Unbiased Analysis of Today's Healthcare Issues

Does your employer cover transgender benefits?

Written By: Jason Shafrin - Jul• 27•15

It may be more likely than you think. The Health Business Blog (via Business Insurance) notes that:

…the Office of Personnel Management recently required Federal Employee Benefit Plan providers to cover transition-related care…About half of large employers offer transgender-related surgical coverage compared with 5 percent in 2007, according to a National Business Group on Health survey.

Why would an employer cover these benefits? Altruism? Not entirely. David Williams writes:

  • An increasing belief that such coverage is medically necessary, and therefore in keeping with the overall philosophy of health insurance
  • A desire to increase competitive positioning in recruiting, by appearing progressive
  • A realization that the overall costs are likely to be small, typically less than 0.5% of total health care costs
  • Employer worry that failing to offer these such benefits could lead to discrimination claims

It could be the case that health insurance policies are reflecting changing perceptions of transgender individuals in the US.

Friday Links

Written By: Jason Shafrin - Jul• 24•15

Basket vs. Umbrella clinical trials

Written By: Jason Shafrin - Jul• 22•15

How do you determine if a drug is effective?  Typically, biostaticians rely on a randomized control trial where half the patients receive the treatment of interest and the remaining half receive either a placebo or the current standard of care depending on the trial design.

Recent advances in cancer, however, call for more sophisticated designs.  Some cancer treatments are only effective for patients with specific biomarkers; this treatment heterogeneity complicates the trial design.  Further, some new treatments–such as immuno-oncology therapies–may improve health for patients with multiple tumor types.

How do biostasticians deal with these issues?

Richard Simon of the National Cancer Institute discussed two specific trial types in a recent AMCP article.

  • Umbrella trials: Umbrella studies are designed to test the impact of different drugs on different mutations in a single cancer type…The trial design can help to facilitate patient screening and accrual, and is quite suitable for trials examining low-prevalence diseases.  The primary features of umbrella trials are: (i) the inclusion of multiple treatments and multiple biomarkers within the same protocol, (ii) a design that allows for randomized comparisons, (iii) a design that can have flexible biomarker cohorts, and (iv) a design that can add/drop biomarker subgroups.
  • Basket trials: Basket studies are designed to test the effect of a single drug on a single mutation in a variety of cancer types. They provide a unique way of merging the traditional clinical trial design with rapidly evolving genomic data that facilitate the molecular classification of tumors.  Basket trials can also screen multiple drugs across many cancer types. A basket design provides evidence for pairing a drug with a validated biomarker in a specific tumor.

International Reference Pricing

Written By: Jason Shafrin - Jul• 21•15

What is international reference pricing (IRP)? IRP is system whereby a country states that they will pay no more than the price paid by another country or a basket of countries. In theory, countries could also regulate drug prices by saying that they would not pay more than X% of country A’s price or X% of the reference basket of country A, B and C. How does this work in practice? A paper by Houy and Jelovac (2015) repots:

In 2010, all EU countries except Germany, Sweden, and the UK extensively use IRP [international reference pricing]. This policy leads to an interdependence of prices between countries. Many authors recognize that this interdependence gives pharmaceutical firms an incentive to launch new drugs in high-price countries first and to delay launch or even not to launch new drugs in low-price countries.

Who uses reference pricing and which countries’ prices are most important in determining a countries own price?

Slovakia had the maximum number of countries in the reference basket (n=26 ) and Luxembourg had the minimum number of RCs (n=1 ). Germany (n=13 ), Spain (n=13 ), France (n=11 ), and the UK (n=11) were the countries most frequently referenced.

The authors create a model pharmaceutical firms’ response to IRP and reach three conclusions:

First, there is no withdrawal of drugs in any country in any period. Second, whenever the drug is sold in a country, it is also sold in all countries with larger willingness to pay (WTP). Third, there is no strict incentive to delay the launch of a drug in any country.


Quotation of the Day

Written By: Jason Shafrin - Jul• 20•15

The human mind is generally far more eater to praise and dispraise than to describe and define.  It wants to make every distinction of value; hence those fatal critics who can never point out the differing quality of two poets without putting them in an order of preference as if they were candidates for a prize.

C.S. Lewis, The Four Loves.

Half a trillion dollars

Written By: Jason Shafrin - Jul• 19•15

Clearly, the care family members provide for sick relatives add significant value to the life of the infirm. Many non-economists may consider the cost of this care as “free” because family members typically are not paid for this services.  However, nothing could be further from the truth.  If family members were not caring for their elderly relatives, the cost to care for elderly patients would be increased nursing home admissions and additional home health visits.  Further, adults often must give up on their own careers to help out with their elderly parents.

Thus, it is not surprising that a recent AARP study found that the cost of caregiving is high.  What may be surprising is just how high it is. According to the Valuing the Invaluable: 2015 Update report:

In 2013, about 40 million family caregivers in the United States provided an estimated 37 billion hours of care to an adult with limitations in daily activities. The estimated economic value of their unpaid contributions was approximately $470 billion in 2013, up from an estimated $450 billion in 2009.

Adults who care for elderly parents often do not get the credit they deserve.  Thus study shows not only does caregiving provide valuable intangible benefits to the infirm, but it also generates significant monetary value as well.


Written By: Jason Shafrin - Jul• 16•15

Health Wonk Review is up

Written By: Jason Shafrin - Jul• 16•15

The “Hot Summer Nights, Cool Summer Drinks” edition of the Health Wonk Review is up at InsureBlog.  Hosted by the always-insightful Hank Stern, it filled with useful insights from the world of health policy.

Choice in the Health Insurance Exchanges

Written By: Jason Shafrin - Jul• 15•15

I have posted frequently on the ACA and narrow networks (here and here). How narrow are the networks plans available in the health insurance exchanges? How does provider choice differ between standard commercial insurance plans and those in the exchanges? A study by Avalere finds:

…exchange plan networks include 42 percent fewer oncology and cardiology specialists; 32 percent fewer mental health and primary care providers; and 24 percent fewer hospitals. Importantly, care provided by out-of-network providers does not count toward the out-of-pocket limits put in place by the ACA.


Choice is always a good thing. However, does less choice reduce cost? Likely yes. Does less choice decrease quality? It depends on which providers are included in the network, but the answer is also likely yes. The question is whether any quality decreases are offset by lower premiums through lower reimbursement to these narrower networks of providers. Are patients better or worse off in exchanges? Additional research is needed.

Cholera and Haiti

Written By: Jason Shafrin - Jul• 14•15

Cholera has been a huge problem for Haiti. The excellent investigative journalist and author Rose George reports:

Five years on, cholera has killed nearly 9,000 Haitians. More than 730,000 people have been infected. It is the worst outbreak of the disease, globally, in modern history.

In 2014, Cholera was on the verge of being eradicated from Haiti:

After the dreadful death tolls of 2010–12, disease spread and fatality were being cut by nearly half each year. There were 352,033 cases and 2,927 deaths in 2011, compared to 27,659 cases and 295 deaths in 2014 (although the number of cases in 2013 in Haiti was still more than the rest of the world’s put together).

“In 2014 we were close to eliminating cholera. We were really close,” says Gregory Bulit, the emergency manager for UNICEF.

Later that year, however, cholera is back in full force. There were over 5,000 cases in October 2014 alone. Cholera can be easily treated with rehydration and IVs. So why hasn’t it been eradicated? In short, a lack of sanitation.

…[Haiti’s] sanitation is described as “practically non-existent”. Port-au-Prince has only one operational waste treatment centre for a city of two to three million people. People who do have latrines have them emptied manually by an underclass of bayakou (men who jump, often naked, into the pits and shovel out their contents). Hardly any of that shit is disposed of at the treatment plant; instead, it ends up anywhere the bayakou can put it. It’s the same ‘anywhere’ where the majority of Haitians without latrines go to do their open defecation. It’s the anywhere where cholera thrives.

Although there are more glamorous places to donate your money, getting sanitation for those who need is one of the best ways to improve health in developing countries.