Friday, March 6, 2015

Universal health coverage in a graphic

The debate on universal health coverage can be captured in the following graphic.


The best that India can hope for the foreseeable future is to achieve high people coverage, of reliable standards, for a defined basic set of medical conditions, involving the more common high-episode (like heart ailments, dialysis etc) conditions. The conditions coverage should include the provision of generic drugs and all basic diagnostic tests, made freely available for those below a certain income level through public facilities as well as by contracting in from private providers. 

Saturday, February 21, 2015

Rising healthcare costs - example of anti-cancer drugs

In the context of rising medical costs without commensurate improvements in health condition, Tim Taylor points to a JEP paper by David Howard, Peter Bach, Ernst Berndt, and Rena Conti on how the life outcomes of anti-cancer drugs has changed with increasing prices in the US market. Their study, which involved studying the pricing trends of 58 anti-cancer drugs (focused on extending survival times for cancer patients) approved for sale in the US between 1995 and 2013, found sharply launch prices with limited increases in life years (estimated from randomized clinical trials or modeling studies that formed basis of FDA approvals).

Their study graphs the treatment-episode costs (in 2013 dollars) vs incremental survival benefits and finds that prices increase by 120% for each additional life year gained or $75000 for each year gained. Further newer drugs are not associated with any increase in survival benefits compared to older drugs.
The second graph plots the drug price per life-year gained (price per treatment episode divided by survival benefits) against the drug's approval date. This shows that drugs price adjusted for benefits and inflation rose by $8500 per year. In other words, patients who paid $54,100 for a year of life paid $139,100 in 2005 and $207,000 in 2013.
While conventional wisdom on drugs pricing focuses on high R&D costs, the authors claims that the real reasons for these large increases with limited benefits may lie elsewhere. They point to reference pricing - the new drug is priced a little higher than its existing competitor - as one contributor. Further, government programs which mandate pharma companies to sell drugs at a discount to certain buyers encourages them to mark-up their sales price for a higher negotiations benchmark.

At a fundamental level, as the authors of the paper claim, the fundamental challenge in managing health care costs is about how physicians, insurers, and regulators should approach "treatments that are more costly but also offer small incremental benefits". 

Thursday, February 19, 2015

More on premature de-industrialization

Dani Rodrik has a new working paper on premature de-industrialization that  highlights the challenge facing countries like India which have staked its growth on manufacturing. He examines the trends in the shares of manufacturing employment (manemp), nominal manufacturing value added (nommva), and real manufacturing value added (realmva) for a sample of 42 developed and developing countries over a long period from late 1940s to early 2010s.

Controlling for various factors, including period and country fixed effects, his regression results point to a much larger effect of premature de-industrialization on manemp than on realmva. For a representative country with median population in the sample (27 million), the manemp peaks at much lower income levels than realmva. The manemp starts to fall after peaking at about 20% at an income level of $5500, while realmva peaks much higher and at a much later stage (in fact at $70000 per capita income). Since the relative price of manufacturing declines as countries get richer, the nommva peaks earlier than realmva.
His model also points to a strengthening of the premature de-industrialization trend among economies since the 1990s. For the representative economy, since 1990 the share of manufacturing employment tends to peak at earlier income levels and at a lower rate.  
The same trend is observed for manufacturing output in recent decades.
Interestingly, Prof Rodrik finds that these trends are less strong for countries, especially from East Asia, who have had a comparative advantage in manufacturing.

These trends can be possibly explained by a combination of two arguments. The demand-side argument is that consumption preferences shift away from goods and towards services as incomes grow. This would cause a shift away from manufacturing in both employment and value added. The supply-side argument is that in view of technological progress and its impact on manufacturing productivity, the elasticity of substitution of labor between manufacturing and other sectors is less than one. However, while this causes the employment share to decline, the share of value added keeps rising. 

Monday, February 16, 2015

Corporate weakness and rising NPAs in India

As we enter Budget fortnight in India, two more signs that a transition to higher economic growth trajectory may be some distance away. First, corporate outlook, a pointer of underlying aggregate demand conditions, as reflected in their earnings data does not look promising,
For the three month period ended December 2014, India Inc’s profit growth has been the worst in five quarters, with the aggregate net profit of 2,941 companies declining 16.9%. Even after adjusting for one-offs (or extra-ordinary transactions), it is down 6.3% over the year-ago period... Sales growth is also the weakest in at least 12 quarters. For the Sensex companies, the reported net profit is down 6.5% year-on-year, its weakest show in six quarters, on a 2.2% decline in sales... On aggregate basis, Sensex profit was 7.5% lower than estimates... FMCG companies witnessed a dismal volume growth of 3-7% due to delay in recovery of urban discretionary demand... Operating profit margins of 1,992 manufacturing companies in the sample were down 100 basis points year-on-year and 140 basis points sequentially, largely due to decline in sales and a rise in employee and power and fuel expenses. 
 Second, BS also points to a rise in gross NPAs among public sector banks, except for SBI,
Barring State Bank of India, most public sector banks reported a sharp rise in bad loans in the quarter ended December, 2014... bad loans of over Rs 24,000 crore were added to already heavy kitty of stressed assets, and public sector banks’ (PSBs) share in it was a staggering Rs 21,466 crore... Banks are likely to see a spike in loan restructuring as the window for getting regulatory leeway in terms of lower provisioning closes on March 31 this year. In the nine months of the current financial year, gross NPAs worth Rs 51,252 crore were added. Thus, outstanding portfolio of bad loans of listed banks was Rs 4, 85,000 crore by the end of December 2014... Rating agency ICRA has indicated that the gross NPAs at system level would breach its earlier estimate of 4.2% by March 2015. It could be around 4.3%.
I have told this story earlier. Aggregate demand remains subdued in the face of inflation-induced decline in purchasing power. Rural demand, a major contributor to aggregate demand in the high growth 2003-08 period, was propped up by both the NREGS employment program and the gradual increases to Minimum Support Price (MSP). Without commenting on its merits, their recent scaling back is certain to adversely affect demand. The resultant downward pressure on top-line growth and profitability of corporates, who are already reeling from debt-laden balance sheets, would discourage new investments. The distressed balance sheets of credit suppliers are only a second order problem. 

Sunday, February 15, 2015

The age of negative interest rates

Nothing captures the consequences of the obsession of world'a major economies with monetary policy fixes to their real economy problems better than this graphic which shows the five year sovereign debt of six countries trading at negative yields.
In other words, investors are paying to hold the debt of these countries. Fundamentally, in a deflationary environment, lenders can make money even with negative interest rates. Further, if market expectations are for further decline in yields, investors can make money by buying even negative yielding bonds as long as their prices keep rising.

The ECB's big bazooka decision to purchase 60 billion euros worth sovereign bonds every month for a prolonged period has jolted central banks outside the eurozone to respond to its potential vulnerabilities. Faced with a weak eurozone and the potential for a break-up of the currency union, speculators have been piling into safer assets of economies like Denmark and Switzerland with the hope of making large profits if those currencies appreciate. Given this and the prevailing deflationary environment, the risks are mainly two-fold - appreciation of currency and accumulation of bad quality assets.

The SNB's decision in mid-January to revoke the euro-franc peg, itself put in place in September 2011 to stem an appreciating currency, was motivated by growing apprehension about the riskiness of rapidly rising stock of eurozone sovereign bonds. The result of revoking the peg was that Swiss franc appreciated over 15% overnight. In order to mitigate the adverse impact on the currency, the SNB simultaneously lowered what it costs lenders to keep money at the central bank from minus 0.25% to minus 0.75%. In contrast, Denmark, which has pegged the krone with euro, appears to believe that the negatives from currency appreciation outweigh the threats from accumulating euro-zone assets. Accordingly, since January the Danish central bank has spent about $24 bn buying euro assets and has lowered rates four times to minus 0.75% on commercial lending.

Sweden and Finland are the latest entrants to the negative interest rate club. The former lowered the benchmark interest rate, the rate at which Swedish commercial banks can take out loans from the Riksbank to minus 0.1%. Last week Finland raised $1.14 bn in a five-year bond auction at minus 0.017%, becoming the first nation in the region to pay negative rates on its debt. Apart from stemming currency appreciation, especially important for countries deeply dependent on exports, negative rates are also aimed at encouraging companies and individuals to invest and spend more and possibly stoke inflation.

It is not just countries that are seeing negative interest rates. Nestle's two year corporate bond, which is due to mature in October 2016, touched the negative territory last week. The eurozone government's austerity programs (and resultant lower deficits) and ECB's sovereign bond-buying program have shrunk the pool of government bonds available for financial institutions (which need safe bonds as collateral for short-term borrowing), forcing them to turn to blue-chip corporate debt. The stock of negative yield sovereign bonds have risen to $3.6 trillion or 16% of global sovereign bonds. See also this and this for more on negative interest rates.