1. International evidence on medical spending risk Robert Lieberthal August 9, 2011

2. Acknowledgements Funding from the Agency for Healthcare Research and Quality Lots of great input  My thesis committee  Casualty Actuarial Society review committee  Participants at the 2011 CAS Reinsurance Conference

3. Outline U.S and other countries aren’t so different We would like to predict the effect of the PPACA  Use health systems in other countries as a model Modeling medical spending across countries is challenging Medical linked insurance with long tails may now be riskier

4. The U.S. is different in well known ways High spending  Absolute spending  Percent of GDP  Per capita (Still) no universal health insurance in the U.S.  Significant uninsured minority  Most developed countries have universal or near universal coverage Large private sector in U.S. healthcare  Relative to other countries  Public companies concentrated in pharmaceuticals  Some countries have physician private practice

5. U.S. spending is high and growing Medical spending as a share of GDP in four OECD countries

6. U.S. and other countries face similar challenges Unsustainable rates of spending growth  Especially for government budgets Multiple rounds of health reform  Serially address access, cost, quality Battling stakeholders Defining the role of insurance  PPACA was centered on this Health insurance, long term care insurance  Medical malpractice next?

7. U.S. spending growth is moderate Per capita spending growth rates in 11 OECD countries

8. Insurance is about the risk Magnitude of growth rates less important for annual renewal insurance Deterministic claims growth should be manageable for longer term insurance Claims volatility is a risk for long term insurance  Variance around the trend line  New slope for trend line  Structural break/new data generating function for claims Longer the term of insurance, the worse this is  Some risk implies an opportunity for insurance  Black swans, extreme tails implies possibly uninsurable risk

9. U.S. spending volatility is low Per capita spending growth rates in 11 OECD countries

10. Public spending drives a lot of the volatility

11. Better models require a lot more data Each country has approximately 50 data points  Not like price, which is monthly Many moving parts  Multiple policy changes  Demography  Macroeconomic shocks Strong unit roots  In overall spending  In the growth in spending in many countries High autoregressivity?  It’s hard to tell  Possible spuriously low standard errors Forecast effects  1-2 years is ok  5-10 or more is a problem

12. Many health insurance lines of business have long tails Guaranteed renewability  Given medical trend for computing premiums  Guarantee can run 10 years or more  Early mistakes can be costly Workers’ compensation  Insurer may be paying many years into the future  Standard of care improves  Social inflation—insurers must forecast spending growth (not just inflation) Excess casualty reinsurance  “Leveraged effect of limits on severity trend”  Claims below the limit are unobserved  Losses jump from zero to positive  Hard to see the trend rate  Excess trend can be above or below total trend rate

13. Numerical example of a long tailed contract Base case scenario  $10,005 of expected claims  $12,000 upfront premium  Payments spread over 10 years  7% expected trend  3% discount rate, 3% return on reserves Gross load = 20%  Initial expected gross surplus of $1,995  Final expected gross surplus of $2,681 (nominal)

14. 3 alternative scenarios for higher than expected claims Mean reversion in claims  9% trend in year 1 followed by return to base case nominal premiums Mean reversion in trend rate  9% trend in year 1 followed by 7% trend thereafter Autoregressive trend  9% trend in year 1 followed by 7.5% trend thereafter

15. Persistent trend growth can cause variation from expectations for a 10 year full insurance contract ScenarioNaive premium Total discounted claims Final gross surplus Time 0 gross surplus Time 0 gross load Base case12000100052681199520% Mean reverting claims 12000100212659197920% Mean reverting trend 12000102152400178517% Autoregressive trend 12000104362101156415%

16. Persistent trend growth can cause losses for a 10 year excess reinsurance contract ScenarioNaive premium Total discounted claims Final gross surplus Time 0 gross surplus Time 0 gross load Base case 2400200153639920% Mean reverting claims 2400201451938619% Mean reverting trend 240021932782079% Autoregressive trend 24002403-3 0% 20% excess reinsurance case

17. Solutions to forecast errors in medical spending Liability side  Better prediction of claims growth  Prediction markets Asset side  TIPS inflation hedging bonds Could be “sliced” to be medical only Most medical spending growth comes from quantity changes not prices  Macromarkets Buy shares in GDP or medical spending growth Health insurance futures haven’t worked Public policy  Government reinsurance for health insurance  Could exacerbate problems in other lines linked to medical care

18. Many problems with medical spending are out of our hands Medical spending is linked to overall economic growth GDP growth, demography even less controllable Medical trend is not outrageous in the U.S.  Trend = GDP growth + Rate of aging  Fits prior trend well  Same for other countries PPACA  May fix some problems  Some fixes may cause spill overs

19. The best solutions involve humility PPACA—new insurance opportunities  ACOs will need risk management services  Chances to profitably manage new populations? Challenges involve an uncertain future  Will we get more volatility like other countries with publicly funded healthcare?  Significant trend volatility to deal with here and abroad  Trend breaks and implications for long tailed lines Public policy implication—exercise caution  In changing the healthcare system  In writing long tailed insurance and reinsurance tied to medical claims

20. Could health policy be responsible for volatile trend? Paper is available in the CAS E-Forum  http://www.casact.org/pubs/forum/11spforum/ http://www.casact.org/pubs/forum/11spforum/ Future work on this problem  Convergence of systems over time  Figure out if public systems are causing the volatility, and how  Will trend U.S. get more volatile?