Working Paper No. 23518 Medicaid, the government program for providing health insurance to low-income and disabled Americans, is the largest health insurer in the United States with more than 73 ...million enrollees. It is also the sector of the U.S. public health insurance system that relies most heavily on the tools of regulated competition with more than 60% of its enrollees enrolled in a private health plan in 2014. However, regulated competition in Medicaid differs from the typical model, emphasizing the tools of competitive procurement -- such as competitive bidding, the threat of exclusion from the market, and auto-assignment of enrollees to plans -- to attempt to improve efficiency, instead of relying primarily on the forces of consumer demand. In this paper, we discuss how Medicaid combines the tools of competitive procurement with the tools of regulated competition and some potential consequences of this hybrid model.
Working Paper No. 23444 The Affordable Care Act Marketplaces were introduced in 2014 as part of a reform of the U.S. individual health insurance market. While the individual market represents a small ...slice of the U.S. population, it has historically been the market segment with the lowest rates of take-up and greatest concerns about access to robust coverage. As part of the reform of the individual insurance market, the Marketplaces invoke many of the principles of regulated competition including (partial) community rating of premiums, mandated benefits, and risk adjustment transfers. While the Marketplaces initially appeared to be successful at increasing coverage and limiting premium growth, more recent outcomes have been less favorable and the stability of the Marketplaces is currently in question. In this paper, we lay out in detail how the Marketplaces adopt the tools of regulated competition. We then discuss ways in which the Marketplace model deviates from the more conventional model and how those deviations may impact the eventual success or failure of these new markets.
Nonlinear spatial encoding fields for magnetic resonance imaging (MRI) hold great promise to improve on the linear gradient approaches. Unlike the linear techniques, the nonlinear encoding leads to a ...spatially varying signal-to-noise ratio (SNR). This paper demonstrates the possibility to tailor the encoding fields to focus the high SNR areas to a region of interest. To achieve this, a metric is derived to quantify the spatially dependent performance for arbitrary encoding schemes.
To define the role of surgical shunting for patients with poor hepatic reserve (Child's class C) in the era of TIPS.
Most physicians prefer TIPS to surgical shunting for patients with poor hepatic ...reserve because of anticipated poor long-term survival.
Sixty-two patients of Child's class C with bleeding varices not amenable to endoscopic sclerotherapy or banding were prospectively randomized to undergo TIPS or 8-mm prosthetic H-graft portacaval shunt (HGPCS) from 1993 to 1999. Resource consumption and survival after shunting were determined.
Twenty-nine patients underwent TIPS and 33 underwent HGPCS. After HGPCS, survival at 3 years was favorable but not statistically superior. TIPS was more often associated with shunt stenoses/occlusions, recurrent hemorrhage, shunt revisions, and shunt failure. Long-term follow-up documented that after HGPCS, patients required fewer hospital and ICU days and fewer units of RBCs transfused. After HGPCS, cost of care was less, as was the median cost of care per day of survival.
For Child's class C patients undergoing HGPCS or TIPS, long-term survival is similar, though favoring HGPCS. Similarly, measures of resource consumption and cost of care following hospital discharge favor HGPCS. HGPCS should be preferentially applied for acceptable patients without access to convenient capable post-shunt care or without definitive plans for imminent transplantation.
Insurance markets often feature consumer sorting along both an extensive margin (whether to buy) and an intensive margin (which plan to buy). We present a new graphical theoretical framework that ...extends a workhorse model to incorporate both selection margins simultaneously. A key insight from our framework is that policies aimed at addressing one margin of selection often involve an economically meaningful tradeoff on the other margin in terms of prices, enrollment,and welfare. Using data from Massachusetts, we illustrate these tradeoffs in an empirical sufficient statistics approach that is tightly linked to the graphical framework we develop.
Insurance markets often feature consumer sorting along both an extensive margin (whether to buy) and an intensive margin (which plan to buy). We present a new graphical theoretical framework that ...extends the workhorse model to incorporate both selection margins simultaneously. A key insight from our framework is that policies aimed at addressing one margin of selection often involve an economically meaningful trade-off on the other margin in terms of prices, enrollment, and welfare. For example, while a larger penalty for opting to remain uninsured reduces the uninsurance rate, it also tends to lead to unraveling of generous coverage because the newly insured are healthier and sort into less generous plans, driving down the relative prices of those plans. While risk adjustment transfers shift enrollment from lower- to higher-generosity plans, they also sometimes increase the uninsurance rate by raising the prices of less generous plans, which are the entry points into the market. We illustrate these trade-offs in an empirical sufficient statistics approach that is tightly linked to the graphical framework. Using data from Massachusetts, we show that in many policy environments these trade-offs can be empirically meaningful and can cause these policies to have unexpected consequences for overall social welfare.
Medicaid, the government program for providing health insurance to low-income and disabled Americans, is the largest health insurer in the United States with more than 73 million enrollees. It is ...also the sector of the U.S. public health insurance system that relies most heavily on the tools of regulated competition with more than 60% of its enrollees enrolled in a private health plan in 2014. However, regulated competition in Medicaid differs from the typical model, emphasizing the tools of competitive procurement -- such as competitive bidding, the threat of exclusion from the market, and auto-assignment of enrollees to plans -- to attempt to improve efficiency, instead of relying primarily on the forces of consumer demand. In this paper, we discuss how Medicaid combines the tools of competitive procurement with the tools of regulated competition and some potential consequences of this hybrid model.
Hepatocyte nuclear factor (HNF)4α is a central regulator of gene expression in cell types that play a critical role in metabolic homeostasis, including hepatocytes, enterocytes, and pancreatic β ...cells. Although fatty acids were found to occupy the HNF4α ligand-binding pocket and were proposed to act as ligands, there is controversy about both the nature of HNF4α ligands as well as the physiological role of the binding. Here, we report the discovery of potent synthetic HNF4α antagonists through a high-throughput screen for effectors of the human insulin promoter. These molecules bound to HNF4α with high affinity and modulated the expression of known HNF4α target genes. Notably, they were found to be selectively cytotoxic to cancer cell lines in vitro and in vivo, although in vivo potency was limited by suboptimal pharmacokinetic properties. The discovery of bioactive modulators for HNF4α raises the possibility that diseases involving HNF4α, such as diabetes and cancer, might be amenable to pharmacologic intervention by modulation of HNF4α activity.
► HNF4α modulators were identified by high-throughput screening ► Fatty acids act as HNF4α antagonists in an HNF4α-responsive assay ► Synthetic HNF4α antagonists are selectively cytotoxic to transformed cells
HNF4α is a nuclear receptor transcription factor that plays a central role in differentiation and cellular metabolism. Natural ligands for HNF4α are fatty acids, but there is little evidence that they regulate HNF4α. Now, Kiselyuk et al. describe small molecule HNF4α antagonists and characterize their activity.
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