Substack

Saturday, December 7, 2024

Weekend reading links

The world’s richest man... is in the middle of lobbying Beijing over important decisions for his $1tn electric vehicle business, Tesla... Shanghai accounts for more than 40% of Tesla’s car manufacturing capacity... Tesla has received billions of dollars in cheap loans, subsidies and tax breaks from the Chinese government. The carmaker is highly dependent on its Shanghai factory, the biggest in its global network, for not only selling to the country of 1.4bn people but also exporting its China-made cars to other parts of the world. Musk’s Chinese suppliers, especially in batteries, are also crucial to the company’s global manufacturing operations, including in the US...
For Musk, the Shanghai factory is Tesla’s biggest, producing millions of cars and delivering revenues of $54bn over the past three years — accounting for 23 per cent of its total sales. Tesla has also said its new adjacent factory, building battery packs for electricity storage, is on track to start production in the first quarter of 2025... “Musk is not only vulnerable to Beijing’s pressure given his extensive business interests in China, he also seems to genuinely enjoy close relationships with China’s authoritarian leaders,” says Yaqiu Wang, research director for China at Freedom House, a US-based advocacy group. “This dynamic creates ample opportunities for the CCP to influence Trump’s China policy.” 

... more importantly to Xi Jinping’s economic planners, the rapid delivery of Tesla’s high-tech factory helped turbocharge the nation’s nascent electric vehicle industry, both in terms of the local supply chain and popularising the EV among retail consumers. Chinese policymakers had “dreamed for 20 years” of a domestic auto industry but the “inflection point was Tesla’s launch in Shanghai”, says Bill Russo, the former head of Chrysler in China and founder of Shanghai-based consultancy Automobility. “Just like the iPhone unleashed a host of Chinese smartphone companies, the Tesla Model 3, initially, unleashed the Chinese EV wave,” Russo says. Over the past five years, Tesla’s global operations have deepened their reliance on Chinese suppliers, whose scale, efficiency and levels of automation have become world-leading.

... the future success of Musk’s business in China hinges on obtaining — and maintaining — regulatory approval for his FSD platform, the company’s semi-autonomous driving software... whether Beijing could use Tesla as leverage when negotiating with Trump — both in terms of Tesla’s FSD approvals and access to supplies of key components. “Tesla is looking for a solution on FSD so that could be part of the discussions on tariffs: we give you FSD, you negotiate on tariffs,” says one analyst at a US brokerage, who asked not to be named.

2. Cash transfers to women is the flavour of the times

Nine Indian states with ongoing or proposed cash transfer schemes for women have collectively allocated $18 billion in their 2024-25 Budget Estimates, amounting to 0.5 per cent of India’s gross domestic product (GDP) for the same financial year, according to research by Goldman Sachs.
3. Rana Faroohar describes the coming Trump years as a high stakes geopolitical poker.
If you think of the global economy as one giant Las Vegas gaming table, the US consumer market as the world’s most valuable chip and Trump as a wily deal maker in a high-stakes poker game, then you will better understand what the next four years might look like. For starters, let’s remember that nothing — and I mean nothing — that the next US president says can be counted as fact until the ink is dry — and if history is a guide, probably not even then. We keep trying to analyse Trump’s moves in the way we would those of a normal president. But he is not a normal holder of the office, and never will be. He is a compulsive dealmaker, someone who loves to drive a hard bargain and win — or at least appear to.
4. Ruchir Sharma points to signatures of American exceptionalism in its equity markets gone too far.
The US accounts for nearly 70 per cent of the leading global stock index, up from 30 per cent in the 1980s. And the dollar, by some measures, trades at a higher value than at any time since the developed world abandoned fixed exchange rates 50 years ago... America’s share of global stock markets is far greater than its 27 per cent share of the global economy... At the height of the dotcom bubble in 2000, US stocks were more expensively valued than they are now. But the US market did not trade at nearly so vast a premium to the rest of the world... On indices that weight stocks equally regardless of size and correct for the domination of Big Tech, the US has outperformed the rest of the world by more than four to one since 2009... America’s drawing power in the global debt and private markets is also stronger than ever. So far in 2024, foreigners have poured capital into US debt at an annualised rate of $1tn, nearly double the flows into the Eurozone. The US now attracts more than 70 per cent of the flows into the $13tn global market for private investments, which include equity and credit.

This is an important point

Though most observers think the world is increasingly multipolar, investors believe it is increasingly unipolar — and that makes the markets a zero-sum game. In the past, including the roaring 1920s and the dotcom era, a rising US market would lift other markets. Today, a booming US market is sucking money out of the others. Investors still like to believe that fundamentals drive prices and sentiment. But there comes a time when sentiment starts to drive fundamentals. When money leaves smaller markets, the outflows weaken the currency, force the central bank to raise rates, slow the economy and make the nation’s fundamentals look worse. Talk of bubbles in tech or AI, or in investment strategies focused on growth and momentum, obscures the mother of all bubbles in US markets. Thoroughly dominating the mind space of global investors, America is over-owned, overvalued and overhyped to a degree never seen before.

5. US imports from Mexico

6. FT has a good article on a secret Japanese project to reclaim its leadership in the semiconductor industry (its market share has fallen from over 50% at the end of 1980s to less than 15% today) with an audacious technological bet.
Rapidus... has raised billions of dollars from both the government and Japan’s leading companies and banks... it is one of the world’s most capital intensive start-ups — and among the riskiest technological bets ever placed by the Japanese government. At the heart of the Rapidus project is an attempt to prove that bespoke chips can be efficiently and profitably produced in small quantities rather than large batches, an idea that overturns the received wisdom in advanced semiconductor manufacturing. About 90 per cent of the world’s advanced chips are produced by Taiwan Semiconductor Manufacturing Company, whose model involves operating at massive scale — with the huge capital costs that involves. If Rapidus succeeds, it would challenge both the economics and geography of the industry... In... three years... Rapidus has leapt from concept to reality. A massively expensive plant is rising from the forests of Hokkaido, 900km north of Rapidus’s headquarters in Tokyo...

In December, it will take delivery of an extreme ultraviolet lithography (EUV) machine from Dutch equipment maker ASML, vital for manufacturing the two-nanometre chips the company is targeting for trial production from April. If all goes to plan, mass production is set to begin in 2027... The government has already pledged ¥920bn for Rapidus and in November unveiled a package of ¥10tn ($65bn) for the artificial intelligence and semiconductor industries over the next seven years that could include funds that would double state backing for the company... Alongside huge returns and investment for Japan, Rapidus could open up an entirely new vista for cutting-edge chip production, allowing new companies and countries to enter the industry. It could also ease one of the key geopolitical issues of the day: the concentration of manufacturing expertise in Taiwan... Japan is still home to a deep reservoir of expertise and niche dominance of semiconductor tools and equipment businesses...

Rapidus and Japan’s hope of success rests on two highly contested propositions. The first is that the surging AI market means that there will be sufficient demand from smaller customers for customisable special-use chips — bespoke designs that prioritise efficiency and can outperform more generic chips, such as those produced by Nvidia, in specific tasks. Rapidus believes that such customers will pay a premium for speed of production and because they cannot get the required capacity from TSMC, which has its hands full with bigger orders. Rapidus thinks it can win 10 per cent of what it estimates to be the $90bn foundry market. The second, more controversial, bet is that it can reject the core industry premise of large-scale batch manufacturing — printing hundreds of wafers at the same time — in favour of a much quicker single-wafer process.

Atsuyoshi Koike, a veteran chip industry executive, claims that producing individual silicon wafers, one after another and at high speed, generates data that can improve efficiency in real time. This increases quality and consistency and raises the “yield rate” — the percentage of chips produced deemed shippable to customers... The company will also use so-called advanced packaging to improve performance by integrating multiple chips more closely together to increase speed and efficiency. Rapidus will, says Koike, boast the “world’s shortest total cycle-time”, meaning the total amount of time it takes to process a wafer in a fabrication plant. And he thinks he can hit yield rates of up to 90 per cent within a year. “Usually it takes up to one year to reach 30 per cent yield and to start the production. But our speed is so fast we can move easily to reach 50 per cent yield at the start of production,” he predicts. “Within one year it might be possible to hit 80 to 90 per cent. The key is how to generate feedback quickly.”

7. With R&D spending across sectors of just 4.7 bn euros, India is a global R&D minion. 

It’s R&D spending in technology sectors is just 0.3 bn euros, 2.3 bn euros in automobile and parts, 1.44 bn in health care, and 0.6 bn in basic materials. 

This compares with the total R&D spending of 596.15 bn euros among US companies, 222.01 bn among Chinese, 116.3 bn among Japanese, 103.77 bn among German, 37.02 bn among S Korean, 35.92 bn among British, 31.66 bn among French companies. 

8. The US economy is a clear standout outlier among advanced economies. 

US labour productivity has grown by 30 per cent since the 2008-09 financial crisis, more than three times the pace in the Eurozone and the UK... Data from the Conference Board shows that, in the past few years, labour productivity has dropped relative to that of the US in most advanced economies... According to data by Preqin, the US accounts for 83 per cent of the amount of VC funding in G7 economies over the past decade. The country also attracted 14.6 per cent of the world’s overall greenfield foreign direct investment in the first 10 months of 2024, according to fDi Markets data — a record high. Germany, by contrast, registered its lowest share of global FDI in 18 years.
9. Guru Madhavan makes an important point cautioning the relentless search for efficiency maximisation.
The difference between medicine and poison lies in the dose. This truth speaks directly to government reform. As Washington prepares to launch an efficiency crusade, we must remember that efficiency, wrongly dosed, can sicken the very system it means to improve. This principle extends beyond metaphor. Just as our bodies maintain seemingly inefficient back-up systems (like two kidneys), and financial systems keep seemingly inefficient capital reserves, governments need built-in redundancies and safety margins to function effectively during crises. But widespread worship of efficiency has now created the unfortunate tendency to prioritise it over efficacy at all costs.
10. Renewable energy costs are falling.
Offshore wind, the global average cost has fallen to $81 per megawatt hour, down from $137 in 2018, according to the most recent data from BloombergNEF. That compares with $72 per MWh for coal-fired power plants and $83 for gas-fired power plants, respectively — figures unthinkable just a few years ago.
The article itself recounts the fascinating rise and fall of Ørsted as a Danish wind power pioneer.
Ørsted’s own transformation has its roots in the run-up to the international UN climate change conference in Copenhagen in 2009. Denmark’s national energy company was then known as Dong Energy, and its oil and gas wells and coal-fired power stations accounted for about a third of the country’s entire CO₂ emissions. The conference left a lasting mark on Anders Eldrup, a former top civil servant in Denmark’s finance ministry who was then Ørsted’s chief executive. Before it even began, he announced a plan for the company to produce an ambitious 85 per cent of its electricity and heat from renewables by 2040, up from 15 per cent at the time... State support, high wind speeds in the North Sea and the fact that turbine makers Siemens Energy and Vestas were based near by made the nascent offshore wind sector seem like a good bet. Ørsted pushed the industry forward, developing ever-larger farms such the Hornsea 1 project off the Yorkshire coast — the first globally to exceed 1GW capacity, which started generating in February 2019... In 2017, a year after it listed in Copenhagen, the company sold off its oil and gas production business to the chemicals empire Ineos for just over $1bn. It was also rechristened in honour of the 19th-century Danish physicist Hans Christian Ørsted, who discovered electromagnetism... By late 2020, Ørsted’s valuation reached £51bn — higher than BP’s, even though it produced a fraction of the energy...

In the years following the pandemic, as interest rates jumped, supply chains came under strain and investors looked at higher returns elsewhere, Ørsted and others came under increasing pressure. To secure financing — a challenge for renewables companies, where costs are heavily front-loaded — many had already locked in electricity prices on large projects. That was a particular problem in the US, where Ørsted also overestimated its ability to get tax credits from the federal government. When the company warned in August 2023 that discussions were not progressing well, investors began to worry. Early that November, when Ørsted said it would walk away from two huge offshore wind projects in New Jersey, triggering some $4bn in impairments, its shares tumbled almost 30 per cent. The subsequent 12 months have been rough: the company announced that its finance chief and chief operating officer would leave, a suspension of dividends, a downgrade to its renewables target to 35-38GW by 2030 (a reduction from 50GW) and up to 800 job cuts.

11. McKinsey & Co. agrees to a fine settlement of more than $122 million to resolve a felony bribery investigation from its work in South Africa. 

The fine... was part of a deferred prosecution agreement that would dismiss the bribery charge against the company after three years if McKinsey meets the conditions of the deal. Separately, a former McKinsey senior partner, Vikas Sagar, who was a leader in its Johannesburg office, pleaded guilty to conspiring to violate an anti-corruption law, prosecutors said. The bribery investigation stemmed from work that McKinsey’s South African branch performed, starting more than a decade ago, for two state-owned companies: one overseeing the country’s run-down electric generating system, the other managing its freight rail system and ports. Mr. Sagar received confidential information about the companies that led to multimillion-dollar consulting contracts, and in return, some of the money McKinsey and its local partners made was routed to two officials as bribes, prosecutors said. “McKinsey Africa participated in a yearslong scheme to bribe government officials in South Africa and unlawfully obtained a series of highly lucrative consulting engagements” that netted McKinsey $85 million in profits, Damian Williams, the U.S. attorney for the Southern District of New York, said in a statement.

It's surprising that such egregious bribery incidents have little stigmatisation effect of western corporations like McKinsey. Imagine a similar incident involving a company from a developing country. 

12. Declining EV sales trajectories in N America and Europe. 

Matthias Schmidt, an independent car analyst, estimates that EV volumes will decline by 29 per cent this year in Germany, Europe’s largest market, after Berlin abruptly pulled purchase subsidies for EVs in late 2023. France is planning to slash EV purchasing subsidies by as much as half for some families next year... According to analysis by NGO group Transport and Environment, the average price of an EV in Europe was around €40,000 before taxes in 2020. Today, the price is around €45,000. A separate study by the European Commission suggests that the median price European consumers are prepared to pay for an EV is €20,000, including new and secondhand sales.

13. Some measures of China's manufacturing dominance

China accounts for only 15 per cent of global consumption, less than its 18 per cent share of world GDP and far below its 30 per cent share of manufacturing. That made it reliant on demand in other countries to absorb its enormous excess production... China’s share of global gross production had risen from 5 per cent in 1995 to 35 per cent by 2020 — three times that of the US and more than the next nine countries combined... Its share of global manufactured exports was 20 per cent in 2020, up from 3 per cent in 1995 and dwarfing the US, Japan and Germany. Out of a total of about 5,000 products, China held a dominant position in exports for almost 600 in 2019, at least six times greater than for the US or Japan and more than double that of the EU.
And this is causing problems
Yet policymakers are doubling down on manufacturing. China’s nominal fixed asset investment in manufacturing is expected to grow 9 per cent this year compared with 6.5 per cent last year, according to Morgan Stanley estimates. This threatens to create even more industrial capacity in a country where domestic consumption accounts for about 55 per cent of GDP compared with 70 per cent in rival exporters Japan and Germany, and 80 per cent in the US. China’s dominance of green industries such as electric vehicles, solar panels and batteries has already led to trade restrictions from the EU and the US. And its sluggish domestic demand is causing overcapacity across many other manufacturing segments, analysts say... China’s inability to raise domestic consumption has left it in an unenviable position: weak demand at home and trade-related tensions abroad.

Thursday, December 5, 2024

Market failures from profit maximisation in US healthcare

A Bloomberg series (this and this) chronicles US hospital chains' widespread use of Nurse Practitioners (NPs) in primary care to emergency rooms. NYT has a two-part series (this and this) on how pharmacy benefit managers (PBMs) are driving up drug prices and forcing out independent drug stores across the US. 

The four articles are a case study on how profit maximisation incentives in sectors like health care distort incentives, erode service quality, hurt consumer welfare, and inflict pain on customers and communities. 

The Bloomberg series illustrates the example of Hospital Corporation of America (HCA), a $84 billion for-profit, which is the largest hospital chain in the US, with its over 180 network hospitals across the country having treated over 1.9 million patients in 2022 alone. 

It has gone the farthest in using NPs to maximise efficiencies

Busy ERs are constantly triaging, determining where the physicians on duty are most needed. And nurse practitioners have significant responsibility and authority—perhaps more than many patients realize. In important respects, they’re now at the center of health care in the US… There are already more than 300,000 nurse practitioners, and that figure is rising far faster than the number of doctors. In 2014 there was 1 NP for every 5 physicians and surgeons in the US, according to the Bureau of Labor Statistics. Last year the ratio was 1 to 2.75. The gap is going to shrink further still: Nurse practitioner is the fastest-growing profession in the country, and the ranks are expected to climb 45% by 2032.

After getting an advanced degree—typically a master’s or doctorate in nursing—and an additional license, nurse practitioners are allowed to treat patients in many of the same ways medical doctors do, including diagnosing ailments and prescribing medications. The shift has many benefits. For patients, more clinicians means getting care sooner. (The average wait time for an appointment with a physician is at an all-time high of 26 days.) For health-care organizations, NPs are cheaper to employ than physicians, and under some circumstances the organizations can bill insurers for their time at physician rates. The NPs themselves can get more pay, more prestige and a better work-life balance than registered nurses, which many NPs formerly were.

Such demand creates its own supply albeit with serious distortions

The problems result from the surging number of programs, which graduate thousands of NPs a year without adequately preparing some of them to care for patients. The former director of the largest NP program in the country says she can’t recall denying acceptance to a single student. More than 600 US schools graduated students with advanced nursing degrees in 2022, according to US Department of Education data. That’s triple the number of medical schools training physicians. More than 39,000 NPsgraduated in the 2022 class, according to the AANP, up 50% from 2017.

Unlike the training program for physicians, education for NPs isn’t standardized. Some candidates attend in-person classes at well-regarded teaching hospitals, but a much larger number are educated entirely online, sometimes via recorded lectures that can be years old. Interaction with professors is often limited to emails and message boards. These circumstances make the required clinical portion of an NP’s education even more important—but compared with doctors’ residencies, those stints are brief, and students say they’re of wildly variable quality. In 2022 the advanced nursing programs that awarded the most degrees were offered by institutions that deliver the classroom portion of instruction primarily over the internet…

Early waves of NP students were often experienced registered nurses seeking to increase their skills and responsibilities. But as demand spiked, more schools began offering “direct entry” programs that accepted students with a bachelor’s degree in unrelated fields. Today the fastest among them can prepare students for NP licensure exams in three years of education that encompasses a bachelor’s in nursing, registered nursing licensing (all NPs have to become RNs, even if they haven’t yet worked in the field) and a master’s in nursing. In 27 states, licensed graduates are allowed to treat patients and prescribe drugs with no physician oversight, even if they have no prior nursing experience… With a separate license from the Drug Enforcement Administration, NPs can also prescribe controlled substances. This license has made NPs particularly attractive to telemedicine companies… Students must obtain 500 clinical hours to graduate. That’s less than 5% of the amount required of medical doctors before they can practice medicine.

Fundamentally, the demand for NPs is driven by unit economics

Physicians are in short supply, and NPs can fill the gap. There’s also a financial motivation. A primary care physician costs $344,308 a year, whereas a primary care NP costs about $156,546, according to 2022 data compiled by Kaufman Hall, a health-care consulting company. Yet primary care NPs can generate $424,979 of direct revenue a year, only $37,000 less than a physician. Put another way, NPs are twice as profitable.

The largest US hospital chain, HCA, a for-profit firm, is illustrative of the extreme dependence on NPs.

This staffing pattern has soundly rewarded HCA’s shareholders.

The company has one of the lowest ratios of physicians and advanced practice providers (a catchall term for nurse practitioners and physician assistants) per bed among more than 600 US health-care systems that the federal government tracks. Registered nurses and other support staff aren’t included in that tally, but other government data that accounts for a wide range of roles also show HCA tends to staff leanly. It’s one reason HCA is widely regarded as one of the most efficient operators in its industry, with the largest profit margins of any American hospital chain that trades on the stock market. Shares have returned fivefold in the past decade, even after falling recently amid concerns about reduced Affordable Care Act subsidies.

With the advances in technology and data analysis, it has now become possible, in theory at least, to disaggregate the job of doctors and parcel many parts out to NPs and others.

Some HCA staff say the company is merely going where the data is taking it—a future with fewer medical doctors. This trend has been evident for years in primary care: Fewer physicians are pursuing it, and NPs have filled that role for many Americans. HCA staff who spoke to Businessweek said that shift is now underway in other practice settings. In many of them, “we will get to a point where there will be no physicians left,” says one executive who recently left HCA after several years at its Nashville headquarters and asked for anonymity to speak on the sensitive topic. “You just won’t have physician oversight, because we won’t have the supply.

The power of economies of scale and search for cost-minimisation has been a big driver of the historical evolution of HCA.

The Hospital Corp. of America was co-founded by Dr. Thomas Frist Sr. more than a half-century ago in Nashville. Frist, a cardiologist and internist, complained he had trouble getting his patients into nearby hospitals, so he opened his first for-profit hospital, a squat, five-story facility called Park View, as a remedy. Frist’s son Thomas Jr. saw the power in economies of scale, and the company started gobbling up more facilities. American health care has been bending Frist’s way ever since, and HCA’s value has soared. Thomas Jr. has become the world’s 56th-richest man, with a $30 billion fortune largely derived from his HCA shares. His younger brother, Bill, became majority leader in the US Senate, where he helped pass the Medicare Modernisation Act of 2003, allowing retirees to receive benefits through private insurers. The company’s gravitational pull has turned Nashville into the world’s unofficial headquarters of for-profit health care, drawing more than 900 companies to the area. Its own holdings have exploded, too, with more than 180 hospitals across several states, and a toehold in the UK. 

Within that portfolio, Chippenham and its affiliated facilities are a powerhouse, the company’s fifth-largest by revenue, federal data show. Closely watched from corporate headquarters, Chippenham executives have frequently been plucked for bigger roles, charged with running dozens of hospitals in HCA’s system. Big revenue doesn’t necessarily mean big resources. In Richmond, Chippenham’s emergency room has a troubling reputation. Current and former employees describe limited staffing and resources that guarantee they’ll be caring for patients in hall beds and in the waiting room on a nightly basis. Patients describe waits stretching for several hours amid blood smears and vomit bags… traveling nurses who have worked at several facilities told Businessweek that Chippenham stands out for its chaos and lack of resources and staff. Nurses in the hospital’s intensive care units describe getting “tripled” multiple times a week—being responsible for three patients at a time. The standard is two… Some of the nurses said they’d worked at nonprofit facilities that never tripled them. The problems were so well known that even some community members were wary. 

HCA’s acquisitions are good illustration of how its practices have transformed the healthcare sector for the worse (in this case dramatically worsening the quality of a highly reputed non-profit).

HCA’s makeover of Mission Health in Asheville, North Carolina, offers a vivid example of how the company’s staffing strategies can affect caregivers, patients and the company’s bottom line. In 2019, HCA paid about $1.5 billion for Mission Health, a nonprofit system with several facilities and a reputation as one of the Southeast’s premier health-care centers. HCA executives promised to preserve Mission’s quality while boosting profits by using the corporation’s size to deliver better “purchasing power and back-office efficiencies.” 

Soon, HCA began drastic staff reductions at the system’s flagship facility, Mission Hospital, and conditions deteriorated rapidly, according to a lawsuit filed by the state attorney general. Wait times in the emergency room swelled, nurse-to-patient ratios in ICUs often fell to half the state minimum, and surgeons reported they frequently lacked sterile medical instruments because of cuts to the cleaning staff, the lawsuit said. When HCA executives brushed aside complaints from Mission board members and employees, two-thirds of its physicians left, according to a research paper published by Mark Hall, director of the Health Law and Policy Program at Wake Forest University. Mission’s emergency room was so severely understaffed that it jeopardized patient safety, a federal investigation concluded…

The drastic reductions in Mission’s labor costs were a boon to the hospital’s finances. In the four years before the sale, Mission earned an average of $38 million in profit from patient care. In 2022, Mission’s profit reached $96 million, driven primarily by “sharply reduced staffing for patient care under HCA,” according to Hall’s research.

This graphic captures how HCA increased profitability across its network hospitals using these practices. 

The PBMs intermediate the insurance for prescription drugs by negotiating with drug companies, paying pharmacies, and helping decide which drugs patients can get at what price. The three largest ones - CVS Health, Cigna and UnitedHealth Group - oversee prescriptions for more than 200 million Americans and control nearly 80% of the market, up from less than 50% in 2012

P.B.M.s sometimes push patients toward drugs with higher out-of-pocket costs, shunning cheaper alternatives… Even when an inexpensive generic version of a drug is available, P.B.M.s sometimes have a financial reason to push patients to take a brand-name product that will cost them much more… They often charge employers and government programs like Medicare multiple times the wholesale price of a drug, keeping most of the difference for themselves. That overcharging goes far beyond the markups that pharmacies, like other retailers, typically tack on when they sell products. The largest P.B.M.s recently established subsidiaries that harvest billions of dollars in fees from drug companies, money that flows straight to their bottom line and does nothing to reduce health care costs. 

The P.B.M.s, which are responsible for paying pharmacies on behalf of employers, are driving independent drugstores out of business by not paying them enough to cover their costs. Small pharmacies have little choice but to accept these lowball rates because the largest P.B.M.s control an overwhelming majority of prescriptions. The disappearance of local pharmacies limits health care access for poorer communities but ultimately enriches the P.B.M.s’ parent companies, which own drugstores or mail-order pharmacies. P.B.M.s sometimes delay or even prevent patients from getting their prescriptions. In the worst cases, patients suffer serious health consequences… Even people who don’t take prescription drugs end up paying higher insurance premiums and taxes as a result of inflated drug costs… If they were stand-alone companies, the three biggest P.B.M.s would each rank among the top 40 U.S. companies by revenue.

This description of the evolution of PBMs is instructive.

P.B.M.s have been around since the late 1950s. They initially handled requests mailed in by pharmacies and patients seeking reimbursement for the costs of prescription drugs. Over the decades, P.B.M.s have had different owners, including drug makers and large chains of pharmacies… The modern P.B.M. emerged in 2018. The giant health insurers Aetna and Cigna were trying to achieve the growth demanded by Wall Street. They sought to merge with the P.B.M.s, whose profits were soaring. Aetna and CVS combined. Cigna bought Express Scripts. (UnitedHealth had built its own P.B.M.)

It would turn out to be a seminal moment, one that would rapidly and radically change the American health care system by further shifting power into the hands of giant conglomerates and away from employers and patients. Today, P.B.M.s feed off a system where everything is extraordinarily complicated — including how much a drug actually costs.

The PBMs have evolved business models that allow them to obsfuscate and capture a significant share of the discounts obtained from drugs manufacturers. They have set up subsidiaries to negotiate discounts with drug manufacturers.

The creation of the subsidiary, Emisar, has allowed UnitedHealth to retain billions of dollars of those savings, without having to share them with employers. Emisar and similar subsidiaries established by Express Scripts and Caremark are known as group purchasing organizations, or G.P.O.s. They were created, starting in 2018, amid growing pressure from employers to share with them more of the manufacturers’ discounts. In response, the P.B.M.s altered their business model. The new subsidiaries still received rebates from drug companies, and they passed on those rebates to the P.B.M.s, which in turn sent the savings to employers. But the G.P.O.s also began imposing new fees on drug manufacturers. 

Because those were fees, not rebates, and because the fees were technically collected by a different company, the P.B.M.s weren’t contractually obligated to share them with their clients. And the P.B.M.s could truthfully say that they were returning to employers almost all of the drug companies’ rebates. They didn’t have to mention the fees… In 2022, P.B.M.s and their G.P.O.s pocketed $7.6 billion in fees, double what they were bringing in four years earlier, according to Nephron, a consulting firm… Emisar operates mainly in Ireland, and Express Scripts’ Ascent is in Switzerland, which means their profits are taxed at much lower rates than if they were generated in the United States… When drug companies paid more in fees, they offered less in rebates… Employers… receive rebates. But they can’t see the billions of dollars in fees that the G.P.O.s take for themselves…

The conglomerates that own the big P.B.M.s also own pharmacies. CVS has thousands of drugstores. And all three operate warehouse-based pharmacies that send prescriptions to patients through the mail. The three P.B.M.s push, and sometimes force, patients to use their pharmacies, whether mail-order or, in CVS’s case, the physical drugstores. One common strategy is to not allow patients to receive 90-day supplies of drugs if they fill prescriptions at outside pharmacies… One surefire way for the P.B.M. or its in-house pharmacy to profit is to charge thousands of dollars more than what a drug costs… The steepest markups often involve generic versions of expensive medications for conditions like cancer.

This article shows how PBMs have been systematicallt underpaying small pharmacies (how much the drugstores are reimbursed for medications), driving them out of business. This, in turn, benefits the largest PBMs who also run competing pharmacies. 

In every state, The Times identified at least one example since 2022 in which an independent drugstore closed and the pharmacist blamed P.B.M.s. In some states, like Pennsylvania, such closings have become routine. They have disproportionately affected rural and low-income communities, creating so-called pharmacy deserts that make it harder for residents to get prescriptions and medical advice.

One study, paid for by a pharmacy association, found that the markup that P.B.M.s were charging on brand-name drugs was 35 times higher when the drugs were sold through their own mail-order pharmacies than when the drugs were sold by independent drugstores. Government studies have identified a similar phenomenon… The benefit managers decide which pharmacies are available to patients through their insurance. To be included, a pharmacy must agree to a contract with the P.B.M. that details the formula for how much the pharmacy will be reimbursed for drugs… Because the top P.B.M.s collectively control the overwhelming majority of prescriptions, pharmacies that forfeit their business could not survive.

The closure of small pharmacies have left communities without any drug stores.

Nearly 800 ZIP codes that had at least one pharmacy in mid-2015 now have none, according to an analysis of pharmacy data by Luke Slindee, a consultant who has been tracking pharmacy closings around the country… When small drugstores close, communities can be harmed in ways that are hard to measure. Getting your flu shot becomes less convenient. As residents grow accustomed to traveling long distances for their medications, they do more of their other shopping far away from home, draining revenue from local businesses. Relying on mail-order pharmacies deprives customers of an easy way to get advice from a trusted local pharmacist… Research has found that after pharmacies close, their older customers are less likely to consistently fill their prescriptions and end up missing doses… Even when a small pharmacy stays in business, low reimbursement from P.B.M.s can make it harder for its customers to get their medications. Many small drugstores sidestep their contracts with P.B.M.s and decline to dispense certain medications — especially high-cost brand-name products for conditions like diabetes and obesity — because they lose money on them. Customers must go elsewhere.

Some observations 

1. The evolution of PBMs from being small payment-handling intermediaries to mega-firms with interests all along the prescription drug supply chain has not only not delivered the promised benefits in terms of efficiencies and value sharing across the chain but has also left patients, employers, and insurers with higher costs. Similarly, the emergence of massive hospital networks, far from transmitting benefits across stakeholders from economies of scale, has engendered perversions like substituting away from higher-cost doctors towards lower-cost NPs, besides seriously worsening the quality of care. 

2. There’s a fundamental problem with the pure financial metrics-driven business growth strategy in sectors where quality of service delivery is critical. The exclusive and obsessive focus on financial metrics will invariably lead the management down the path of cost-cutting and revenue maximisation. In this efficiency maximisation drive, and especially in large systems and where quality of service is critical, it’s hard not to avoid skimping on things that are central to quality. 

The example of the increased use of NPs across hospital networks in the US is yet another example on the perils of such efficiency maximisation. As the articles show, the disaggregation of the doctor’s work and parcelling some parts of it out to NPs ends up seriously eroding the quality of care delivered. Besides, the sharp differential in the costs of doctors and NPs will invariably incentivise pushing the boundaries on substituting the doctor with the NP.

3. Firm size in itself (and the associated detached and impersonal management) is a problem in services where quality is critical. In such services, personalised care and engagement is a critical value proposition. No technological innovation or business structure can be a substitute. The small hospital networks and independent pharmacies bring attributes critical to the effectiveness of service quality that the large firms cannot replicate. 

4. A market dominated by a few large conglomerate firms will invariably distort incentives and engender dynamics that will hurt consumer welfare. Vertical and horizontal integration with opaque ownership and accounting disperses costs and accountability across the conglomerate. It engenders market failure and is a recipe for perversions like price gouging, cross-selling, profit maximisation etc. 

In general, the ownership and management structure of massive PBMs and hospital networks will tend to generate excessive efficiency and profit-maximisation impulses that detract from quality and consumer welfare. It’s very difficult, even impossible, to achieve the balance between shareholder and stakeholder value maximisation, and the latter invariably falls aside with time. It’s almost the inexorable logic of capitalism, one which gets exacerbated by private equity ownership. 

5. The rapid expansion of the supply side in any sector where service delivery quality is critical is fraught with problems. It resonates with the troubled examples of multiple instances when state and central governments in India have sought to rapidly increase the institutions (and seats) offering engineering, medical, nursing, and other professional courses. 

When done at scale and too quickly, blended learning and online instruction approaches are likely to struggle to meet the fidelity requirements. Baumol’s cost disease is real in sectors like education and there are hard limits to the application of technology to address the problem.

6. The example of HCA should serve as a cautionary tale for those who preach the ideology of the superiority of for-profit companies. The degeneration in the quality of service of Mission Health, a reputed non-profit hospital network, after being bought by HCA and turning for-profit is an apt case study. 

It’s an oft-repeated ideological argument in countries like India that its education system can be improved by permitting for-profit institutions. The US for-profit hospital networks and Nursing Colleges are good examples of the problems with the introduction of profit incentives to sectors like healthcare and education.

Monday, December 2, 2024

India's power sector problems in a graphic

I blogged here with a set of proposals to address India’s recurrent power sector bailouts. But the post did not directly explain the causes for the recurrence of the problem. This post will seek to offer an explanation.

The graphic below captures the life-cycle of debt accumulation by the electricity distribution companies (discoms) that lead to central government bailouts and their mechanism. 

There are two fundamental problems that contributes to its recurrence:

1. Even after the slate is wiped clean with a bailout, the tariff increases continue to lag behind the rising cost of supply. This is because the AT&C and other unprovisioned losses (as explained in the earlier post) accumulate again on the discoms’ balance sheet.

2. The two power sector development finance institutions, Power Finance Corporation (PFC) and Rural Electrification Corporation (REC), provide opex loans to the discoms and state government off-balance sheet entities to finance the rising losses.

While the first is a state-level political economy problem, the second is a central-level political economy problem. Just as state governments cannot constantly raise tariffs to keep up with the cost of supply, the central government cannot avoid the pressures from (private) generators to offer these bailouts.

How can this gridlock be broken?

If the banking regulator, RBI, can tighten the oversight of PFC/REC and prohibit opex loans, then addressing the second problem might be a slightly less difficult challenge than addressing the first. This would force the state governments to support the discom losses directly from the budget. And given the scale of opex funding that keeps alive the discoms and states (till the next bailout), this strain on the budget will get quickly exposed and likely force the kind of hard decisions that are required. 

However, complicating matters, PFC and REC's exposure to these same captive government borrowers is such that it's not possible to suddenly shut credit taps without very badly damaging themselves. Therefore, there’s a need to calibrate any such phase down. 

In any case, given the complex nature of the political economy surrounding power tariffs and free farm power, this might perhaps be the only policy response to address the problem of recurrent power sector bailouts in India.

Saturday, November 30, 2024

Weekend reading links

1. Jared Bernstein, Chair of the White House Council of Economic Advisors, makes an important point while justifying the Biden administration's large fiscal stimulus.
Twenty-twenty hindsight is an analytical luxury — certainly one we didn’t have in January of 2021. Back then, we had millions of unemployed people. We had Covid deaths peaking. The economy was improving, but it was far from reopened. And vaccinations hadn’t been anywhere near adequately distributed. So the extent of uncertainty regarding the impact of Covid on the economy warranted a very strong rescue plan. And I don’t regret the plan. We certainly got more heat than I envisioned at the time, no question, but we also got a lot more growth, less child poverty, fewer evictions, more business survivals, and a much quicker return to full employment and very little economic scarring... I used to say, back then, “The risk of doing too little was greater than the risk of doing too much.”

2. NYT on the China risk that Elon Musk is riding on. In every industry Musk is in, his main competitors are the Chinese - EV, batteries, solar panels, boring machines, and satellite launches. Tesla is still awaiting permission in China for full-self driving, something which domestic competitors have already secured. 

As an illustration, during President Xi's latest visit, SpaceSail, the state-backed Chinese satellite launch company, signed a deal with the Brazilian government to launch satellites for Brazil. 

In terms of corporate risk, brand Elon Musk stands completely at the mercy of two forces he cannot control at all - Donald Trump and China. Worsening matters, the two conflict with each other at several points, making it tails he loses and heads the other side wins!

3. DHL and NYU have a Global Connectedness Tracker which gives a wealth of information.

4. EV car manufacturing in China

The business of car-making in China is far more promiscuous. Huawei has Seres-style alliances with three other major local manufacturers and presents itself as a provider of smart software, hardware and retail expertise that more traditional automakers can put on four wheels. It’s also joined forces with Anhui Jianghuai Auto Group Corp., or JAC, which manufactures cars for US-listed EV-maker Nio Inc., on a soon-to-be-released luxury people mover. Xiaomi is now making its SU7 in-house, but even there it initially tied up with BAIC Motor Corp. in developing it.

5. The problems with Trump's threat to tax Canadian imports.

“How do you compete with China if you price Quebec aluminum, Ontario cars, Saskatchewan uranium and Alberta oil prohibitively?” Flavio Volpe, the president of the Automotive Parts Manufacturers’ Association, a Canadian industry group said, citing some top Canadian exports to the United States. “Half of the cars made in Canada are made by American companies, and half of the parts that go into all the cars made in Canada come from U.S. suppliers, and more than half of the raw materials are from U.S. sources,” Mr. Volpe added. “We are beyond partners. We are almost as inseparable as family.”

6. China EV market facts 

BYD, Tesla’s biggest rival in China, has demanded its suppliers slash prices by 10 per cent, as the world’s largest auto market braces for a fresh salvo in a cut-throat price war. The carmaker urged its suppliers to send over their quotes by December 15 and officially mark down prices starting next year, executive vice-president He Zhiqi wrote in an email circulated on social media on Wednesday. “In 2025, the EV market . . . will go into a grand final battle and a knockout tournament,” he said. “To enhance BYD cars’ competitiveness . . . you and your team must take it seriously and effectively exploit space for cost reduction”... “The rise of China’s auto industry cannot come at the expense of the livelihood of domestic workers and suppliers,” one supplier responded. “We are unable to accept your company’s request and unwilling to take part in this type of co-operation that violates business ethics and human nature.” In the first nine months of 2024, the average time BYD took to clear its bills payable, most of which were attributed to suppliers, was 144 days, longer than the 124 days a year earlier, according to company filings.

7. Claudia Sheinbaum is pushing ahead with radical reforms as the new President of Mexico.

During her first weeks in office, she has thrown her weight behind a package of López Obrador’s most controversial ideas, branded “Plan C”. Her first year in office will be spent implementing elections for judges, dismantling regulators and cementing the dominance of state companies in the energy sector... Mexico will be by far the biggest country to elect all its judges via popular vote, in a process Sheinbaum backed enthusiastically throughout the campaign, arguing that it would reduce corruption and make the distrusted judiciary more accountable... Together we are going to transform the judiciary, truly from the bottom, from the people of Mexico,” she said at a recent rally in Zacatecas. “What is democracy? The power of the people by the people and for the people.” Despite warnings from the US government, business leaders and lawyers that it would damage judicial independence and democracy, Sheinbaum pressed ahead.

But she has to preside in the long shadow of her predecessor and mentor Andres Manuel Lopez Obrador (AMLO) 

Much of Morena’s leadership — in the party and congress — is seen as more loyal to its founder than to her, a profound risk as she faces a recall referendum three years into her six-year term.

8. As President designate Trump threatens a full-scale tariff war, here's a graphic pointing to who will likely be hurt the most.

There are many worthy academic studies of the Trump tariffs from 2018. While not the most riveting reads, they give a reasonably clear account of the evidence... The evidence suggests: US importers bore the vast majority of the cost of tariffs. Overall, for a 20 per cent tariff, the importer paid 18.9 per cent higher prices with the ex-tariff price reducing just 1.1 per cent. Tariffs were passed on to US importers much more than US exchange rate depreciations, where contracts tend to be fixed for a period in dollars... While US importers paid, these costs were not always passed on directly to US consumers. Washing machines were a bit of an exception where prices rose. In other areas, prices barely increased. It is less certain whether retailers spread the tariff effect over multiple goods, margins were squeezed or products were bought ahead of tariffs being imposed... The incidence of US tariffs clearly appears to fall on the US corporate sector, with it then passed on to households in a combination of lower profits, higher prices and lower wages.

9. We are not yet at peak fossil fuel emissions.



10. The souring of China market ambitions of Western financial institutions.

In spring 2009, Beijing’s state council, the country’s top decision-making body, set an ambitious target: Shanghai would become an international financial centre by 2020... More than 15 years after China pledged to turn Shanghai into an international financial centre, the port city has failed to live up to its early promise... American law firms, once participants in huge cross-border financial flows, have left the city as foreign investment plummets. No western bank has participated in a single IPO on Shanghai’s stock market this year, and, in a domestically-focused market, the need for foreign staff is increasingly unclear. Asset management firms that flocked to the city in the hope of a loosening of China’s capital controls must reckon with the prospect that Beijing will tighten them instead.

11. Important point about Tamil Nadu's manufacturing base

Tamil Nadu has been pursuing a policy of creating multiple electronics manufacturing clusters across the state rather than locating them in one area. Apart from Sriperumbudur, it is creating a cluster near Tiruchirappalli where Jabel Inc, an American electronics major, will set up a production facility. Coimbatore, the minister said, will focus on electronics and semiconductor design. Madurai, meanwhile, is being prepped to house large global capability centres.

12. For all punditry around what to expect from the Trump White House, Alan Beattie has, in my opinion, the best assessment.

If you enjoy watching narratives disintegrate and re-form like crystals in a supersaturated solution, you’ll have loved the last few days in Washington... The value of palace politics in analysing the Trump administration will be strictly limited. The economic and trade team will be a gaggle of vying courtiers under an erratic president motivated by instinct and prejudice. This was, after all, exactly what we got during Trump’s first term. This time, his compulsion to listen to voices outside that circle urging him to deport foreign-born workers or pursue security goals even if they damage the US economy will be even stronger. It’s more productive to look at what powers the administration has and what it can get done if it tries... As in Hollywood, nobody knows anything. The one pretty safe bet is that Trump will use tariffs over the next four years. But it is very unclear how they might be employed, or for what end, or what other economic and financial tools might also be deployed, or whom he will be listening to at any given time. This week is a warning to anyone who thinks they have the Trump administration all figured out. They do not.