Our Publications

The Distribution of Medicare Accelerated and Advance Payment Program Loans Among California Health Systems

By Daniel R. Arnold, Surina Khurana, and Brent D. Fulton | Published August 3, 2020 | Link to Report

This report provides a summary of the loans that the largest health systems in California received through Medicare Accelerated and Advance Payment Program. The financial health of these health systems should continue to be monitored during the duration of this pandemic.

The Distribution of Provider Relief Payments Among California Health Systems

By Richard M. Scheffler, Daniel R. Arnold, Surina Khurana, and Brent D. Fulton | Published July 9, 2020 | Link to Report

California Governor Gavin Newsom issued an executive order on March 19, 2020 that effectively prevented hospitals from performing elective procedures to free capacity for a possible surge of COVID-19 patients (order lifted on April 22, 2020). This report examines the financial status of the largest health systems in California, with a particular focus on their liquid assets for financial solvency. It then reports the amount they have received in CARES Act provider relief payments. Overall, 24% of the estimated reduction in net patient revenue was offset by direct CARES Act grants, but the offset varied widely by hospital. The report then presents the correlation between provider relief payments and a hospital’s private insurance share of patient revenue, operating margin, and the hospital market concentration of the county in which it resides. We find hospitals with a larger share of net patient revenue from private insurers and hospitals residing in highly concentrated hospital markets received larger payments per adjusted patient day. The results suggest that careful monitoring of future relief payments is needed.

What are the Health Care Costs of COVID-19 in California?: State and County Estimates

By Richard M. Scheffler, Daniel R. Arnold, Brent D. Fulton, Alexandra Peltz, Taylor L. Wang, and John Swartzberg | Published June 25, 2020 | Link to Report

Based on recent antibody studies that report about a 5% prevalence in California, we estimate the health care costs of treating coronavirus disease 2019 (COVID-19) to be $2.4 billion in California — six times the annual cost of influenza in the state. Costs vary dramatically across counties due to significant differences in population size, health care prices, and payer mix. Estimated costs are $617 million in Los Angeles, $64 million in San Francisco, and $204 million in San Diego. The cost per infected person is $1,326, $1,774, $289, and $629 for commercial, Medicare, Medi-Cal/CHIP, and uninsured enrollees, respectively. We also calculate the costs under scenarios of 15%, 30% and 60% prevalence — the latter being a lower threshold of the prevalence generally assumed to be needed before herd immunity is achieved. Our costing model will be updated as new information about the prevalence and health care utilization and costs are reported for California.

Sustaining Universal Coverage Through California’s Integrated Care Delivery System

By Stephen M. Shortell, Richard M. Scheffler, Shivi Anand, and Daniel Arnold | Published May 8, 2019 | Link to Report

This Brief highlights 1) California’s comparative advantage in having a large number of integrated care model physician organizations; 2) provides evidence on their ability to provide lower cost, higher quality value-based care; and 3) proposes a plan for expanding such models across the state to meet the ongoing needs and preferences of all Californians that will have universal health insurance coverage.

The Seven Percent Solution: Costing and Financing Universal Health Coverage in California

By Richard M. Scheffler and Stephen M. Shortell | Published February 24, 2019 | Link to Full Report

As of 2017, California’s uninsured rate stands at just over 7 percent. Moving towards universal health coverage in California for the 3.72 million projected to be uninsured in 2020, of which about 1.5 million are undocumented, is a significant challenge but has considerable benefits. A healthier workforce will be more productive and absenteeism will decline.4 Moreover, taxes collected from these healthier workers will increase. All Californians will have their risk of disease lowered. Universal coverage will allow all Californians to have improved access to care so they can prevent and treat illnesses that can be passed on to others. Children will have a better start to life and there will be less absenteeism in schools. In addition, the expensive treatment in emergency rooms would surely decline. Beyond these benefits for all Californians, it is the right thing to do. Most Californians support universal coverage, but have reservations about the cost of doing so.

California Dreamin’: Integrating Health Care, Containing Costs, and Financing Universal Coverage

By Richard M. Scheffler and Stephen M. Shortell | Published February 8, 2019 | Link to White Paper | Link to Attendee List

Building on California’s distinct integrated health system we show how expanding it and using risk adjusted capitation payments are able to reduce spending and improve quality. Moreover, this approach puts California on a path that will achieve universal coverage. Finally, we provide a new plan to finance universal coverage in California.

Consolidation in California’s Health Care Market 2010-2016: Impact on Prices and ACA Premiums

A Report by the Petris Center | Published March 26, 2018 | Link to Full Report

This report details the rapid consolidation of the hospital, physician, and insurance markets in California from 2010 to 2016. It finds that the vast majority of counties in California warrant concern and scrutiny according to the DOJ/FTC Guidelines. It also finds that consumers are paying higher health care prices and ACA premiums as a result of market consolidation.  The significant variation in prices and ACA premiums across the state  – particularly the large discrepancy between Northern and Southern California – suggests regulatory and legislative solutions need to be implemented to address health care market concentration in California.

Proposal to Use Three Initiatives to Lower Healthcare Spending and Finance Universal Health Insurance Coverage in California

By Richard M. Scheffler, Brent D. Fulton, Donald D. Hoang, and Stephen M. Shortell | Published March 28, 2018 | Link to Full Report

Health expenditures in California continue to grow with respect to the state’s gross domestic product, resulting in healthcare becoming more unaffordable to the state, employers, and individuals. In this report, we project health spending in the California from 2015 to 2022. We then estimate potential reductions in spending from the Berkeley Forum for Improving California’s Healthcare Delivery System’s initiatives to increase the use of global budgets/integrated care systems, patient-centered medical homes, and palliative care. By 2022, these initiatives generate an estimated $15.4 billion in health spending reductions, an amount sufficient to provide universal health insurance coverage in the state at a cost of $7.2 billion. The State of California, the federal government, and the private sector should consider accelerating their programs related to these initiatives to help achieve these health expenditure reductions. A companion article “Financing Universal Coverage in California: A Berkeley Forum Roadmap” to this report was published on the Health Affairs Blog on March 29, 2018.

Health Care Market Concentration Trends In The United States: Evidence And Policy Responses

By Brent D. Fulton | Published September 2017 in Health Affairs |Link to Full Article

This paper analyzes market concentration trends in the United States from 2010 to 2016 for hospitals, physician organizations, and health insurers, finding that hospital and physician organization markets became increasingly concentrated over this time period. Concentration among primary care physicians increased the most, partially because hospitals and health care systems acquired primary care physician organizations. The paper finds that a large number of Metropolitan Statistical Areas (MSAs) are highly concentrated – in 2016, reaching 91% for hospitals, 65% for specialist physicians, 39% for primary care physicians, and 57% for insurers. The paper concludes that public policies that enhance competition are needed, such as stricter enforcement of antitrust laws, reducing barriers to entry, and restricting anticompetitive behaviors.

Insurer Market Power Lowers Prices In Numerous Concentrated Provider Markets

By Richard M. Scheffler and Daniel R. Arnold | Published September 2017 in Health Affairs |Link to Full Article

Consolidation of health systems has rapidly increased in the last two decades: from 1998 to 2015, there were 1412 hospital mergers in the United States; 40% of those came after 2009. The paper uses prices of hospital admissions and visits to five types of physicians to analyze how this growing provider and insurer market concentration—as measured by the Herfindahl-Hirschman Index (HHI)—interact and are correlated with prices. The paper finds that insurers have the bargaining power to reduce provider prices in highly concentrated provider markets for cardiologist, radiologist, and hematologist/oncologist visit prices. This leads to a policy dilemma: there are no insurer market mechanisms that will pass a portion of these price reductions on to consumers in the form of lower premiums. The study concludes by discussing how large purchasers of health insurance, such as state and federal governments, as well as the use of regulatory approaches, could provide a solution.