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Does President Trump Read “JAMA Network Open?”

It is doubtful Trump reads much beyond his own signature on Executive Orders and Twitter commentary. Someone is attempting to align him with current thinking creating a persona of his being a thoughtful and reasoning president as opposed to . . . ?

In “Again, Healthcare Cost Drivers Pharma, Doctors, and Hospitals ,” I had posted stats from a 2016 JAMA paper covering the period from 1996 to 2013. Healthcare costs had increased $1 trillion of which 50% was due solely to pricing. One significant factor in the JAMA report was the $66 billion increase in costs for diabetes treatment of which $44 billion was due to pharmaceuticals pricing. One impact to diabetes treatment was Eli Lilly’s increases for Humalog which was $21 per vial in 1996. By 2017, the price increased to $275 (700%) for a vial, a one-month supply. Humalog is a decades old drug and the manufacturing has not changed significantly.

“JAMA Network Open” has issued an end of May 2018 paper on pharmaceutical pricing trends covering the years from the period 2012 – 2017, “Trends in Prices of Popular Brand-Name Prescription Drugs in the United States.” The question it asks:

• What are the prices of top-selling brand-name prescription drugs in the United States and how have these prices changed in recent years?

answer:

• In this evaluation of 49 common top-selling brand-name drugs; 78% of the drugs have been available since 2012, have seen an increase in insurer and out-of-pocket costs by more than 50%, and 44% have more than doubled in price.

and concludes:

• Brand-name drug pricing associated with government-protected market exclusivity is likely to continue to increase and warrants greater price transparency.

Similar to what President Trump has proposed which “still” does not empower constituents to seek alternatives and typically the alternatives are just as costly.

Study Methodology

Data was obtained of 35 million individuals from the Blue Cross Shield Axis (data base) for the time period of January 2012 through December 2017. The researchers reviewed prescribed drugs exceeding $500 million in US sales or $1 billion in worldwide sales.

Within the identified parameters of 2012-2017 sales, 132 brand-name prescription drugs were identified. 49 of the 132 top-selling drugs exceeded 100 000 pharmacy claims, substantial cost increases among these drugs was experienced within the inclusion parameters with a 76% median cost increase, and 48 of the drugs had regular annual or biannual price increases.

Thirty-six of the 49 drugs were available since 2012. Twenty-eight had experienced an increase in insurer and out-of-pocket costs exceeding 50% and 16 more than doubled in price. Insulins such as Novolog, Humalog, and Lantus and tumor necrosis factor inhibitors such as Humira and Enbrel experienced highly correlated price increases coinciding with some of the largest growth in drug costs.

The results of the study revealed the median sum of out-of-pocket and insurance costs paid by patients or insurers for common prescriptions and presented both annually and monthly.
Pricing increases for 13 new drugs from January 2015 through December 2017) and entering the market in the last 3 to 6 years was not different than those (36) having been on the market longer, a 29% increase [median] from January 2015 through December 2017.

Nor did the study differentiate between drugs with or without a FDA approved therapeutic equivalent (number of drugs, 17 vs 32; median, 79% vs 73% price change).

Changes in prices paid were highly correlated with third-party estimates of changes in drug net prices (ρ = 0.55; P = 3.8 × 10−5), suggesting that the current rebate system incentivizes high list prices and greater reliance on rebates resulting in increased overall costs.

“The study concludes the growth of drug spending in the United States associated with government-protected market exclusivity is likely to continue. Greater price transparency is warranted.”

Interpretation? Pharmaceutical companies (and I will include companies such as Mylan [EpiPens]) are using the patent drug laws and resulting exclusivity time period to maximize profit margins ($14.50 for every $1 invested [WHO]) protecting their products from competition. A similar exclusivity holds true for generic products also (time periods for the introduction for a similar generic product). “Can You Patent The Sun (Jonas Salk)?

I sat over dinner with one Exec. VP from a major pharmaceutical company who confirmed what I had said in an earlier post (Can You Patent The Sun?) and here. A new pricing strategy is being used by pharmaceutical companies which maximizes return based upon benefits achieved in treatment, life, healthcare system, and in society. It is a well thought out reasoning being delivered by intelligent purveyors of healthcare supplies portraying a modicum of caring or concern for societal welfare while pursuing the profit motive. Novartis CEO Vas Narasimhan (not the one I talked to);

“Cell and gene therapies are bringing about a new era of cancer medicines going beyond ‘just improving lives and are saving them.’ The new therapies are challenging the traditional model for paying for medical treatment and the industry is divided on this approach. Pricing for these one-time usage therapies are to be based on four key measures of value – the improvements they offer to patients both clinically and in terms of their quality of life, and the resulting benefits to the health-care system and society.”

The pricing application is not limited to new drugs, cancer meds and gene/cell therapies; it is also being applied to older drugs and also generic replacements.

Findings:

Between 2012 – 2017, the study reveals an industry wide increase in costs for top-selling brand-name prescription drugs and less costly generic replacements. The increase in costs, biannual, and annually for 36 pharmaceuticals since 2012 can also be seen in newer drugs coming on the market after 2012. A pattern or practice of pricing determination based upon 4 values in the pharmaceutical market which will continue into the foreseeable future.

This particular chart depicts annual net price and annual paid price increases showing the percentage increases. This becomes more interesting where I cover “rebates” and whether the reduce costs.

Given median cost increases of 9.5% annually, the yearly increases will result in a doubling of costs for brand name drugs in this study every 7 to 8 years.

New and old brand-name competition does little to control rising costs of products which can be used interchangeably (hence this shoots transparency in the foot for constituents talking to pharmacists) such as Humira and Enbrel or diabetes drugs such as Humalog, Humulin, and Novolog. “Relative cost changes are highly synchronized” resulting in large increases over the last 6 years. As mentioned there appears to be a pattern or practice of pharmaceutical companies acting in concert.

There is little evidence of price changes associated with the existence of therapeutic equivalents such as generics, biosimilar drugs, or drugs entering the market later.

Legislated pricing transparency may lead patients to seek alternative drugs if available which may result in different pricing trends than what was observed over the six years of when the study was done. The impact of such is unknown as is the likelihood of those trends as they may already be in progress due to volume changes or speculation of volume changes due to expiration of exclusivity.

Neither was there evidence of products entering the market 3 to 6 years ago having different trends compared with other drugs in the first years of availability.

Transparency is need in the costing of drugs and the setting of prices by manufacturers. Only in the US, does the manufacturers of the product set the pricing. In Europe, pricing is influenced by governments.

Research and Development

There is a balancing act between reasonable pricing for consumers and the costs for bringing innovative drugs to market. The United States does provides strong patent laws globally. However, legal strategies by the pharmaceutical industry such as patenting the peripheral aspects of a drug (think EpiPen and its cap) extend protections beyond the original patent and delay generic and biosimilar versions. Furthermore, if a generic version brought to market by one company can not be used in the same manner by following the instructions of the brand name version; the company of the patented version can ask the FDA to block the generic version (again think Mylan’s Brand EpiPens and the TEVA generic [See; “Can You Patent The Sun?“]).

Healthcare and pharmaceutical companies can maintain exclusivity and pricing as set by the manufacturer much longer and well beyond the original patent limits with a range of new innovations. In similar countries as the US as found in western Europe, governments set pricing. The end result is a large discrepancy in pricing between the US and European countries for the same drug.

It is near impossible for private insurers to negotiate pharma pricing and Medicare is forbidden to do so. The Institute for Clinical and Economic Review’s value-based price benchmark is one approach to establish appropriate pricing. Using the four key measures the ICER assigned a cost effectiveness value of up to $1,688,000 for Kymriah for its use in children. This analysis takes into account all of the R&D cost in developing a drug, bringing it to market, and the cost save as measured against other therapies. Using the same ICER 4-point value-based analysis and understanding the range effectiveness determined by the ICER, Novartis set Kymriah list price for pediatric use at $475,000, well below the ICER’ cost effectiveness value, and $373,000 for adult cancers.

So, how is this drug paid for by the less financially endowed patients? Coupons by the manufacturer and rebates to the insurance payor set a net price for the patient which is price and profit neutral.

Rebates

Several points; Transparency of how rebates occur and affect net pricing is limited as to the impact of them on the pharmaceutical industry and healthcare insurance, rebates on list prices set by manufacturers are given by the manufacturers to commercial healthcare insurance and some government programs not including Medicare, and the rebates will vary by drug, by payer, and constitute “16% of all private insurer-branded drug spending returned as rebates in 2016.”

Whether rebates lower or increase costs is debated due to the lack of transparency of their application.

Due to the lack of data, this particular JAMA study used third party information or estimates of net price data on each drug. The observations did reveal a high correlation between increases in the rates of insurer and out-of-pocket costs paid for each drug and the net prices (ρ=0.55). The association suggests the offered industry supposition of higher list prices and greater reliance on rebates reducing costs may not be true.

Instead and a bit redundant by me, the paper offers an opposing supposition of increases in list prices, and the resulting increases in insurer and out-of-pocket costs paid, may coincide with increases in net prices, which in turn make these drugs more expensive overall. Seemingly biannual price increases should not be considered benign pricing strategies to offset paid against net price discrepancies in the current rebate system.

If true, this would be a façade making it appear rebates have an impact on final costs to the healthcare system and pricing to the patient. Rebates may only be a shuffling $dollars around.

Greater transparency of the process is needed to determine what is and what is not a cost save. The transparency is not for the purpose of patients deciding what to buy or pharmacists to recommend alternatives; although, it could be used by constituents to support healthcare proposals to bring prices down.

A healthcare system and its coverage without a foundation or mechanisms to control or account for costs is simply a blanket to pricing and hides its impact.

Run75441 (Bill H)

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Two articles to think about, one on opioids, the other billing for hospital care

Via Naked Capitalism:

Place based economic conditions and the geography of the opioid overdose crisis

By Shannon Monnat, Associate Professor, Syracuse University. Originally published at the Institute for New Economic Thinking website

Over 400,000 people in the U.S. have died from opioid overdoses since 2000. However, there is widespread geographic variation in fatal opioid overdose rates, and the contributions of prescription opioids, heroin, and synthetic opioids (e.g., fentanyl) to the crisis vary substantially across different parts of the U.S. In a studypublished today in the American Journal of Public Health, we classified U.S. counties into six different opioid classes, based on their overall rates and rates of growth in fatal overdoses from specific types of opioids between 2002-04 and 2014-16 (see Figure 1). We then examined how various economic, labor market, and demographic characteristics vary across these different opioid classes. We show that various economic factors, including concentrations of specific occupations and industries, are important to explaining the geography of the U.S. opioid overdose crisis.

 

1 in 6 hospital patients get a surprise bill for out of network care

By Rachel Bluth, Kaiser Health News reporter. Originally published at Kaiser Health News.

About 1 in 6 Americans were surprised by a medical bill after treatment in a hospital in 2017 despite having insurance, according to a study published Thursday.

On average, 16% of inpatient stays and 18% of emergency visits left a patient with at least one out-of-network charge. Most of those came from doctors offering treatment at the hospital, even when the patients chose an in-network hospital, according to researchers from the Kaiser Family Foundation. Its study was based on large employer insurance claims. (Kaiser Health News is an editorially independent program of the foundation.)

The research also found that when a patient is admitted to the hospital from the emergency room, there’s a higher likelihood of an out-of-network charge. As many as 26% of admissions from the emergency room resulted in a surprise medical bill.

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Social Security and the NYT

(Dan here….)  Via the New York Times comes an article on the Social Security shortfall.  No explanations given for what the shortfall context is, and not till the end was a fix suggested.  In comments calling SS a ponzi scheme (with no explanation) was common, or with the fix mostly was about lifting the cap.  Only one commenter referred readers to a Bruce Bartlett article from 2013 on the matter,

From an e-mail by Dale Coberly

Forgive me,  I have studied this problem and may actually know what I am talking about.
All we have to do is pay an extra dollar per week per person per year.  After next year It will be more like a dollar and ten cents.  And if we wait another year it will be about a dollar and twenty cents for the first few years,  then a great deal less than a dollar per week on average. This would keep Social Security solvent essentially forever.  The Deputy Chief Actuary at Social Security agrees that this is true.
This would mean people are paying more, but not a lot more, for their Social Security.  That is they would be setting aside enough money through Social Security to save enough to live on when they will no longer be able to work.  Don’t fool yourself:  working longer is not going to be possible for at least half the population.  And since they will have paid for it themselves, there is no reason they should not be able to retire if they want to even if they “could” work longer.
The Social Security Trustees Report says that about a one and a half percent (about fifteen dollars per week) one time “immediate and permanent” increase  would keep SS solvent for the next seventy five years.This would not be a real burden, or even noticeable once people got over their overreaction to the increase.  Even the about twenty dollars per week that would come in 2035 or so if we wait to the last minute will not be a real burden.  Wages will have risen by about two hundred dollars per week by then.  Again, no no one would think twice about it if it weren’t for the Big Liars making it sound like some kind of tragedy:  “You are going to have to put aside an extra twenty dollars per week, out of your two hundred dollar raise, in order to have enough to live on for the extra two to four years you will expect to live.” [Dollar amounts are in present terms.  SS pay as you go financing automatically takes care of inflation and real interest.]
The thing is they keep talking about it as if “we” — that is “the government”– can’t afford it.    But we — that is each of us — certainly can afford it.
But “they” want to talk about it as if “the government” was going to have to come up with trillions of dollars.  And they call it “socialism.”  Meanwhile the “progressives”  want to make it socialism by “making the rich pay” for it.
Social Security was carefully designed to NOT be welfare. It’s just the worker saving enough of his own money to pay for his own food and shelter when he will be too old to work, and insuring himself against the possibility that otherwise he might not be able to save enough. The government does not pay for any of this. The “rich” do not pay for more than they will get back with reasonable interest, including its insurance value.
Since you have been lied to intensively for at least the last thirty years,  you will not easily understand this or believe it. But it can be proven with attention to real math and real facts. There is no hope the people will understand it if no one tells them. The question is are you willing to do the work?

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Income Inequality (I’m tooting my own horn)

I’ve been on the beat of income inequality since I started blogging here.  My theory: We changed the way we make money from one of making it from producing (polishing rocks into tools) to one of making money from money.  When you can make money from moving money, you don’t need to compete.  Just buy back your stock, just collect rents, just get your tax cuts.

The World Bank has a new report out on Inequality 2018.   I want to direct you to a chart that appears on page 7.

World Bank Inequality 2018 Report Chart

Now, here is one half of the chart I posted December 7, 2007.

Income vs Consumption 1963 to 2005

Notice the approximate time of the crossing over of the Bottom 99%’s income vs the Less chained Personal Outlay?  Look at that top chart from the World Bank. Notice the date?

I will tell you, that the 2 dates coincide with one other number.  15%.  That is the share of income I calculated at the time of crossing over of my chart for the 1%.  All of this was done using Saez’s data.   One more chart.  The other half of my December 7, 2007 posting.

Income vs Consumption 1929 to 1962

This is the first half of my data for that December posting.  Notice what happens around 1942.  At that crossing over, the top 1% share of income falls below 15%.  Coincidence?

Prior to 1942, we were coming out of the Great Depression.  The relationship of the 3 lines in my chart prior to 1942 look to be the same as after 1996.

One other thing to notice, around 1988.  The share of income for the 99% fell below disposable income.  Prior to this since 1942 it was riding even to sometimes above the disposable income.  You know what happened in 1988?  Two years past the 1986 tax law with the reduction of the top tax rates, reduced to 3 brackets and changes made to be able to pay more with stock shares.  Prior to that, it became legal in 1982 for companies to buy back stock.

We changed how we make money and no one is pointing this out as to why the nation is in such a mess.  It won’t matter if we bring back manufacturing.  It won’t matter if we raise the minimum wage.  Neither of these things will make the full change we want such that we revert back to post 1942/pre 1988.  We have to change the way we make money.

One last thing I wish those running for president would point out: Taxes are not bad.  They are not the problem.  How we are spending the money is the problem.   You know, spend it so we are actually building nations/public capital instead of letting the current capital be sucked dry!

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Robert J. Samuelson Goes Whole Hog Against Dems On Social Programs

Robert J. Samuelson Goes Whole Hog Against Dems On Social Programs

I want to follow Dean Baker in dumping on the Robert J. Samuelson Monday, 9/11/19 WaPo column on “The Democrats’ fairy-tale campaigns.”  He may be right that lots of proposals have been put forward with no clear accounting of how much all of them will cost, but RJS also fails to recognize some might save money, such as a properly structured universal health care program that might move us more towards the costs we see in other nations.  Of course, RJS regularly uses this column to call for cuts in Social Security benefits, so that some of these candidates dare to call for increased such benefits has him really riled up.  How dare they!?!?

Aside from reminding that RJS has regularly been misguided on Social Security projections, he goes after  him for not noting the role of patents and other regs supporting monpoly power, especially in the health care sector, including supporting outrageously high doctor salaries.

As it is, RJS whines about the size of budget deficits and claims the next president will need to increase defense spending.  This latter is not obvious. Trump has done a lot of increasing it, and restoring damaged US alliances does not obviously call for more spending.  How about just behaving better and making outrageous demands of US allies, including a stupid trade war?

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Scenes from the May employment report: expect more lackluster reports, and layoffs in manufacturing

Scenes from the May employment report: expect more lackluster reports, and layoffs in manufacturing

Three months ago when the poor February jobs report came out, I was just about the only commentator who saw it as a harbinger rather than an outlier. On Friday the naysayers got silenced.Let’s see how the more leading aspects of the employment report played out, with an eye towards the near future. To cut to the chase, expect more lackluster total payroll gains in the coming months, and further, it is a near certainty that there will be layoffs in manufacturing, probably totaling at least 50,000.

But first, let’s take a quick look at wage growth, which has pulled back slightly from the beginning of this year. Nominal wage growth is significant because employers do not give out inflation-indexed wage increases, and the pattern is that, as underemployment decreases below about 9%, wage growth increases:

That isn’t cause for concern yet, given the noise in the series, including at least two prior temporary downturns in this expansion alone. But on the other hand, note that an extended period of a slowdown or flatness in growth has tended to occur in the final stage of expansions. This is best shown when we track the YoY change in percent of wage growth itself (i.e., the second derivative), averaged quarterly in the graph below:

 

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For party voting preference, which is more important, age or education? Looks like we have an answer

For party voting preference, which is more important, age or education? Looks like we have an answer

For all the slicing and dicing that has been done in voting metrics for 2016 and 2018, one quandary has stood out. We know that higher educational attainment has strongly correlated with voting for Democrats, and we also know that there was a stark age difference in votes between Clinton and Trump in 2016: a majority of voters younger than 45 voted for Clinton, while a majority over 45 voted for Trump.

But the level of educational attainment has not remained static over time. With each passing generation, more and more students are getting a college degree, and advanced degrees as well.

So are the voting patterns mainly showing us that more younger voters have college degrees? Or is it really about generational experience? For example, is a Silent Generation or Boomer college graduate more likely to vote Democrat than a GenXer or Millenial with no college? This week I finally saw a graphic that spells out the answer, and here it is:


Age is more decisive, hands down. The only anomaly that even comes close is that voters aged 30 to 44 with a high school degree were only slightly more likely to vote Democratic than voters aged 45 to 64 without a high school degree.

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A Bernie Sanders Narrative for Seniors

A Bernie Sanders Narrative for Seniors

What follows is some unsolicited advice for the Sanders campaign.

Politico has an important piece on the downside of the extraordinary age bias in Sanders’ support.  Like a teeter totter, the large advantage Sanders enjoys among younger voters is counterbalanced by his dismal showing among the older crowd.  The article reviews voting breakdowns from the 2016 campaign and current poll results, and it shows that Sanders is not just behind among seniors, but way, way behind.  His political strengths guarantee he will survive the winnowing of the twenty-odd 2020 pretenders, but sheer arithmetic suggests he will need to make significant inroads among older voters, something he hasn’t done up to this point, to overtake Biden—assuming of course Biden doesn’t overtake himself.

So how can he do this?  The first thing to realize is that he doesn’t need absolute majorities among retirees and near-retires, just enough support so his advantage among the non-elderly isn’t erased.  The second is that direct material benefits alone are never enough.  People don’t simply vote in their immediate financial interest, although of course interests play an essential role.  Economic motives are like nuclei around which layers of narrative form, but it’s the narrative—the meaning—that orients people, and an economic condition can be explained in multiple ways.  Not all explanations are equally valid, of course, but in politics that’s largely irrelevant.  So yes, Sanders can and should talk up Social Security expansion and how universal health insurance would benefit  those on Medicare too.  But that’s not a sufficient political strategy; it lacks an encompassing narrative.  This narrative doesn’t have to be one all older people will gravitate to, but it has to speak to a significant portion of them.

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A Very Erroneous Chart in the Economic Report of the President

A Very Erroneous Chart in the Economic Report of the President

Menzie Chinn has been reading the latest Economic Report of the President and finds a very erroneous and misleading chart, which is figure 1-6 from this this document (see page 45), which states:

Equipment investment, in particular, exhibited a pronounced spike in the fourth quarter of 2017, as both the House and Senate versions of the TCJA bill, which were respectively introduced on November 2 and November 9, stipulated that full expensing for new equipment investment would be retroactive to September 2017. This created a strong financial incentive for companies to shift their equipment investment to the fourth quarter of 2017, so as to deduct new equipment investment at the old 35 percent statutory corporate income tax rate. After the initial spike in the rate of growth in fixed investment, standard neoclassical growth models would predict a return of the rate of growth to its pre-TCJA trend, but from a higher, post-TCJA level, with the capital-to-output ratio thereby asymptotically approaching its new, higher steady-state level.

Earlier on page 43 we see:

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Tariffs and Monetary Policy: Moral Hazard and Rent Seeking

Tariffs and Monetary Policy: Moral Hazard and Rent Seeking

President Trump’s threat to impose tariffs on Mexico over immigration has pushed Federal Reserve Chair Jay Powell to say that if the tariffs lead to economic growth slowing, the Fed will cut interest rates.  While the bump may be about to end, this announcement was followed by a  solid global surge of stock markets on June 4 followed by smaller increases the next day.  This sets up a moral hazard situation for Trump where if he behaves irresponsibly on trade policy (with even GOP senators basically freaking out), the Fed might bail him out with interest rate cuts.

How is rent seeking entering into this?  I note a point just made by Dean Baker, that all these tariffs Trump is imposing on his own without any Congressional approval offer him the option of allowing specific exemptions from them.  So Trump can grant exemptions to specific sectors or even firms that favor him.  So Trump’s trade wars are opening up a whole new vista for rent seeking.

Finally, and unsurprisingly, many of his trade policies look to fail to achieve their supposed goals.  This is pretty obvious for the case of the tariffs on Mexico, which by potentially weakening the Mexican economy weaken Mexico’s ability to reduce Central Americans from to the US.  Another case involves the Chinese firm Huawei, supposedly both to enhance US national security and support the US high tech sector.  But according to a story in the Washington Post, 6/5/19 reports that 61 percent of experts say that Trump’s ban on US firms supplying parts to Huawei will both weaken US national security by reducing US influence over Huawei and the whole 5G sector, with the relevant US firms being hurt.  I do not think even the Fed can bail the US economy out from this mess.

Barkley Rosser

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