Michael Burry, well-known for his prescient investment strategies, delved early in his career into a distinct and less-publicized bubble within the American healthcare system. Long before he positioned himself against the U.S. housing market collapse, Burry explored the dynamics leading to an explosive increase in rehabilitation medicine driven by federal policies that unintentionally favored such expansion.
In a newsletter published Thursday, Burry revisited a scholarly paper he authored as a medical student extern at Northwestern University in August 1994. The paper provides an analysis of how government reimbursement criteria indirectly spurred the rapid growth of inpatient rehabilitation hospitals. He emphasized the continued relevance of his findings by stating, "the government plays no small role, and the business of medicine follows the incentives that are laid down for it." This observation reflects the enduring impact of federal frameworks on how healthcare providers structure services and investments.
The period from the early 1980s through the early 1990s saw what Burry termed an eruption in the infrastructure of rehabilitation hospitals, which expanded despite broader concerns about escalating healthcare costs during that era. This phenomenon was strongly associated with federal payment policy discrepancies. Specifically, beginning in 1983, acute-care hospitals transitioned into a fixed-payment system, thereby assuming financial risk for patient treatment durations. In contrast, inpatient rehabilitation facilities retained a cost-based reimbursement model. This asymmetry in payment structures markedly influenced hospital practices and strategic decisions.
Under the fixed-payment system, acute-care hospitals faced incentives to minimize patient length of stay to control expenses, as they would not receive additional payments for prolonged care. Conversely, rehabilitation hospitals, reimbursed according to costs incurred, had financial motivations to invest heavily and expand capacity. Consequently, the number of rehabilitation hospitals and specialized units more than doubled within a decade, swelling from 74 to 159 facilities and from 345 to 848 units. Medicare covered over half the patients in these facilities, underlining the sector's dependency on federal healthcare funding.
Burry highlighted that this dependency on federal policy rendered the rehabilitation sector particularly vulnerable to regulatory changes. He referenced a then-proposed rule by the Health Care Financing Administration, the precursor to the Centers for Medicare & Medicaid Services, which aimed to penalize hospitals for discharging patients to rehabilitation facilities. He asserted that such a policy, if enacted, could have devastating effects on rehabilitation medicine nationwide.
His paper serves as an early warning regarding policy-induced bubbles in healthcare, underscoring that these expansions are largely predictable by analyzing financial incentives set by government programs.
In recent policy developments, the healthcare industry continues to confront structural uncertainties tied to federal regulations. The government has proposed new payment models, known as GUARD and GLOBE, to benchmark Medicare drug pricing against international benchmarks, thereby representing efforts to curb rising pharmaceutical expenditures and realign industry incentives.
Market participants in leading healthcare stocks have faced notable volatility as the political landscape surrounding the continuation of Affordable Care Act subsidies remains unsettled. High-profile investors, including Mark Cuban, have voiced concern over the concentration of power within insurance companies and pharmacy benefit managers, accusing these entities of exploiting independent physicians within the current framework. Cuban critiqued the implementation of the ACA, asserting that its present form is flawed, though he attributed this to political mismanagement rather than the legislation itself.
Such commentary indicates ongoing policy friction points and highlights complex challenges inherent in reforming the U.S. healthcare system while balancing cost control, access, and quality.