Friday wonk dump: What I’ve been reading

Below is a dump of thoughts and stuff I’ve read recently. I might circle back to some of it in the new year. Or I might not. I figured this is better than nothing.

Market Death Spirals

  • As distinct from death spirals of plans and the prevailing issue with respect to exchanges.
  • Contrary to conventional wisdom, Buchmueller and DiNardo found that New York’s market did not experience a death spiral when it  implemented guaranteed issue and community rating without a mandate in the 1990s. (Adrianna touched on this paper recently.) Their results are consistent with the separating equilibrium theory of Rothschild and Stiglitz. Low risk consumers don’t exit the market. They just buy less complete coverage. (H/t Nick Bagley.)
  • Consistent with conventional wisdom, Lo Sasso and Lurie found large adverse selection into markets that implemented guaranteed issue/community rating reforms in the 1990s. (Ungated working paper version here.) See also Lo Sasso’s NIHCM Expert Voices brief.


  • Powell et al. provide a conceptual framework for overuse by primary care providers. It’s based on the theory of planned behavior that posits that behavior is determined by “an intention or behavioral plan that enables the attainment of a goal.” In brief, PCPs overuse care because they are trying to accommodate beliefs and expectations pertaining to outcomes for patients, themselves, and their organizations, as well as normative beliefs and beliefs about control. PCPs also may filter their intentions through a process of assessment that is constrained by aspects of care delivery such as time spent with patients.
  • Mathias and Baker discuss threats to development and potential unintended consequences of overuse measures.
  • Chan et al. describe and critique the current state of overuse measurement. A key point, among many, is that defining “low-risk” populations is difficult but necessary to turn back or prevent the spread of overuse of many therapies and services worthwhile for “high-risk” patients.


  • Obviously some overlap with overuse.
  • Bentley et al. provide a conceptual framework for US health system waste, decomposing it into administrative, operational, and clinical components.
  • Bohmer describes four habits of high-value health care organizations: (1) specify and plan what you do, (2) related, deliberately design all sub-systems, processes, and infrastructure to match delivery with patient need, (3) measure what you do with external oversight, (4) feedback measurement to refine (1) and (2). Isn’t roughly this the only way to get better at anything? Be clear about what you do and intend to do. Assess how well you do it. Feedback and refine. Seems obvious. And to the extent health providers and systems don’t already do this in serious ways is shameful, bordering on malfeasance in light of the vast public expenditures that support them.

Threats to Reference Pricing


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