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We develop a framework to measure the role of hospital allocation in racial disparities in health care and use it to study Black and white heart attack patients. Black patients receive care at lower-performing hospitals than white patients. However, over two decades, the performance gap between hospitals treating Black and white patients shrank by over two-thirds. This progress is due to more rapid performance improvement at hospitals that tended to treat Black patients, rather than reallocation of patients. Hospital improvement is correlated with adoption of a productivity-raising input, beta-blockers. Our work highlights reallocation and performance improvement as future disparity-reduction levers.

The United States spends substantially more on health care than most developed countries, yet leaves a greater share of the population uninsured. We argue that incremental insurance expansions focused on addressing market failures will propagate inefficiencies and will fail to facilitate the active policy decisions needed to achieve socially optimal coverage. By instead defining a basic bundle of services that is publicly financed for all, while allowing individuals to purchase additional coverage, policymakers could both expand coverage and maintain incentives for innovation, ensuring universal access to innovative care in an affordable system.

We measure inequities from the COVID-19 pandemic on mortality and hospitalizations in the United States during the early months of the outbreak. We discuss challenges in measuring health outcomes and health inequality, some of which are specific to COVID-19 and others that complicate attribution during most large health shocks. As in past epidemics, pre-existing biological and social vulnerabilities profoundly influenced the distribution of disease. In addition to the elderly, Hispanic, Black and Native American communities were disproportionately affected by the virus, particularly when assessed using the years of potential life lost metric. For example, Hispanic and Black Americans in 2020 saw 39.5 and 25 percent increases in excess mortality relative to trend, compared to a less than 15 percent increase for Whites;we find losses in potential years of life three to four times larger among Hispanic and Black compared to White Americans. Individual-level data from a commercially insured population show that otherwise similar Black and Hispanic enrollees were hospitalized due to COVID-19 at a higher rate than White enrollees. We provide a conceptual framework and initial empirical analysis which seek to shed light on contributors to pandemic-related health inequality, and suggest areas for future research.

The natural fishery or wild stock of fishes especially fresh water in India is significantly declining due to manmade stressors. The invasion of fishes and size composition are an essential component of stream, river and other large water bodies ecosystem and represents an evident of structure, function, depth and health of stream/river. During study period 683 specimens of Oreochromis niloticus were collected from February 2019 to January 2020 in Sirsa fish landing centre from the lower stretch of the Tons river at Prayagraj, Uttar Pradesh, India. Size composition of fishes was varied from 82 to 463 mm (total length). The maximum total length of O. niloticus in the catches indicated that its increasing colonisation success in the river Tons. Size composition of fishes was also indicated that the stock of O. niloticus in the Tons river was in healthy condition. The 231-260 mm size group was most dominated (15.67%) compared to 261-290 mm (12.44%) and 291-320 mm (11.71%) in the total exploited stock. The middle size group was maximum exploited with 51.24% from the Tons river at Prayagraj. Higher size group contributed sizeable proportion with 25.04% in the exploited stock. The exploitation pattern was unsystematic in higher size group due to contribution of higher proportion. Current exploitation pattern is unsystematic but O. niloticus is powerfully invaded from the lower stretch of the Tons river at Prayagraj.

Context: To what extent does pharmaceutical revenue growth depend on new medicines versus increasing prices for existing medicines? Moreover, does using list prices, as is commonly done, instead of prices net of confidential rebates offered by manufacturers, which are harder to observe, change the relative importance of the sources of revenue growth? Methods: This study uses data from SSR Health LLC to address these research questions using decomposition methods that analyze list prices, prices net of rebates, and sales for branded pharmaceutical products sold primarily through retail pharmacies. Findings: From 2009 to 2019, retail pharmaceutical revenue growth was primarily driven by new products rather than by price increases on existing products. Failing to account for confidential rebates creates a more prominent role for price increases in explaining revenue growth, because list price inflation during this period was 10.9%, whereas net price inflation was 3.3%. Conclusions: Policies that restrict price growth on existing medicines likely need to be coupled with policies that reduce launch prices to have a meaningful long-term impact on pharmaceutical revenue growth. Using pharmaceutical list prices is often an inadequate approximation for net prices because the role of rebates has increased and varies by drug class.

Policy Points Only a small minority of new drugs in "nonprotected" classes are widely covered by Part D plans nationwide in the year after US Food and Drug Administration (FDA) approval. Part D plans frequently apply utilization management restrictions such as prior authorizations to newly approved drugs in both protected and nonprotected classes. Drug price influences both formulary inclusion (in nonprotected classes) and coverage restrictions (in both protected and nonprotected classes), while other drug characteristics such as therapeutic benefits are not consistently associated with formulary design. Plans do not seem to favor the minority of drugs that are determined to offer added therapeutic benefit over existing alternatives.Medicare Part D is an outpatient prescription drug benefit for older Americans covering more than 46 million beneficiaries. Except for mandatory coverage for essentially all drugs in six protected classes, plans have substantial flexibility in how they design their formularies: which drugs are covered, which drugs are subject to restrictions, and what factors determine formulary placement. Our objective in this paper was to document the extent to which Part D plans limit coverage of newly approved drugs.We examined the formulary design of 4,582 Part D plans from 2014 through 2018 and measured (1) the decision to cover newly approved drugs in nonprotected classes, (2) use of utilization management tools in protected and nonprotected classes, and (3) the association between plan design and drug-level characteristics such as 30-day cost, therapeutic benefit, and the US Food and Drug Administration (FDA) expedited regulatory pathway.The FDA approved 109 new drugs predominantly used in outpatient settings between 2013 and 2017. Of these, 75 fell outside of the six protected drug classes. One-fifth of drugs in nonprotected classes (15 out of 75) were covered by more than half of plans during the first year after approval. Coverage was often conditional on utilization management strategies in both protected and nonprotected classes: only seven drugs (6%) were covered without prior authorization requirements in more than half of plans. Higher 30-day drug costs were associated with more widespread coverage in nonprotected classes: drugs that cost less than $150 for a 30-day course were covered by fewer than 20% of plans while those that cost more than $30,000 per 30 days were covered by more than 50% of plans. Plans were also more likely to implement utilization management tools on high-cost drugs in both protected and nonprotected classes. A higher proportion of plans implemented utilization management strategies on covered drugs with first-in-class status than drugs that were not first in class. Other drug characteristics, including availability of added therapeutic benefit and inclusion in FDA expedited regulatory approval, were not consistently associated with plan coverage or formulary restrictions.Newly approved drugs are frequently subject to formulary exclusions and restrictions in Medicare Part D. Ensuring that formulary design in Part D is linked closely to the therapeutic value of newly approved drugs would improve patients' welfare.

Aligning Financial and Legal Accountability Under value-based payment models, there is a misalignment between organizations’ incentives to spend wisely and individual physicians’ incentives to redu...

Cyprinus carpio (e.g. culture and wild/capture) constitute a large part of daily meal of human population in Indian sub-continent. It shows benthic and sedentary behavior. Age structure of C. carpio was studied during February 2019 to January 2020 from fish landing centre at Sirsa, Prayagraj, Uttar Pradesh, India. The key scales were studied for estimation of age structure in the present study. A total of 548 fish specimens in length ranges between 97 to 687 mm and age classes of 0+ to 9+ were observed. Age structures were determined for male, female and pooled samples separately. The 1+ age group was most dominating stock with shared 23.53%, 24.64% and 24.09% in case of male, female and pooled samples, respectively. The age group 2+ was second dominating age class and this age class more attracted to fishermen for the exploitation. In case of pooled sample, 1+ age group was also dominated compared to 2+ and 3+ age groups. The old age groups of fishes were shared very minute proportion in the total stock. Present study was also indicated that the female fishes live longer than male from the Tons river at Prayagraj, India.

Do We Spend Too Much on Health Care? Health system reforms — such as changes in insurance design, patient cost sharing, payment reform, or price regulation — should be judged by whether they move u...

Background Previous work showed lower cardiac intervention rates for patients with acute myocardial infarction (AMI) in Ontario than in the United States. We assessed whether Ontario's efforts to improve access to rapid percutaneous coronary intervention (PCI) for AMI were associated with improved timeliness of care and whether this closed the gap between the 2 jurisdictions. Methods In this retrospective cohort study, we followed adults aged 66-99 years in the US and Ontario for 30 days after admission for incident AMI between 2003 and 2013 using health administrative data from both countries. We calculated the proportion of patients who received cardiac catheterization, PCI and coronary artery bypass grafting on the day of and within 30 days of admission overall and according to AMI type (ST-segment elevation AMI [STEMI] v. non-STEMI) and risk group (low, medium or high predicted risk of 30-d mortality). Results We followed 414 216 patients in the US and 112 484 in Ontario. The large disparities in cardiac intervention rates observed in 2003 mostly disappeared over time. By 2013, the proportion of patients who received same-day PCI was only slightly higher in the US than in Ontario (22.3% v. 19.2%), whereas the converse was true for 30-day PCI (44.0% v. 41.3%). In 2013, patients with STEMI in the US and Ontario received PCI at nearly identical rates on the day of admission (66.3% v. 63.8%); however, more patients at high risk with STEMI in the US than in Ontario received PCI, both on the day of admission (55.5% v. 44.7%) and by 30 days (60.5% v. 55.0%). Interpretation Despite differences in resources and organization of delivery systems, by 2013, timely receipt of PCI by Ontario patients with AMI lagged only slightly behind that by US patients. A higher supply of PCI centres in the US may have facilitated earlier intervention among patients at high risk with STEMI.

Importance: Germany's unique approach to coverage determination and pricing has ensured that effective medicines remain on the market, often at prices reduced through negotiation. However, less is known about trade-offs of this approach with regard to initial availability of medicines. Objective: To examine differences in the timing and scope of new medicines available in Germany and the US. Design, Setting, and Participants: This retrospective cohort study analyzed initial availability of new medicines approved by regulatory agencies in Germany and the US between January 1, 2004, and December 31, 2018, and followed up through December 31, 2019. Data analysis was conducted from January 1, 2020, to July 1, 2022. A total of 599 novel approvals were reviewed. Generic, biosimilar, vaccine, and combination medicines were excluded. Exposures: US Food and Drug Administration approvals were reviewed for therapies categorized as new molecular entities or new active ingredients. German approvals were reviewed from secondary administrative data of authorized medicines that determine availability in Germany, including data presented by the European Medicines Agency. Main Outcomes and Measures: Approvals were analyzed to determine the percentage of medicines approved and available in the US, Germany, or both countries and compare the times to reach the market. Results: Analysis of 599 new medicines demonstrated that fewer were available in Germany compared with the US (80% vs 92% of all potential therapies) and that the median difference in time to market was 4 months (95% CI, -44.40 to 44.76 months). Forty-nine medicines were approved in Germany but not in the US, 75% of which were rejected by the US Food and Drug Administration, were withdrawn, or had US equivalent agents. Conclusions and Relevance: In this cohort study, fewer new medicines were available in Germany compared with the US between 2004 and 2018. In addition, drugs entered the German market later than in the US. OA Förderung 2022

Regulatory review of new medicines is often viewed as a hindrance to innovation by increasing the hurdle to bring products to market. However, a more complete accounting of regulation must also account for its potential market expanding effects through quality certification. We combine data on FDA approvals for follow-on indications and patient-level data on utilization, and examine whether FDA approval of a follow-on indication increases the use of a drug for that indication. We find 5 facts for the market-expanding role of regulation: (1) follow-on approvals increase the share of patients taking a drug with that indication by 4.1 percentage points, or 40% increase over baseline use, at the time of approval; (2) there is little market learning prior to or following the approval of the follow-on indication, suggesting that such approvals fully certify the new use; (3) the effect of these approvals is larger for uses in a different disease area than previous indications, an increase equivalent to over 4 ½ years of market-learning; (4) it is FDA approval, not the initiation of clinical trials that generate the expansion in market size; (5) the market expansion is consistent with physicians prescribing the medicines more because of higher perceived benefits, not reduced administrative costs.

Clupisoma garua is a medium-sized freshwater catfish with very high market value in Indian sub-continent. Besides immense food value, the fish is also known as a game fish. The fish samples for this study were randomly collected from middle stretch of the river Ganga at Allahabad during July 2014–June 2015. The size composition of the samples varied from 135 to 446 mm. The maximum exploitation was observed in 171–210 mm size group (29.04%), while minimum in 411–450 mm (0.83%) in stock samples. In general, lower size groups were highly exploited compared to middle and higher size groups. Male population dominates over females in 211–250, 251–290 and 331–370 mm size groups, in contrary, female was dominant in size groups from 131–170, 171–210 and 291–330 mm.

In this article, we develop an economic framework for Medicare reform that highlights trade-offs that reform proposals should grapple with, but often ignore. Central to our argument is a tension in administratively set prices, which may improve short-term efficiency but do so at the expense of dynamic efficiency (slowing innovations in new treatments). The smaller the Medicare program is relative to the commercial market, the less important this is; but in a world where there are no market prices or the private sector is very small, the task of setting prices that are dynamically correct becomes more complex. Reforming Medicare should focus on greater incentives to increase competition between Medicare Advantage plans, which necessitates a role for government in ensuring competition; premium support; less use of regulated prices; and less appetite for countless “pay for performance” schemes. We apply this framework to evaluate Medicare for All proposals.

Executive SummaryOn the thirty-fifth anniversary of the adoption of the Orphan Drug Act (ODA), we describe the enormous changes in the markets for therapies for rare diseases that have emerged over...

We use the design of Medicare’s prescription drug benefit program to demonstrate three facts about the health consequences of cost-sharing. First, we show that an as-if-random increase of 33.6% in out-of-pocket price (11.0 percentage points (p.p.) change in coinsurance, or $10.40 per drug) causes a 22.6% drop in total drug consumption ($61.20), and a 32.7% increase in monthly mortality (0.048 p.p.). Second, we trace this mortality effect to cutbacks in life-saving medicines like statins and antihypertensives, for which clinical trials show large mortality benefits. We find no indication that these reductions in demand affect only ‘low-value’ drugs; on the contrary, those at the highest risk of heart attack and stroke, who would benefit the most from statins and antihypertensives, cut back more on these drugs than lower risk patients. Similar patterns exist for other drug–disease pairs, and irrespective of socioeconomic circumstance. Finally, we document that when faced with complex, high-dimensional choice problems, patients respond in simple, perverse ways. Specifically, price increases cause 18.0% more patients (2.8 p.p.) to fill no drugs, regardless of how many drugs they had been on previously, or their health risks. This decision mechanically results in larger absolute reductions in utilization for those on many drugs. We conclude that cost-sharing schemes should be evaluated based on their overall impact on welfare, which can be very different from the price elasticity of demand.

We use the design of Medicare’s prescription drug benefit program to demonstrate three facts about the health consequences of cost-sharing. First, we show that an as-if-random increase of 33.6% in out-of-pocket price (11.0 percentage points (p.p.) change in coinsurance, or $10.40 per drug) causes a 22.6% drop in total drug consumption ($61.20), and a 32.7% increase in monthly mortality (0.048 p.p.). Second, we trace this mortality effect to cutbacks in life-saving medicines like statins and antihypertensives, for which clinical trials show large mortality benefits. We find no indication that these reductions in demand affect only ‘low-value’ drugs; on the contrary, those at the highest risk of heart attack and stroke, who would benefit the most from statins and antihypertensives, cut back more on these drugs than lower risk patients. Similar patterns exist for other drug–disease pairs, and irrespective of socioeconomic circumstance. Finally, we document that when faced with complex, high-dimensional choice problems, patients respond in simple, perverse ways. Specifically, price increases cause 18.0% more patients (2.8 p.p.) to fill no drugs, regardless of how many drugs they had been on previously, or their health risks. This decision mechanically results in larger absolute reductions in utilization for those on many drugs. We conclude that cost-sharing schemes should be evaluated based on their overall impact on welfare, which can be very different from the price elasticity of demand.

In medicine, the reasons for variation in treatment rates across hospitals serving similar patients are not well understood. Some interpret this variation as unwarranted and push standardization of care as a way of reducing allocative inefficiency. An alternative interpretation is that hospitals with greater expertise in a treatment use it more because of their comparative advantage, suggesting that standardization is misguided. A simple economic model provides an empirical framework to separate these explanations. Estimating this model with data for heart attack patients, we find evidence of substantial variation across hospitals in allocative inefficiency and comparative advantage, with most hospitals overusing treatment in part because of incorrect beliefs about their comparative advantage. A stylized welfare calculation suggests that eliminating allocative inefficiency would increase the total benefits from the treatment that we study by 44%.

We develop a simple framework to measure the role of hospital allocation in racial disparities in health care and use it to study Black and white Medicare patients who are treated for heart attacks – a condition where virtually everyone receives care, hospital care is highly effective, and hospital quality has been validated. We report four facts. (1) Black patients receive care at lower-performing hospitals than white patients, even when they live in the same hospital market or ZIP code within a hospital market. (2) Over the past two decades, the gap in performance between hospitals treating Black and white patients shrank by over two-thirds. (3) This progress is due to more rapid performance improvement at hospitals that tended to treat Black patients, rather than faster reallocation of Black patients to better hospitals. (4) Hospital performance improvement is correlated with adoption of a high-return low-cost input, beta-blockers. Closing remaining disparities in allocation and harnessing the forces of performance improvement, including technology diffusion, may be novel levers to further reduce disparities.

What Values and Priorities Mean for Health Reform We all want different things from our health plans, and our preferences vary in ways that don’t line up with our party affiliations. If we want to ...

Gene therapy and gene editing could have profound effects on the health care system — and these impacts are only just beginning.

This Viewpoint challenges US hospital claims that government funding to train physicians is necessary to offset costs, maintain physician supply, and keep costs

Alzheimer’s Disease (AD) affects one in ten people aged 65 or older and is the most expensive disease in the United States. We describe the central economic questions raised by AD. While there is overlap with the economics of aging, the defining features of the ‘economics of Alzheimer’s Disease’ is an emphasis on cognitive decline, choice by cognitively impaired patients, and a host of issues where dynamic contracts between patients and caregivers are hard to enforce. There is enormous scope for economists to contribute to our understanding of AD-related issues, including drug development, efficient care delivery, dynamic contracting within the family and with care providers, long-term care risk, financial decision-making, and public programs for AD. These topics overlap with many areas of economics -- labor economics, health economics, public finance, behavioral economics, experimental economics, family economics, mechanism design, and the economics of innovation -- suggesting the presence of a rich research program that should attract many economists.

Rising list prices are often used to illustrate the burden of prescription drug spending, but payers routinely negotiate rebates from manufacturers that generate differences between list and net prices. List prices are easily available and affect patient cost-sharing, but net prices are confidential and affect innovation incentives. We use novel data on medicines sold in a retail setting to quantify rebate growth, the sensitivity of pharmaceutical price indices to list versus net prices, and contribution of net price growth to revenue growth. From 2012 to 2017, we find average rebates increased from 32% to 48%, owing entirely to growth in rebate-levels over a product lifetime rather than shifts towards high rebate products. Annual inflation of list prices was 12% while that of net prices was 3%, implying that financial rewards to manufacturers per unit sold have not grown proportionally to list prices. This pattern is mirrored in 19 of the 20 top drug classes by revenue including insulins, where list and net price inflation were 16% and 2% annually respectively. Finally, we find price growth explains 76% of revenue growth when measured by list prices but 31% of revenue growth when measured by net prices. Moreover, new product entry is the most important factor affecting pharmaceutical revenue growth. These findings provide a cautionary note on using list prices for policy analysis.

Random samples were collected monthly from August 2011 to July 2012 for determination of age, growth and age pyramid of Oreochromis niloticus from the Yamuna river, India. Age of O. niloticus varied from 0+ to 6+ age groups. It was observed that the fish attained the mean length (pooled samples) 16.96, 24.33, 31.12, 36.44, 40.54 and 43.50 in 1+ to 6+ age group, respectively. The growth increment in O. niloticus was recorded 16.96, 7.37, 6.79, 5.32, 4.10 and 2.86 for 1+ to 6+ age groups, respectively. It is obvious from the present observations the aquatic environment of the Yamuna river at Allahabad was favorable to O. niloticus, and for the reason growth was good. The urn shaped age pyramid was recorded.

A study on the landings of various species recorded randomly from December 2003 to June 2004 from fish landing and marketing centers on the Ken at Banda, on the Paisuni at Karwi and Tons at Chakghat and Sadiapur (Prayagraj), revealed that the average catch day-1 of the Ken river was dominated by Cyprinus carpio followed by Aorichthys spp. and miscellaneous fish. In contrast the Paisuni R. was dominated by Labeo calbasu followed by Hypophthalmichthys molitrix and miscellaneous while the latter group dominated over Aorichthys spp and L. calbasu in the Tons R. Among selected species Labeo rohita commands higher price (Rs 61.7), Tor tor moderate (Rs 52.5) and L. calbasu lower price (Rs 37.5)

A quantitative ultra-performance LC (UPLC) method was developed and validated to successfully separate, identify, and quantitate the major polyphenolic compounds present in different varieties of sorghum (Sorghum bicolor) feedstock. The method was linear from 3.2 to 320 ppm, with an r2 of 0.99999 when using luteolinidin chloride as the external standard. Method accuracy was determined to be 99.5%, and precision of replicate preparations was less than 1% RSD. Characterization by UPLC-MS determined that the predominant polyphenolic components of the sorghum varietals were 3-deoxyanthocyanidins (3-DXAs). High-throughput screening for 3-DXA identified four unique classes within the sorghum varieties. Certain feedstock varieties have been found to have a high potential to not only be plant-based colorants, but also provide significant amounts of bioactive 3-DXAs, making them of unique interest to the dietary supplement industry.

Contrary to the hopes of its supporters, indication-based drug pricing will result in higher prices for patients who benefit the most from a given drug, higher utilization by patients who benefit least, higher overall spending, and higher manufacturer profits.

Fishes are a prominent feature in most national economics and employments. Riverine ecosystems present unique opportunity to employment of fishers and youth community in the Ganga basin, India. Present study was undertaken to fish catch from the middle stretch of the Ganga river at Allahabad, India during the period July 2014 to June 2015. Annual fish landing demonstrated that the catch was dominated by miscellaneous group (22.16 kg day -1 ) followed by Oreochromis niloticus (12.76 kg day -1 ) and Sperata seenghala (12.63 kg day -1 ) and they accounted for 23.19 per cent, 13.36 per cent and 13.21 per cent, respectively. In case of Indian major carps, Cirrhinus mrigala shared maximum contribution with 7.73 kg day -1 (8.09%). Catla catla and Labeo rohita shared 1.45 (1.51%) and 2.35 kg day -1 (2.46%), respectively. The landing of fishes fluctuated from season to season from the Ganga river at Allahabad, India. For conservation point of view Cyprinus carpio and O. niloticus species should be monitored in the Ganga river. Both species are very harmful for the Ganga river ecosystem.