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Is the PP-ACA Un-Constitutional?

A Texas court has declared the entire ACA unconstitutional

Austin Frakt PhD

By Austin Frakt PhD

And I’ve got an op-ed in the Washington Post about why the court is wrong. Here’s a taste:

Who cares if a zero-dollar mandate is constitutional or not? Why does it matter in the slightest? And what on earth does it have to do with the rest of ACA?

You might have thought that the right remedy would be to invalidate the penalty-free mandate. Doing so would align with Congress’s evident view that an ACA without an individual mandate was preferable to an ACA with it. That’s what I argued in an amicus brief with a bipartisan group of law professors.

Instead, the court held that the entire ACA was “inseverable” from the purportedly unconstitutional mandate. To reach that conclusion, the judge leaned heavily on Congress’s findings from 2010, where it said that the individual mandate was “essential” to the law.

But the mandate that the 2010 Congress said was essential had a penalty attached to it. The finding is irrelevant to a mandate that lacks any such penalty.

In any event, it doesn’t matter what Congress meant to do in 2010. It matters what Congress meant to do in 2017, when a different Congress made a different call about whether the mandate was essential. We know what Congress wanted to do in 2017: repeal the mandate and leave the rest of the act intact. Its judgment could not have been plainer. (I know. I was there! So were you. It wasn’t that long ago.)

***

***

You can read the whole thing here. My co-amici, Jonathan Adler and Abbe Gluck, have a New York Times op-ed sounding similar themes.

I’ll probably write them up more extensively in the coming days, but I’ve also got tentative thoughts about the immediate consequences of the decision (short answer: nothing right now) and the potential difficulties with getting a quick appeal of the decision.

***

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Conclusion

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Doctor Shortage Under Obamacare?

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 Fears Put to Rest

By AUSTIN FRAKT PhD

The demand for primary care doctors has gone up as more people have gotten health care coverage …. But so has appointment availability.

Doctor Shortage Under Obamacare? Fears Are Put to Rest

 Conclusion

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On Non-Financial Conflicts of Interest

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Devastating?

Austin Frakt PhD[By Austin Frakt PhD]

Noam Schieber’s NYT piece today is devastating.

About selecting papers to be most prominently featured at a top economics conference, David Card is quoted,

“‘I choose papers that are going to be written up’ in the mainstream press. […] ‘It’s what the people want.’”

via Non-financial conflicts of interest.

***

Censure

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Assessment

Has this philosophy seeped into medicine, the financial services industry and health economics; etc?

Dr. David Edward Marcinko MBA

More: Another report casts skeptical eye on patient satisfaction surveys

Conclusion

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UPDATE

Conflicts of interest, the NEJM, and where we go next

Posted: 04 Jun 2015 03:20 PM PDT

If you haven’t yet, take a look at Lisa Rosenbaum’s NEJM essays (here, here, and here) calling for new thinking about researchers and financial conflicts of interest. The essays are nuanced and go against the grain of much recent writing on research ethics.

Rosenbaum’s essays have generated many responses (the Lown Institute has collected some of them here). I examine Rosenbaum’s views in an essay in the New Republic. I’m sympathetic to many of her arguments, but I think we need more transparency in science, not less (see also here). Austin explores her views herehere, and here. Rosenbaum has elicited some exceptionally harsh rejoinders, including one from two former editors-in-chief of the NEJM.

This discussion has been intense because the stakes are very high. If manipulated research data allow bad drugs to enter the market, people can die. Conversely, if unjustified prejudice against industry slows the progress of research, that could kill people too.

@Bill_Gardner

Top 12 Articles [Health Administration Reading List]

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On Health Economics, Finance and Insurance, Quality Care and Organizational Behavior

1. Substantial Health And Economic Returns From Delayed Aging May Warrant A New Focus For Medical Research

By Dana Goldman and others (Health Affairs)

2. Trends Underlying Employer Sponsored Health Insurance Growth For Americans Younger Than Age Sixty-Five

By Carolina-Nicole Herrera and others (Health Affairs)

3. Accountable Care Organization Formation Is Associated With Integrated Systems But Not High Medical Spending

By David Auerbach, Hangsheng Liu, Peter Hussey, Christopher Lau, and Ateev Mehrotra (Health Affairs)

4. The Quality Of Care Delivered To Patients Within The Same Hospital Varies By Insurance Type

By Christine S. Spencer, Darrell J. Gaskin, and Eric T. Roberts  (Health Affairs)

5. Understanding State Variation In Health Insurance Dynamics Can Help Tailor Enrollment Strategies For ACA Expansion

By John Graves and Katherine Swartz (Health Affairs)

6. When Medicare Cuts Hospital Prices, Seniors Use Less Inpatient Care

By Chapin White and Tracy Yee (Health Affairs)

7. More Americans Living Longer With Cardiovascular Disease Will Increase Costs While Lowering Quality Of Life

By Ankur Pandya, Thomas Gaziano, Milton Weinstein, and David Cutler (Health Affairs)

8. Surgical Skill and Complication Rates after Bariatric Surgery

By John Birkmeyer and others (New England Journal of Medicine)

Reading list

9. Who Is in Control? The Determinants of Patient Adherence with Medication Therapy

By Sergei Koulayev, Niels Skipper and Emilia Simeonova (National Bureau of Economic Research)

10. Fifty Years of Family Planning: New Evidence on the Long-Run Effects of Increasing Access to Contraception

By Martha Bailey (National Bureau of Economic Research)

11. Identifying the Health Production Function: The Case of Hospitals

By John Romley and Neeraj Sood (National Bureau of Economic Research)

12. ACA Standoff

By Jeffrey Drazen and Gregory Curfman (New England Journal of Medicine)

Assessment

Feel free to send us links to your own hot topic reading list so that we may share.

Conclusion

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What If Broccoli Were Like Buying Health Insurance?

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Some Food for Thought

Source: Jen Sorensen via Austin Frakt PhD of the Incidental Economist.

Assessment

Many a true word hath been spoke in jest. [c 1665 in Roxburghe Ballads (1890) VII. 366].

Conclusion

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Some Thoughts on the Marginal Healthcare Dollar

Can this Vital Buck be More Efficiently Used?

By Dr. David Edward Marcinko MBA CMP™

[Editor-in-Chief]

Recently, healthcare economist Austin Frakt PhD offered these points about healthcare dollars spent on the margin:

1. Spending on health is not without value. It does improve lives [See Cutler]. Yet, we spend much to get that value.

2. Price per QALY is very high [See Aaron’s series on spending and his other on quality).

3. Just staying within the realm of health, the price per QALY on another “service” might be a lot lower [like nutrition, exercise, and healthy habits, etc].

http://theincidentaleconomist.com/wordpress/could-the-marginal-health-care-dollar-be-put-to-better-use/?utm_source=feedburner&utm_medium=email&utm_campaign=Feed%3A+TheIncidentalEconomist+%28The+Incidental+Economist+%28Posts%29%29

Note: The quality-adjusted life year (QALY) is a measure of disease burden, including both the quality and the quantity of life lived. It is most often used in assessing the value for money of a medical intervention. The QALY model requires independent utility, neutral risk and constant proportional tradeoff behavior.

Understanding Marginal Profit

Recalling the equation: Profit = (Price x Volume) – Total Costs

We could amend it and say that:

Total Profit = P x V – (FC + VC) or: Total Profit = Price x Volume – (Fixed Costs + Variable Costs)

However, most medical office or clinic contracts today are based not on total profit, but on additional or marginal profit, because overhead costs always remain and clinic fixed costs are not important in contracted medicine.

And, for other pricing decisions, the equation can again be re-written, to emphasize variable costs, as follows: Marginal Profit = (P x V) – VC.

In other words, the marginal benefit must exceed the marginal cost of practice.

Cost-Volume-Profit Analysis

Now, once a basic understanding of marginal profit and medical cost behavior is achieved, the techniques of cost-volume-profit analysis (CVPA) can be used to further refine the managerial cost and profit aspects of the medical office business unit. CVPA is thus concerned with the relationship among prices of medical services, unit volume, per unit variable costs, total fixed costs, and the mix of services provided.

Assessment

Austin felt that if [*]od were jointly designing all health-related systems and functions of society and government – He’d look at the marginal cost/QALY over all possible ways to spend the next dollar and pick the smallest. How about you?

But, it’s not always going to be on health care services and it probably isn’t given what we’re already spending for those and what we’re getting for that spending.

Conclusion

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Is There an “Efficient Frontier” for Medicare Payment Reform?

An Essay on Financial Health Risk Self-Selection

By Dr. David Edward Marcinko MBA CMP™

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[Publisher-in-Chief]

Health economist Austin Frakt PhD, of the Incidental Economist, alerted us to this recent publication “Achieving Cost Control, Care Coordination, and Quality Improvement through Incremental Payment System Reform”, by and from: (Averill, et al., JACM, 2010). The paper describes various Medicare payment reform methods.

The Abstract

The healthcare reform goal of increasing eligibility and coverage cannot be realized without simultaneously achieving control over healthcare costs. The reform of existing payment systems can provide the financial incentive for providers to deliver care in a more coordinated and efficient manner with minimal changes to existing payer and provider infrastructure. Pay for performance, best practice pricing, price discounting, alignment of incentives, the medical home, payment by episodes, and provider performance reports are a set of payment reforms that can result in lower costs, better coordination of care, improved quality of care, and increased consumer involvement. These reforms can produce immediate Medicare annual savings of $10 billion and create the framework for future savings by establishing financial incentives for long-term provider behavior changes that can lead to lower costs.

Patient Risk Sharing

Of course, the third dimension of risk [beyond traditional doctor/hospital provider and Medicare insurer] would be the risk borne by the patient insured (degree of cost-sharing or “consumer responsibility”). This relationship is represented diagrammatically right here:

Brief Review of MPT

Modern portfolio theory (MPT) attempts to maximize investment portfolio expected returns for a given level of risk by carefully choosing the proportions of various asset classes. As a mathematical formulation, the concept of diversification aims to select a collection of assets that collectively lowers risk [measured by standard deviation] more than any individual asset class. This pleasing point is known as the “efficient frontier.” And, it can be seen intuitively because different types of assets often change in value in opposite ways.

Is There an Insurance Efficient Frontier?

Health insurance [medical payment reform] econometric considerations may now be extended in this analogy to suggest that medical providers and CMS payers are the surrogates for two dimensions in the MPT. The third might be the risks borne by the patient insured (degree of cost-sharing or “consumer responsibility”), as above.

Assessment

Then, patients could self-select where they wish to fall on the health insurance “efficient frontier”, balancing all three dimensions as in MPT, along with lifestyle and moral hazard considerations, etc.

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Is there an “efficient frontier” for Medicare payment reform?

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