Here it comes: defined contribution health care

The Patient Protection and Affordable Care Act includes provisions to make the individual health insurance marketplace one where all Americans, including those with preexisting health conditions, can obtain affordable coverage. At the same time, the act has failed to address, in any significant way, many of the underlying flaws in the current U.S. health care system that have caused costs to spiral out of control. The combination of persistent U.S. health care cost increases and a viable individual health insurance marketplace will cause a sea change in employer-sponsored health care offerings that is similar to that seen among employer-sponsored retirement benefit plans: movement away from defined benefit approaches and toward defined contribution designs. Although the authors show parallels between the evolution of employers' health care and retirement offerings, they explain why certain key developments will need to occur before defined contribution approaches become as prevalent in employer-sponsored health care plans as they are in today's employer-sponsored retirement plans.     

How to solve the cost crisis in health care

U.S. health care costs currently exceed 17% of GDP and continue to rise. One fundamental reason that providers are unable to reverse the trend is that they don't understand what it costs to deliver patient care or how those costs compare with outcomes. To put it bluntly, few health care providers measure the actual costs for treating a given patient with a given medical condition over a full cycle of care, or compare the costs they incur with the outcomes they achieve. What isn't measured cannot be managed or improved, and this is all too true in health care, where poor costing systems mean that effective and efficient providers go unrewarded, and inefficient ones have little incentive to improve. But all this can be remedied by exploring the concept of value in health care and carefully measuring costs. This article describes a new way to analyze costs that uses patients and their conditions--not organizational units or narrow diagnostic treatment groups--as the fundamental unit of analysis for measuring costs and outcomes. The new approach, called time-driven activity-cased costing, is currently being implemented in pilots at the Head and Neck Center at MD Anderson, the Cleft Lip and Palate Program at Children's Hospital in Boston, and units performing knee replacements at Sch?n Klinik in Germany and Brigham & Women's Hospital in Boston. As providers and payors better understand costs, they will be positioned to achieve a true "bending of the cost curve" from within the system, not in response to top-down mandates. Accurate costing also unlocks a whole cascade of opportunities, such as process improvement, better organization of care, and new reimbursement approaches that will accelerate the pace of innovation and value creation.     

A Fresh Look at U.S. Water and Wastewater Infrastructure: The Commercial and Environmentally Sustainable Path Forward

The growing scarcity of water has a silver lining: water is being transformed into an economic resource whose price will better reflect its true value and thus encourage conservation and stimulate new supplies. This in turn can be expected to put more pressure on water and wastewater organizations to become both commercially and environmentally sustainable. And by making its decision‐making more consistent with economic criteria, the U.S. water industry will be in a better position to address its four major challenges: insufficient capital; industry fragmentation; paucity of innovations; and lack of environmental sustainability. The EPA estimates that maintenance and upgrades of public water systems will require over $344 billion in investment over the next 20 years. The good news, however, is that institutional investors have found major long‐term investment opportunities in water and wastewater infrastructure in the U.K., and have also established a small toehold in the U.S. Focused on increasing the value of the assets they purchase, such active investors can be expected to bring investment discipline as well as capital to water utilities. A more rational approach to the industry's economics will facilitate consolidation of what is a highly fragmented industry, thereby reducing service costs and increasing access to capital, which is badly needed by small U.S. community systems. Contributing further to cost reductions and increased access to capital, a vibrant and commercially oriented industry should also spawn valuable innovation. Finally, more accountable and well‐governed water organizations can become natural leaders in achieving environmental sustainability by ensuring that water is priced to reflect its true costs and that water resources are conserved for the future.     

Defining the road ahead: thinking strategically in the new era of health care reform

Understanding the implications of the new health care reform legislation, including those provisions that do not take effect for several years, will be critical in developing a successful strategic plan under the new environment of health care reform and avoiding unintended consequences of decisions made without the benefit of long-term thinking. Although this article is not a comprehensive assessment of the challenges and opportunities that exist under health care reform, nor a layout of all of the issues, it looks at some of the key areas in order to demonstrate why employers need to identify critical pathways and the associated risks and benefits of each decision. Key health care reform areas include insurance market reforms, grandfather rules, provisions that have the potential to influence the underlying cost of health care, the individual mandate, the employer mandate (including the free-choice voucher program) and the excise tax on high-cost plans.     

University of Texas Roundtable on Financing and Managing Energy Investments in a Low‐Price Environment

During the past 18 months, the U.S. oil industry has seen oil prices plunge from well over $100 a barrel to under $30. In a session that was part of a recent Private Equity Conference at the University of Texas in Austin, the CEO of a small independent producer and a representative of a large global oil and gas company discussed the challenges of financing and operating energy companies in today's low‐price environment with the director of energy research at a brokerage firm, the senior partner responsible for the natural resource investments of a well‐known private equity firm, and the head of the oil and gas restructuring practice of a national law firm. The panelists appeared to reach a consensus on at least the following three arguments:

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