Category: Incentives

Feds Gave Bigger Covid Subsidies to Hospitals Charging Higher Prices

(p. A1) When Covid-19 struck, the U.S. government gave hospitals tens of billions of dollars to help them cope with the strains of the pandemic.

Many of the hospitals didn’t need it.

The aid enriched some well-off systems, while failing to meet the needs of many that were struggling, according to a Wall Street Journal analysis of federal financial-disclosure reports.

The mismatch stemmed in part from the way the federal government determined how much a hospital should get. A main factor used to allocate relief was a hospital’s revenue, rather than Covid caseload or financial distress. The idea was that revenue was a good indicator of a hospital’s size.

Among the recipients were large, wealthy hospital owners—including some nonprofits—that reported profits from patient care during the periods they got aid. Some were well off enough to put money into investment funds, while others spent on new facilities and ex-(p. A10)panded campuses.

Hundreds of other hospitals that got federal funding, however, reported losses. Some were forced to lay off nurses and make other cuts, saying they didn’t get enough aid to overcome their strains. Some served areas that had among the highest Covid death rates.

The revenue-based award system, especially prevalent in the early days of the pandemic, tended to favor hospitals with higher prices.

For the full story, see:

Melanie Evans, Liz Essley Whyte and Tom McGinty. “Covid Aid Went to Hospitals That Didn’t Need the Money.” The Wall Street Journal (Monday, Dec. 5, 2022): A1 & A10.

(Note: the online version of the story has the date December 4, 2022, and has the title “Billions in Covid Aid Went to Hospitals That Didn’t Need It.”)

Regulation of Truckers’ Driving Hours Caused Higher Speeds and More Fatalities

(p. A13) Falling asleep at the wheel is deadly. “It is obvious that a man cannot work efficiently or be a safe driver if he does not have an opportunity for approximately 8 hours sleep in 24,” the Interstate Commerce Commission declared in 1937. Ever since, federal rules have limited the work hours of interstate truckers. Also ever since, truckers, their employers and their customers have circumvented the rules when they stand in the way of making money.

Congress tackled the problem in 2012 by requiring long-distance truckers to track their hours with an “electronic logging device” connected to the engine. The mandatory rest breaks and the limits on drivers’ daily and weekly hours didn’t change, but the Transportation Department estimated that monitoring compliance with an ELD would avoid 1,844 crashes and save 26 lives annually.  . . .

. . .

In “Data Driven: Truckers, Technology, and the New Workplace Surveillance,” Karen Levy makes a provocative case against this approach.   . . .  Her concise and lively book will interest anyone concerned with the complicated business of regulation.

. . .

. . ., Ms. Levy raises important questions about regulation in general by examining the unintended effects of a well-meant initiative designed to address a serious safety problem. She reports on a 2021 study linking ELDs to greater compliance with regulations but no reduction in truck crashes. Fatalities in crashes involving large trucks actually increased, as drivers sped up to cover as many miles as they could during their permitted driving time.

For the full review, see:

Marc Levinson. “BOOKSHELF; Miles of Mandates.” The Wall Street Journal (Wednesday, Jan. 4, 2023): A13.

(Note: ellipses added.)

(Note: the online version of the review has the date January 3, 2023, and has the title “BOOKSHELF; ‘Data Driven’ Review: Miles of Mandates.”)

The book under review is:

Levy, Karen. Data Driven: Truckers, Technology, and the New Workplace Surveillance. Princeton, NJ: Princeton University Press, 2022.

Unintended Consequences Make “Government-Provided Health Care” a “Fiscal and Regulatory Nightmare”

(p. A17) The private plans participating in Medicare’s prescription-drug program, known as Part D, currently draw on three sources of revenue to finance prescriptions: out-of-pocket payments from patients, premium payments made by plan members, and subsidies from the federal government. In 2025, under the Inflation Reduction Act, both government subsidies and out-of-pocket payments by patients are scheduled to be cut sharply. The difference will have to be made up by premiums. But the statute inhibits this third revenue source, which is also subsidized, from increasing more than 6%. That’s hardly enough to cover inflation, let alone compensate for the other two revenue losses.

. . .

Existing plans have room to cut benefits, although the original Part D statute limits their ability to do so. As plans are under no obligation to take a loss, their other choice is to exit the market, which from the patient’s perspective means that all the benefits disappear. In essence, the Inflation Reduction Act statute may prohibit Part D plans from being economically viable, even if it doesn’t explicitly ban them.

. . .

Welcome to the fiscal and regulatory nightmare known as government-provided health care, where those writing the rules don’t understand the consequences of what they do. Democrats hate that Medicare Advantage has been available as a pseudo-private alternative to original Medicare’s single-payer arrangement. Yet they have (unwittingly?) passed a law that so thoroughly disrupts traditional Medicare as to render it the worst of the Medicare options.

For the full commentary, see:

Casey B. Mulligan and Tomas J. Philipson. “The Inflation Reduction Act Comes for Medicare.” The Wall Street Journal (Tuesday, November 22, 2022): A17.

(Note: ellipses added.)

(Note: the online version of the commentary has the date November 21, 2022, and has the same title as the print version.)

Nonprofit Hospitals Get $60 Billion in Annual Tax Breaks in Order to Aid the Poor, but Often Use High-Pressure Opaque Tactics to Collect Full Payment

(p. A1) Nonprofit hospitals must have financial-assistance policies for needy patients, under federal requirements tied to an estimated $60 billion in annual tax breaks.

They often make that aid hard to get. Hospitals put up obstacles, delay checking eligibility and sometimes press for payments that aren’t refunded even if a patient eventually gets qualified for assistance.

That is according to a Wall Street Journal analysis of thousands of nonprofit hospital policies in filings to the Internal Revenue Service and posted by hospitals, as well as thousands of pages of internal documents from government hospitals obtained through public-record requests and the experiences of dozens of advocates and patients who have (p. A9) applied for aid.

. . .

An earlier Journal analysis of Medicare filings highlighted how little of nonprofit hospitals’ billions in revenue goes toward financial help for low-income patients. The new analysis uncovered the barriers many hospitals place in the way of patients who should qualify for assistance—even under the hospitals’ own criteria.

Under tax laws, nonprofit hospitals are set up to function as charities benefiting their communities. Government facilities, whose policies the Journal also looked at, are also intended to serve the public, though they aren’t subject to all the same IRS requirements as private nonprofits. The Journal found that many of these hospitals act like for-profit businesses in their efforts to get paid, even by those who can’t afford it.

. . .

Separate from the analysis of nonprofit hospitals’ IRS documents, the Journal also obtained internal documents on patient-billing procedures from large state and local government hospitals, including academic medical centers, through public-records requests. These hospitals share a similar mission with private nonprofits to serve communities.

The thousands of pages of procedures, scripts and other training material for hospital staff give an inside look at how some hospitals routinely push patients toward payment, including through installment plans that may come with interest. The guidelines often play down or don’t raise the option of financial assistance. Adding to the pressure, these tactics are often deployed before the patient gets care.

In a document titled “Collections Scripting for Non-Emergent Visits,” used by Georgia-based Augusta University Health System, staffers are supposed to start by requesting the entire amount due from the patient, saying, “How would you like to take care of that today?”

For the full story, see:

Anna Wilde Mathews, Andrea Fuller and Melanie Evans. “Some Hospitals Skimp on Aid.” The Wall Street Journal (Friday, Nov. 18, 2022): A1 & A9.

(Note: ellipses added.)

(Note: the online version of the story has the date November 17, 2022, and has the title “Hospitals Often Don’t Help Needy Patients, Even Those Who Qualify.”)

So-Called “Inflation Reduction Act” Reduces Incentive for Pharma Firms to Seek Approval for New Uses of Drugs


(p. A17) It may take years before we can fully appreciate the impact of the Inflation Reduction Act on the pharmaceutical industry, but we’re already getting signs of the damage. While Democrats boast that they’ve given Medicare the power to “negotiate” drug prices, the effect has been to saddle manufacturers with a complex and ill-conceived price-setting scheme. In response, many have canceled drug-development programs, resulting in an unfortunate but predictable loss for patients nationwide.

One poorly crafted provision is driving companies away from research into treating rare diseases. In its Oct. 27 earnings statement, Alnylam announced it is suspending development of a treatment for Stargardt disease, a rare eye disorder, because of the company’s need “to evaluate impact of the Inflation Reduction Act.” Alnylam’s decision turns on a provision in the Democrats’ bill that exempts from price-setting negotiations drugs that treat only one rare disease. The company’s drug is currently marketed as treating only amyloidosis, and thus is exempt from Medicare’s price setting. If Alnylam proceeded with research into treating Stargardt, it would lose its exemption.

That disincentive might be most pronounced in cancer treatments. On Tuesday [Nov. 1, 2022], Eli Lilly announced it is canceling work on a drug that had been undergoing studies for certain blood cancers. “In light of the Inflation Reduction Act,” the company wrote to Endpoints News, “this program no longer met our threshold for continued investment.”

. . .

Nearly 60% of oncology medications approved a decade ago received additional approvals in later years. The new law eliminates the incentive to conduct additional research, because its price-setting mechanisms kick in after nine years for small-molecule drugs and 13 years for biologics, regardless of how much research companies conduct after the drug’s initial approval.

For the full commentary, see:

Joe Grogan. “The Inflation Reduction Act Is Already Killing Potential Cures.” The Wall Street Journal (Saturday, Nov. 4, 2022): A17.

(Note: ellipsis, and bracketed date, added.)

(Note: the online version of the commentary has the date November 3, 2022, and has the same title as the print version.)

Pharmacy Benefit Managers (PBMs) Create Incentives to Reduce Hiring and Pay of Pharmacists

(p. A1) If any group of workers might have expected their pay to rise last year, it would arguably have been pharmacists. With many drugstores dispensing coronavirus tests and vaccines while filling hundreds of prescriptions each day, working as a pharmacist became a sleep-deprived, lunch-skipping frenzy — one in which ornery customers did not hesitate to vent their frustrations over the inevitable backups and bottlenecks.

“I was stressed all day long about giving immunizations,” said Amanda Poole, who left her job as a pharmacist at a CVS in Tuscaloosa, Ala., in June. “I’d look at patients and say to them, ‘I’d love to fill your prescriptions today, but there’s no way I can.’”

Yet pay for pharmacists, who typically spend six or seven years after high school working toward their professional degree, fell nearly 5 percent last year after adjusting for inflation. Dr. Poole said her pay, about $65 per hour, did not increase in more than four years — first at an independent pharmacy, then at CVS.

For many Americans, one of the pandemic’s few bright spots has been wage growth, with pay rising rapidly for those near the bottom and those at the top. But a broad swath of workers in between has lagged behind.

. . .

(p. A16) Pharmacies also faced external challenges. To hold down the cost of prescription drugs, insurance companies and employers rely on so-called pharmacy benefit managers to negotiate discounts with drugmakers and pharmacies. Consolidation among benefit managers gave them more leverage over pharmacies to drive prices lower. (CVS merged with a large benefits manager in 2007.)

Big drugstore chains often responded by trying to rein in labor costs, according to William Doucette, a professor of pharmacy practice at the University of Iowa. Several pharmacists who worked at Walgreens and CVS said the formulas their companies used to allocate labor resulted in low levels of staffing that were extremely difficult to increase.

According to documents provided by a former CVS pharmacist, managers are motivated by bonuses to stay within these aggressive targets.

. . .

In most cases, an industry without enough workers to meet customer demand would simply hire more, or at least raise wages to attract them.

Yet, according to the Bureau of Labor Statistics, neither of those things happened last year. The number of pharmacists employed in the United States dropped about 1 percent from 2020 to 2021. On balance, employers did not raise wages — in fact, median pay fell slightly, even without adjusting for inflation.

. . .

Several pharmacists said they were especially concerned that understaffing had put patients at risk, given the potentially deadly consequences of mix-ups. “It was so mentally taxing,” said Dr. Poole, the Tuscaloosa pharmacist. “Every day, I was like: I hope I don’t kill anyone.”

. . .

Asked about safety and staffing, CVS and Walgreens said they had made changes, like automating routine tasks, to help pharmacists focus on the most important aspects of their jobs.

Many pharmacists contacted for this article quit rather than face this persistent dread, often taking lower-paying positions.

Still, none had regrets about the decision to leave. “I was 4,000 pounds lighter the moment I sent my resignation email in,” said Dr. Wommack, who left the company in May 2021 and now works at a small community hospital.

As for the medication she had taken for depression and anxiety while at Walgreens, she said, “Shortly after I stopped working there, I stopped taking those pills.”

For the full story, see:

Noam Scheiber. “Why Working At Pharmacies Lost Its Luster.” The New York Times (Tuesday, September 13, 2022): A1 & A16.

(Note: ellipses added.)

(Note: the online version of the story has the same date as the print version, and has the title “How Pharmacy Work Stopped Being So Great.”)

Initially Socialist Israeli Kibbutzim Gradually Embraced Entrepreneurial Capitalism

(p. C4) Today, in a break with . . . [its] communal past, Ms. Barnea’s kibbutz is farming for profit, and its main cash crop is medical marijuana. She recently retired from managing the greenhouse that grows the drug.

The shift at Kibbutz Beit HaEmek is just the latest sign of how much Israel’s kibbutzim are changing, as both Israel and the kibbutz movement move away from their socialist roots to become more entrepreneurial and profit-driven.

“We have to survive,” said Ms. Barnea, now 64, walking around the greenhouse as the smell of marijuana wafted past.

. . .

Facing a bleak financial future, young people abandoned the kibbutzim in the 1990s. Meanwhile, Israel’s vibrant technology sector took off, providing an additional pull away from the communes.

To reverse the exodus, Israel’s kibbutzim dismantled much of their socialist model. In 1995, Kibbutz Merom HaGolan became the first to go through a so-called privatization process, paying members salaries on a scale.

Today, most kibbutzim have undergone some form of privatization. Many members now earn salaries outside the kibbutz but pay taxes for the community’s upkeep. New members can take out mortgages with banks and buy land on the kibbutz for their homes.

. . .

Only about 40 kibbutzim still share resources and give equal allowances as envisioned in the original model. Most of these communities had created successful businesses that helped them maintain the communal way of living.

One such community is Kibbutz Sdot Yam, on Israel’s central coast between Tel Aviv and Haifa. In the 1980s, the kibbutz opened a factory that constructed quartz surfaces for tables and floors. Despite that venture’s success, the kibbutz is now considering whether to allow members—most of whom work outside the community—to earn their own salaries, rather than sharing them with the commune, said Doron Stansill, a 47-year-old member.

For the full essay, see:

Rory Jones. “The Kibbutz in a Capitalist Israel.” The Wall Street Journal (Saturday, Oct. 14, 2017 ): C4.

(Note: ellipses added.)

(Note: the online version of the essay has the date Oct. 13, 2017 , and has the title “The Kibbutz Movement Adapts to a Capitalist Israel.”)

NU President Carter May Earn $1.5 Million Per Year by 2023

(p. B1) LINCOLN — The University of Nebraska Board of Regents extended President Ted Carter’s contract by three years on Thursday, potentially keeping the university’s top leader in Nebraska through 2027.

Carter’s new contract, approved unanimously, also raises his base salary by 3% this year and adds a second deferred compensation package to incentivize the president to stay at NU.

In all, Carter’s total compensation could top $1.5 million beginning in 2023.

. . .

Regents also awarded Carter, a former superintendent of the U.S. Naval Academy, a $105,000 performance bonus for the (p. B1) 2021-22 academic year.

That amount is less than the $140,000 he was eligible to receive; Carter hit 89% of the benchmarks set for him by the board last year after first- to second-year retention numbers fell at several NU campuses.

For the full story, see:

CHRIS DUNKER, Lincoln Journal Star. “NU President Given Raise, Extension.” The Omaha World-Herald (Friday, August 12, 2022): B1-B2.

(Note: the online version of the story was updated Sept. 18, 2022, and has the title “Regents approve contract extension, pay raise for NU president.”)

Log4j Open Source Bug Created “Endemic” Risk for “a Decade or Longer”

Continuing worries about the Log4j software bug are consistent with my skepticism of open source software, Openness to Creative Destruction. You can find a brief discussion in the chapter defending patents.

(p. A6) WASHINGTON—A major cybersecurity bug detected last year in a widely used piece of software is an “endemic vulnerability” that could persist for more than a decade as an avenue for hackers to infiltrate computer networks, a U.S. government review has concluded.

. . .

“The Log4j event is not over,” the report said. “The board assesses that Log4j is an ‘endemic vulnerability’ and that vulnerable instances of Log4j will remain in systems for many years to come, perhaps a decade or longer. Significant risk remains.”

. . .

Security researchers uncovered last December a major flaw in Log4j, an open-source software logging tool. It is a widely used piece of free code that logs activity in computer networks and applications.

For the full story, see:

Dustin Volz. “‘Endemic’ Risk Seen In Log4j Cyber Bug.” The Wall Street Journal (Friday, July 15, 2022): A6.

(Note: ellipses added.)

(Note: the online version of the story has the date July 14, 2022, and has the title “Major Cyber Bug in Log4j to Persist as ‘Endemic’ Risk for Years to Come, U.S. Board Finds.”)

My book, mentioned above, is:

Diamond, Arthur M., Jr. Openness to Creative Destruction: Sustaining Innovative Dynamism. New York: Oxford University Press, 2019.

Spreading Smallpox Inoculation to Impress Voltaire

(p. A15) Dimsdale had been summoned by Catherine the Great to inoculate not only the empress herself but also her 13-year-old heir, the Grand Duke Paul.

. . .

As Lucy Ward dramatically relates in “The Empress and the English Doctor: How Catherine the Great Defied a Deadly Virus,” Catherine’s invitation was a high-stakes affair, a testament to Dimsdale’s writings on the methodology of smallpox inoculation and his reputation for solicitous care. His Quaker upbringing had encouraged a brand of outcome- rather than ego-led practice.

. . .

As devastating as smallpox was, for the empress herself and the grand duke who would succeed her to personally undergo inoculation was a risk to both patient and doctor. On the success side stood immunity from the disease, an almost holy example for Catherine’s people, and as-yet-untold riches for her nervous doctor. On the other side, not only the fact that all Russia would refuse the treatment if their “Little Mother” died, but also a disaster for Dimsdale and the son who had accompanied him. Geopolitics came into play too—if things went wrong, some would interpret it as a foreign assassination.

. . .

With a happy result for her and her less-robust son, Catherine sets about publicizing the success. Dimsdale receives the equivalent of more than $20 million and a barony. Bronze medals are cast of Catherine’s profile, reading “She herself set an example.” It helps that Catherine was competitive beyond reason: “we have inoculated more people in a month than were inoculated in Vienna in eight,” she wrote to Voltaire, determined to beat Empress Maria Theresa’s efforts.

For the full review, see:

Catherine Ostler. “BOOKSHELF; Inoculate Conception.” The Wall Street Journal (Thursday, June 23, 2022): A15.

(Note: ellipses added.)

(Note: the online version of the review was updated June 22, 2022, and has the title “BOOKSHELF; ‘The Empress and the English Doctor’ Review: Inoculate Conception.”)

The book under review is:

Ward, Lucy. The Empress and the English Doctor: How Catherine the Great Defied a Deadly Virus. London, UK: Oneworld Publications, 2022.

Private Sector Scores 10 Points Higher Than Government on Customer Experience Index

(p. A4) . . . the government customer experience has improved over time. Federal agencies and programs in 2021 earned an average score of 62.6 points out of 100 in the Customer Experience Index, an annual ranking produced by Forrester Research Inc. The score was the highest federal average the market research company reported since it began studying government in 2015.

But the federal customer experience average still lags 10.7 points behind the private-sector average on the Forrester index.

“There have been people in the federal government doing good [customer experience] work for years,” said Rick Parrish, vice president and principal analyst at Forrester. “The problem is the improvements haven’t been big enough, or fast enough.”

For the full story, see:

Katie Deighton. “Bureaucracy Studies Why It’s So Frustrating.” The Wall Street Journal (Wednesday, April 20, 2022): A4.

(Note: ellipsis added.)

(Note: the online version of the story has the date April 19, 2022, and has the title “White House Presents Plan to Fix Federal Customer Experience.”)