Healthcare Economics and Policy

One of my biggest frustrations with private practice isn’t the practice of medicine—it’s trying to be entrepreneurial in healthcare without violating Stark or Anti-Kickback. These laws don’t just discourage abuse—they discourage innovation. For physicians, the current interpretation makes any new service, tool, or care model legally hazardous unless you partner with a hospital or hand it over to a corporate middleman. The rules are vague, the penalties are severe, and the process is so convoluted that even compliance requires legal teams most physicians can’t afford. Meanwhile, large institutions carve out exceptions, restructure arrangements, and walk right through loopholes that would trigger enforcement for any independent doctor. The result? Fewer physician-owned ventures. More consolidation. Higher costs. Less choice. And a system where the people actually delivering care are the least empowered to improve it. We can’t fix healthcare until we stop tying down the very people who are most capable of building a better version. #deltadocs Jon Kimball, MD David Yam

After years of tension over the corporate practice of medicine, the American College of Emergency Physicians and American Academy of Emergency Medicine (AAEM) now have the same position on CPOM. ACEP's new policy opposes non-physician ownership of emergency medicine practices. It also opposes the "friendly physician" model, where a physician "owns" an LLC on paper, while a large company actually runs the EM practice. "Ownership of medical practices, operating structures, and models should be physician-led and free of corporate influence that impacts the physician-patient relationship. The following types of medical practice ownership and operating structures would likewise constitute the prohibited corporate practice of medicine: ● Ownership of an emergency medicine practice or group by non-physician owners or by physicians who do not have responsibility for the management, leadership, and clinical care of the practice. ● Restricting access of emergency physicians to information and accountings of billings and collections in their name as described in ACEP’s policy statement “Compensation Arrangements for Emergency Physicians." The question is whether (and how) ACEP & AAEM will enforce this policy - possibly via censures of "friendly physicians". #emergencymedicine

The headline that caught my eye this week was "Life expectancy for Californians still lower than before COVID — here's why." Here's my take: The early evidence from California suggests a stubborn persistence of pandemic effects long after most people have "moved on." California's life expectancy in 2024 was 80.54 years, still 0.86 years shorter than it was in 2019. The drivers of mortality have shifted during this period, though, making the potential effects of the pandemic more subtle. For the first time since the pandemic began, drug overdoses and cardiovascular disease now account for a larger share of life expectancy decline than COVID itself. Drug overdoses represented 20 percent of the decline, cardiovascular disease 16 percent, and COVID just 13 percent. The question, however, is whether the cardiovascular disease and even drug overdose effects are somehow also tied to the pandemic. Some researchers, for example, attribute the cardiovascular changes to delayed care during the early pandemic, as people avoided hospitals even during heart attacks out of virus fears. Others point to rising obesity rates or long COVID's inflammatory effects on the heart. Three points here.   1️⃣ I had said at the time that the "skipped" care during the pandemic could prove to be an important test of value in healthcare — if we could skip a bunch of healthcare during the pandemic and do not suffer any subsequent health consequences, it would suggest the skipped care wasn't useful. The opposite, though, can highlight the most important types of healthcare delivered. 2️⃣ Robin Brooks, William Murdock, and I had shown that the effects of the pandemic on prices were remarkably persistent. It will be interesting to see if this same type of "long tail" to the pandemic applies to health outcomes also, as this early evidence suggests. 3️⃣ All these life expectancy measures are "period" rather than "cohort" measures — which means they don't actually measure how long a person born today is expected to live. Instead, they construct a hypothetical person with the survival experience of people at each age alive last year.  That's a convenient way to do the calculation but it generally doesn't line up with how most people think about their own mortality. https://lnkd.in/eeydG2Kd

Gender equality and disability inclusion are essential to creating societies where everyone has equal opportunities and access to resources. This document presents a structured approach to addressing the unique challenges faced by women and girls with disabilities, shedding light on systemic barriers such as discrimination, economic exclusion, and restricted access to education and healthcare. By focusing on participatory approaches, it ensures that those directly affected are involved in shaping solutions, fostering a more inclusive and representative decision-making process. Beyond identifying obstacles, the document provides concrete strategies for making development efforts more inclusive. It explores ways to dismantle harmful social norms, enhance service accessibility, and create economic opportunities that empower women with disabilities. Through real-world examples and evidence-based recommendations, it illustrates how inclusive policies and programs can lead to lasting improvements. The guide also highlights the role of strong legal frameworks and institutional accountability in sustaining progress. For those working to advance gender equality and disability rights, this resource serves as a practical tool for integrating inclusive principles into programs and initiatives. It offers step-by-step guidance on embedding accessibility, participation, and equity into various sectors. By prioritizing lived experiences and collaborative approaches, it reinforces the importance of ensuring that solutions are not only well-designed but also driven by the voices of those most affected.

Eli Lilly released vials of Zepbound at over a 60% discount to the pen list price, but there are several nuances to be aware of. --- Last week, Eli Lilly and Company helped address the Zepbound shortage and price barriers by releasing single-dose vials (announcement in the comments). Vials are cheaper and easier to manufacture for Lilly, but require a few more steps to administer than the pens--like filling the correct dose into the syringe yourself. I included the videos for using the pen vs the vial in the comments. Self-dosing has been a common issue with the compounded versions of tirzepatide. --- The list prices are also different. Lilly lowered the #DrugPrices to $399 (2.5 mg) and $549 (5 mg) for a 4-week supply (compared to the $1,059.87 list price), but didn't make the higher doses available as vials. These vials are also only available through LillyDirect to cash-pay patients. (Important fact: Medicare doesn’t cover #obesity treatments and doesn’t allow patients to use drug coupons) While some patients can achieve the desired #WeightLoss on these doses, most patients need the higher doses to reach their goals. Those higher doses are still only available as pens, and Lilly increased the prices for those using their patient assistance program (restricted to those with commercial insurance that doesn't cover Zepbound) from $550 to $650/month. Lilly also has significant rebates for Zepbound, so the net prices through insurance are likely around $600/month--making these new cash prices a new lowest net price. --- Unfortunately, this announcement wasn't as straightforward as "Eli Lilly lowered the price for Zepbound to $399."

For too long, we have applied a narrow lens to our policy decisions, often overlooking nature's vital role in our economies, societies, and very survival. This approach has led to unintended costs, missed opportunities, and an inaccurate representation of our true national wealth. As a paradigm shift, we must embed the consideration of nature throughout our policy processes, from economic planning to national security strategies and all sector development initiatives. Why is this so crucial? Our sectors, national security, and economies all depend on nature. Yet, we continue to develop policies in these spheres independently, rarely considering nature's roles. This siloed approach is no longer sustainable or sensible in our interconnected world. Mainstreaming nature-based solutions or echo-system adaptation in our decision-making has the potential to create greater gains across economic, social, and environmental outcomes. It will provide us with a more accurate picture of our choices' true costs and benefits, allowing for more informed and sustainable decisions. To achieve this, we need to adopt what we call the "CASE" approach: Cross-sectoral: We must craft policies that make relevant and aligned changes across multiple sectors rather than addressing them one at a time. Appropriate: Nature should be considered at all appropriate points in the decision-making process, even in sectors where it has not been historically accounted for. Strategic: We must focus on decisions that influence impactful pathways, ensuring that our mainstreaming efforts achieve the pace of change needed to improve wellbeing and reverse nature loss. Evidence-based: Our efforts must be grounded in robust scientific evidence, drawing on multiple sources of knowledge and understanding. Implementing this approach will require changes in how we account for our assets, consider our options, evaluate those options, and ultimately make decisions. It will mean including natural capital in our national accounts, considering nature-based solutions alongside traditional approaches, and ensuring that our cost-benefit analyses fully account for environmental impacts and ecosystem services. This is not an easy task. It will require investment in new capacities, the development of new methodologies, and a willingness to challenge long-held assumptions. But the potential benefits are immense. As leaders, we are responsible for ensuring that our governance systems evolve to meet these challenges. By mainstreaming nature in our decision-making processes, we can create a more sustainable, resilient, and prosperous future for all. #naturemainstreaming, #natureinpolicy, #naturebased, #ecosystemservices, #naturalcapital, #sustainabledecisions, #holisticpolicy, #naturepositive, #biodiversityeconomy, #greenaccounting, #natureinclusive, #ecosystemvalue, #naturefirst, #integratedpolicy, #naturesmartdecisions, Green Climate Fund

➡️ New Pre-Print Paper (Arxiv): 📄 Non-traditional data in pandemic preparedness and response: identifying and addressing first and last-mile challenges ✍️ by Mattia Mazzoli, Irma Varela-Lasheras, Sónia Namorado, Constantino Pereira Caetano, Andreia Leite, Lisa Hermans, Niel Hens, Polen Türkmen, Kyriaki Kalimeri, Leo Ferres, Ciro Cattuto, Daniela Paolotti, and Stefaan Verhulst 🔗 Read it here: https://lnkd.in/eXXe2tGX 🤔 The COVID-19 pandemic served as a global stress test for how we integrate non-traditional data (NTD)—from mobility traces and social media activity to wearable data—into public health decision-making. ➡️ As part of the ESCAPE project, and drawing on an expert workshop (Brussels, 2024) and a survey of European modelers, our paper assesses both the promise and persistent limitations of NTD in pandemic preparedness and response. We distinguish between: 🧭 “First-mile” challenges — accessing, harmonizing, and standardizing data. 🚦 “Last-mile” challenges — translating insights into timely, actionable decisions. Some Key findings include: - 66% of datasets faced access issues; - Data-sharing reluctance for NTD was twice that of traditional data (30% vs. 15%); - Only 10% of respondents could use all the data they needed. 🤔 Barriers extend beyond the technical—encompassing institutional inertia and weak data-to-policy translation. To move forward, we propose a roadmap that emphasizes (among other things): ✅ Legal and technical frameworks for data access; ✅ Fusion Centers and Decision Accelerator Labs to bridge analysis and action; ✅ Networks of Scientific Ambassadors to connect scientists and policymakers; ✅ A shift toward a culture of data solidarity and sustained institutional readiness ✅ Advancing data stewardship. ➡️ Grounded in the lessons of COVID-19, this work aims to guide the responsible use of non-traditional data not only for pandemics, but also for emerging challenges like climate shocks and humanitarian crises. 💻 Learn more about ESCAPE: https://lnkd.in/eTU5-7DD ISI Foundation, The Data Tank #DataForHealth #Pandemic #NonTraditionalData #DataStewardship #DataSolidarity #PublicHealth #AIForGood #EvidenceBasedPolicy #DataGovernance

The first confidential rebate in Germany will be for Eli Lilly’s Mounjaro (tirzepatide). The company is using a provision in the Medical Research Act of 2024 that applies until the end of June 2028 (and will be evaluated by the Ministry of Health by the end of 2026).   Lilly confirmed to the broadcaster NDR/WDR that it had reached agreement with the GKV-Spitzenverband (National Association of Statutory Health Insurance Funds) on “the framework conditions for the contract on the reimbursement amount.”   In a letter sent to physicians in early July, Lilly wrote that it was “the first company in Germany to negotiate a price in accordance with the Medical Research Act that is economical and not published.” It noted that the provision is intended to “give pharmaceutical companies more negotiating leeway without influencing pricing in other countries.” Germany is one of the most frequent comparator countries for international reference pricing in Europe and beyond. Information on rebated prices is generally accessible.   In return for confidentiality, the Medical Research Act requires manufacturers to grant an additional price reduction of 9% after the rebated price has been negotiated with the GKV-Spitzenverband. Lilly noted that this extra saving “substantially improved” the drug’s cost-benefit ratio and will lead to “significant savings” for the healthcare system.   Lilly will notify physicians that the list price “does not play a role in their economic considerations and that this does not stand in the way of a regulation in compliance with the necessary framework conditions, in particular the economic efficiency requirement.” The Social Code Book V specifies that services provided within the statutory health insurance system “must be sufficient, appropriate and economical; they must not exceed what is necessary. Insured persons may not claim for service that are not necessary or uneconomical, the service providers may not provide them and the health insurance funds may not approve them.” #Germany #confidential #rebates #Lilly #Mounjaro

Congress recently saw the introduction of the Patients Over Profits Act, led by Senators Warren and Merkley. The bill would prohibit large insurers from owning Medicare Part B or Part C providers, requiring divestiture of clinics they currently own. The concern is valid: when payers own providers, conflicts of interest emerge. Insurers can steer patients into their own clinics, leverage coverage rules to capture more revenue, and do so with little transparency into how those operations run. But here’s the question: if we are concerned about consolidation and monopolistic power in healthcare, why are we only looking at insurers? Hospitals have been consolidating for decades, and the evidence is clear. A 2020 RAND study found that hospital mergers routinely drive commercial prices up, in some cases by 40% or more. Yale researchers recently linked lax antitrust enforcement directly to rising hospital prices. The FTC itself has acknowledged that vertical integration—hospitals buying physician groups—often results in higher costs without clear quality gains. Independent practices get absorbed, outpatient services get billed at hospital rates, and local markets end up dominated by one or two systems. If insurers divest clinics but hospitals continue their acquisition spree, the problem doesn’t shrink—it simply shifts. Perhaps what we should be considering is a framework that is more entity-agnostic. One that doesn’t single out insurers or hospitals, but instead targets the behaviors that reduce competition, limit transparency, and drive up costs—whether that’s through insurer ownership of providers, hospital acquisition of clinics, or other forms of vertical and horizontal consolidation. These are some suggestions for a usable framework: ▪️ Antitrust tools in the form of merger challenges, divestitures, oversight of roll-ups. ▪️ Payment tools like site-neutral reforms that strip out financial incentives for vertical integration. ▪️ Transparency tools in the form of ownership disclosure, price transparency and payment transparency. If applied symmetrically to hospitals and insurers (or indeed any player that enters the market and engages in monopolistic and harmful behavior) the focus shifts from who owns what to what behaviors reduce competition and inflate costs. https://lnkd.in/eUn3DuSR

💡 I’ve been sold a lie. As a Disabled woman, I grew up believing that my greatest accomplishment would be achieving independence. I truly thought I’d be more successful, more lovable, and more appealing if I proved everyone wrong by needing less and less support. But the truth is, my greatest accomplishment has been learning to ask for — and accept — help. Disability aside, we all need help. Really, think about it: when was the last time you asked a friend for advice? Phoned your GP? Stopped someone on the street to ask for directions? We all rely on others every day — so why are Disabled people made to feel ashamed or like a burden for doing the same? Maybe it’s time we reframe what independence really means. In a society that idolises independence, productivity, and self-sufficiency, those who require care are often positioned as burdens or failures. The care/dependency framework challenges this harmful narrative by reimagining care and dependence not as deficits, but as fundamental parts of the human experience. Rooted in feminist and disability justice thinking, this framework centres the reality that all people are interdependent — not just disabled people, but every human being. Rather than viewing dependency as a flaw to be overcome, the care/dependency framework recognises it as a natural, valuable, and even generative aspect of life. It invites us to acknowledge the ways in which we all give and receive care, and to dismantle the shame attached to needing support. Within this model, care is not just an act of charity or obligation, but a political and relational practice — one that can foster connection, trust, and community. This ideology also forces a critical look at the structures that devalue care. In many societies, care work is unpaid or underpaid, outsourced to women, migrants, and racialised communities, and hidden from public view. The care/dependency framework calls for systemic change: equitable policies, community-based care infrastructures, and the celebration of interdependence as a strength, not a weakness. #disability #disabilitystudies #ally #learnwithme #disabilitypridemonth #reframingdisability