. Private funding growth slowed slightly in 2005, increasing 6.0 percent as compared with 7.2 percent in 2004 (data not shown). This pattern was driven in part by reductions in use in several therapeutic classes. Non-narcotic pain relievers experienced the sharpest decline in use because of safety concerns; in addition, Vioxx and Bextra, two COX-2 inhibitors, were removed from the market.²⁶

Growth in drug prices, as measured by the prescription drugs and medical supplies Consumer Price Index (CPI), increased 3.5 percent in 2005, about the same rate as in 2004.²⁷ The average manufacturer price increase for brand-name prescription drugs in 2005 was 6.0 percent.²⁸ However, this strong price growth was offset by a continued shift to generic drugs that cost, on average, 30–80 percent less than brand-name drugs.²⁹ Continued strong growth in mail-order distribution also played a role in the greater use of generics.

Hospital services. Hospital spending represents the largest share of overall health spending, accounting for 31 percent of all dollars spent on health care in 2005 (can be calculated from data in Exhibit 1). Hospital spending growth remained relatively stable between 2001 and 2005, averaging 7.9 percent a year during this period and growing 7.9 percent to $611.6 billion in 2005 (Exhibits 1 and 2). This average is much higher than the average annual growth of 4.0 percent experienced between 1993 and 2000 but below the longer-term average annual growth rate of 11.2 percent between 1970 and 1993.

Since 2001, hospital spending trends have been driven in large part by strong growth in the underlying cost of providing care. Primary factors in this trend include increased compensation and malpractice costs combined with hospitals’ improved ability to pass these costs on to private payers as a result of their stronger negotiating position.³⁰ In the hospital sector, payroll costs account for a large portion of input costs (60 percent in 2002) and often drive trends in hospital spending.³¹ Between 2001 and 2005, growth in the labor component of hospital spending (as represented by the product of employment, average weekly hours, and average hourly earnings) averaged 8.2 percent annually, about the same annual average rate as overall hospital spending.³² This continued increase in labor costs was driven in part by a sustained shortage of hospital workers. A recent survey by the American Hospital Association indicated that nationally, hospitals had a registered nurse (RN) vacancy rate of 8.5 percent, or approximately 118,000 vacancies in 2005, up from a vacancy rate of 8.1 percent in 2004.³³

Private health insurance, which in 2005 accounted for 35.5 percent of hospital spending, increased 7.6 percent that year and remained relatively strong between 1999 and 2005, increasing on average 8.7 percent per year, compared with only 3.2 percent between 1993 and 1999 (data not shown). Hospital spending by public payers also experienced strong growth since 2001, increasing 8.1 percent in 2005, just above the average annual growth of 7.9 percent between 2000 and 2004 (data not shown). This rate is well above the average annual growth recorded between 1993 and 1999 of 3.8 percent.

Physicians and clinical services. Just over one-fifth of all U.S. health spending in 2005 was used to purchase physician and clinical services ($421.2 billion), making it the second-largest health spending category (Exhibit 1). Growth in spending for physician and clinical services averaged 7.9 percent per year since 2000 (data not shown).

In 2005, spending on physician and clinical services slowed slightly to 7.0 percent (Exhibit 2). Both public and private spending for physician and clinical services contributed to this trend. In 2005, the slowdown in public spending was driven primarily by a reduction in Medicaid physician and clinic growth of 2.3 percentage points (7.3 percent in 2005 compared to 9.6 percent in 2004) combined with a more modest reduction in Medicare physician and clinic growth of 0.9 percentage point (9.5 percent in 2005 compared to 10.4 percent in 2004; data not shown). The more pronounced slowdown in Medicaid physician spending was attributable to reduced payments to providers and other cost containment initiatives. Out-of-pocket spending for physician and clinical services grew at about the same rate as it had in 2004, increasing 6.7 percent in 2005. However, physician prices as measured by the Producer Price Index (PPI) and CPI increased at a less rapid pace in 2005 than in 2004. The PPI increased 1.8 percent following growth of 2.0 percent in 2004, and the CPI increased 3.3 percent following growth of 4.0 percent in 2004.³⁴ Physician input price growth, as measured by the Medicare Economic Index, also slowed in 2005, driven primarily by slower growth in nonphysician compensation and professional liability costs.³⁵

Nursing home and home health care services. Spending growth for freestanding nursing facilities picked up in 2005, increasing 6.0 percent to $121.9 billion, following growth of 4.1 percent in 2004 (Exhibits 1 and 2). Almost two-thirds of nursing home care was paid for by public payers in 2005 (Medicaid: 44 percent; Medicare: 16 percent). Medicaid spending growth increased slightly in 2005 to 3.9 percent, while Medicare nursing home expenditures grew 12.0 percent following growth of 16.2 percent in 2004 (data not shown). Growth in the use of Medicare skilled nursing facility (SNF) services and in the payment per day slowed in 2005, contributing to the overall deceleration in public spending.³⁶

Freestanding home health care spending continued to grow rapidly in 2005, increasing 11.1 percent—the third straight year of double-digit growth (Exhibits 1 and 2). Although home health spending is a relatively small share of total health spending (2.4 percent), it was the fastest-growing health spending category between 2003 and 2005. An uptick in private payments in 2005, combined with sustained strong growth in public payments, contributed to the continued robust growth. However, the growth of public home health payments was slower in 2005, increasing 12.4 percent compared with 16.2 percent in 2004. Medicare, the largest payer of home health care services, slowed for the second year in a row, increasing 10.7 percent in 2005. Spending growth for Medicaid home health services also slowed in 2005, the fourth consecutive year of decelerating growth (data not shown).

Concluding Comments

Top Sources Of Funds Types Of Services Concluding Comments NOTES

 
The rate of U.S. health care spending growth in 2005 was the slowest in the health sector since 1999 and barely outpaced overall economic growth. This might be an encouraging sign for the individuals, businesses, and governments that finance health care; however, it is unclear whether this phenomenon is temporary or indicative of a longer-term trend. In the near future, the health economy will continue to be influenced by the emergence of new technology, the aging of the population, changing utilization patterns, and a variety of other factors that will both increase and decrease health spending. It will be necessary to balance these factors with the continuing cost concerns of those who finance health care, as well as with the recent emphasis on tying payments to quality of care. The current moderation in the rise of the health share of GDP indicates that at least for now, health spending is growing at a rate nearly comparable to that of the rest of the economy. The question is whether this convergence is temporary, such as has occurred in previous post-recessionary periods, or indicative of a sustainable trend, like that experienced in the mid-1990s.

Editor's Notes

 
The authors are all with the Centers for Medicare and Medicaid Services, Office of the Actuary, in Baltimore, Maryland. Aaron Catlin (Aaron.Catlin{at}cms.hhs.gov) and Cathy Cowan are economists. Stephen Heffler is director of the National Health Statistics Group. Benjamin Washington is a statistician. Members of the National Health Expenditure Accounts Team are acknowledged at the end of the paper.

The authors thank the other members of the National Health Expenditure Accounts Team: Mary Carol Barron, Micah Hartman, Sean Keehan, Anne Martin, Pat McDonnell, Art Sensenig, Nate Singer, Andrea Sisko, 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, John Poisal, Cathy Curtis, and anonymous peer reviewers for their helpful comments.

NOTES

Top Sources Of Funds Types Of Services Concluding Comments NOTES

 

1. HealthLeaders/InterStudy, "The Competitive Edge Part II Managed Care Industry Report" (1 January 2005): 31.
2. Bureau of Economic Analysis, National Income and Product Accounts, "Table 1.1.5. Gross Domestic Product," 28 September 2006, http://www.bea.gov/bea/dn/nipaweb/TableView.asp?SelectedTable=5&FirstYear=2004&LastYear=2006&Freq=Qtr (accessed 25 October 2006).
3. M. Hartman et al., "Monitoring Health Spending Increases: Incremental Budget Analyses Reveal Challenging Tradeoffs," Health Care Financing Review 28, no. 1 (2006): 3.
4. Bureau of Labor Statistics, Current Employment Statistics, http://www.bls.gov/ces/home.htm#data (accessed 29 September 2006); and M. Mandell, "What’s Really Propping Up the Economy," BusinessWeek (25 September 2006).
5. S. Heffler et al., "Health Spending Projections through 2013," Health Affairs 23 (2004): w79–w93 (published online 11 February 2004; 10.1377/hlthaff.w4.79).
6. Express Scripts, Drug Trend Report 2005, June 2006, http://www.expressscripts.com/ourcompany/news/industryreports (accessed 6 October 2006).
7. American Hospital Association, Hospital Statistics, 2006 Edition (Chicago: Health Forum, 2006); and data from the AHA’s National Hospital Indicator Survey, under contract with the Centers for Medicare and Medicaid Services (CMS).
8. Benefit buydowns included changes in benefit structures and increased consumer cost sharing; see P.B. Ginsburg et al., "Tracking Health Care Costs: Continued Stability but at High Rates in 2005," Health Affairs 25 (2006): w486–w495 (published online 3 October 2006; 10.1377/hlthaff .25.w486).[Abstract/Free Full Text]
9. A more detailed explanation of sponsor analysis is available at Centers for Medicare and Medic-aid Services, "Health Expenditures by Sponsors: Business, Household, and Government," 1 March 2006, http://www.cms.hhs.gov/NationalHealthExpendData/06_NationalHealthAccountsBusinessHouseholdGovernment.asp#TopOfPage (accessed 25 October 2006).
10. In practice, governments can finance health (and other) spending only by collecting taxes or borrowing from the public. Health services and supplies represent spending for health care provided during the year including personal health care, government public health, and administration.
11. This and other information not appearing in this paper can be found at CMS, "National Health Expenditure Data: Overview," 7 June 2006, http://www.cms.hhs.gov/NationalHealthExpendData (accessed 29 November 2006).
12. Personal health care is a subset of national health spending that measures goods and services used to treat or prevent a specific disease or condition in an individual. The non–personal health care portion of national health spending is made up of investment, government public health, and program administration.
13. Herb Kuhn, Center for Medicare Management, CMS, letter to Glenn Hackbarth, Medicare Payment Advisory Commission, 7 April 2006, http://www.cms.hhs.gov/SustainableGRatesConFact/Downloads/MedPAC_Letter_Estimated_2007.pdf (accessed 6 October 2006).
14. CMS, data from the Health Care Information System (HCIS), http://www.cms.hhs.gov/MedicareFeeforSvcPartsAB/Downloads/NationalSum0305.pdf (accessed 8 August 2006).
15. Potentially up to 85 percent of an individual’s or couple’s Social Security income is subject to taxation. The taxation revenue between 50 and 85 percent is allocated to the federal Hospital Insurance Trust Fund.
16. Henry J. Kaiser Family Foundation, Medicaid Budgets, Spending, and Policy Initiatives in State Fiscal Years 2005 and 2006, October 2005, http://www.kff.org/medicaid/7392.cfm (accessed 25 October 2006).
17. Ibid.
18. Ibid.
19. Ibid.
20. National Governors Association and National Association of State Budget Officers, The Fiscal Survey of States, vii, June 2006, http://www.nasbo.org/Publications/PDFs/FiscalSurveyJune06.pdf (accessed 25 October 2006).
21. BEA, National Income and Product Accounts, "Table 3.3. State and Local Government Current Receipts and Expenditures," 28 September 2006, http://www.bea.gov/bea/dn/nipaweb/TableView.asp?SelectedTable=86&FirstYear=2004&LastYear=2006&Freq=Qtr (accessed 25 October 2006).
22. Mercer Human Resource Consulting, National Survey of Employer-Sponsored Health Plans: 2005 Survey Report (Washington: Mercer, 2005).
23. This measure of out-of-pocket spending represents direct spending by consumers for health care goods and services, including payments for services not covered by insurance, coinsurance, and deductibles but excluding premiums paid by enrollees in private health insurance and Medicare supplemental insurance.
24. Personal income was adjusted to include the addition of contributions to social insurance for Medicare, since these are included in households’ spending, and to exclude health benefit payments.
25. P. Fronstin and S. Collins, "Early Experience with High Deductible and Consumer-Driven Health Plans: Findings from the EBRI/Commonwealth Fund Consumerism in Health Care Survey," Issue Brief no. 288 (Washington: Employee Benefit Research Institute, December 2005); and John Dicken, Government Accountability Office, testimony before the Senate Finance Subcommittee on Health Care, hearing on "Health Savings Accounts: Early Enrollee Experiences with Accounts and Eligible Health Plans," 26 September 2006, http://www.gao.gov/new.items/d061133t.pdf (accessed 9 November 2006).
26. Medco Health Solutions, Drug Trend Report 2006 (Franklin Lakes, N.J.: Medco, 2005).
27. BLS, Consumer Price Index, http://www.bls.gov/cpi/home.htm#data (accessed 6 October 2006).
28. D. Gross et al., "Trends in Manufacturer Prices of Brand Name Prescription Drugs Used by Older Americans—2005 Year-End Update," April 2006, http://assets.aarp.org/rgcenter/health/dd134_drugprices.pdf (accessed 25 October 2006).
29. Generic Pharmaceutical Association, "Statistics," http://www.gphaonline.org/Content/NavigationMenu/AboutGenerics/Statistics/Statistics.htm (accessed 25 September 2006).
30. Medicare Payment Advisory Commission, Report to the Congress: Medicare Payment Policy (Washington: MedPAC, March 2006), 44.
31. CMS, "Quarterly Index Levels in the CMS Prospective Payment System Hospital Index using Global Insight Inc. Forecast Assumptions, by Expense Category: 1900–2015," http://www.cms.hhs.gov/MedicareProgramRatesStats/downloads/mktbskt-pps-hospital-2002.pdf (accessed 11 August 2006).
32. BLS, Current Employment Statistics program, http://www.bls.gov/ces/home.htm#overview (accessed 25 September 2006).
33. AHA, "The State of America’s Hospitals—Taking the Pulse, a Chart Pack," 2005, http://www.ahapolicyforum.org/ahapolicyforum/resources/content/StateHospitalsChartPack2006.PPT (accessed 14 August 2006); and AHA, "The State of America’s Hospitals—Taking the Pulse, a Chart Pack" (Chicago: AHA, 2004).
34. BLS, Producer Price Index, http://www.bls.gov/ppi/home.htm#data (accessed 25 September 2006); and BLS, Consumer Price Index.
35. CMS, "Four Quarter Moving Average Percent Change in the CMS Medicare Economic Index using Global Insight Inc. Forecast Assumptions, by Expense Category: 1990–2016," http://www.cms.hhs.gov/MedicareProgramRatesStats/downloads/mktbskt-economic-index.pdf (accessed 29 November 2006).
36. Data from the HCIS; see Note 14.

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