Hershey barred

Some interesting news on hospital merger and anti-trust enforcement.

Via Metro.US

A federal appeals court on Tuesday blocked the proposed merger of the two largest hospital systems in the Harrisburg, Pennsylvania, area.

By a 3-0 vote, the 3rd U.S. Circuit Court of Appeals in Philadelphia ordered a preliminary injunction against the combination of Penn State Hershey Medical Center and PinnacleHealth System.

The court said the U.S. Federal Trade Commission and the commonwealth of Pennsylvania were likely to succeed on the merits of their claim that the merger would be anti-competitive.

The Federal Trade Commission (FTC) had a string of losses this spring at the district court level when they sued to stop mergers in Central Pennsylvania and Chicago. They lose in both cases at the district court level as the judges used (according to relevant healthcare economists) an obsolete standard of assessing market impact.

The FTC is one of the major administrative levers to break up consolidated provider pricing power and as long as the courts are willing to use the FTC’s preferred methodology of determining anti-competetive action, there is a lot of space for the FTC to act on new mergers.



#NotallAssholes

Besides either pointing and laughing or cringing and looking at our fellow countrymen with abject fear and uncertainty, what is on the agenda today

#NotAllAssholes



Good news everybody

One of the fundamental aims of the ACA is being met — people are being covered. Full national Medicaid Expansion would knock off at least another point off. We’re also seeing the cost of the law meeting or beating initial expectations even as premiums are being hiked on the Exchanges. There are plumbing issues and technical problems but the aims of the law are fundamentally being met.

And now for some expert commentary below the fold:
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The Best People

There is this guy.  He’s running for president.  He himself is not particularly experienced at most (all) of what a president does, but we’re not to worry.

Why not?

Because he’s not the detail guy.  He’s the big picture guy, the boss.  He hires the folks who lift and tote.

But that’s OK.

Why?

Because:

“My motto is ‘Hire the best people…”  (Donald Trump: Think Big, 2007).

And now, let us savor:

Donald Trump’s new presidential campaign chief is registered to vote in a key swing state at an empty house where he does not live, in an apparent breach of election laws.

Stephen Bannon, the chief executive of Trump’s election campaign, has an active voter registration at the house in Miami-Dade County, Florida, which is vacant and due to be demolished to make way for a new development….

John_Sell_Cotman_-_Ruined_House_-_Google_Art_Project

Election officials in Miami-Dade make clear to prospective voters that they are required to actually live in the county and to use their home address in election paperwork. “You must reside in Miami-Dade County,” their website states. It adds: “When you register to vote, an actual residence address is required by law.” A county spokeswoman did not respond to questions relating to Bannon’s situation.

Three neighbors said the house where Bannon is currently registered to vote had been abandoned for three months. When the Guardian visited the property on Thursday a large window in the front aspect was missing. A soiled curtain was blowing through it. The driveway was a mess of tree branches and mud.

Bannon never appeared at the house, according to the neighbors.

What’s most striking is that this apparent prima facie  voter fraud — while the more likely to get Bannon into actual legal difficulties — is in a moral sense the lesser of two scandals that have dropped over the last twenty four hours.  Because we’ve also learned this:

Stephen K. Bannon, the new CEO of the Donald Trump campaign, was charged with misdemeanor domestic violence, battery and dissuading a witness following an incident in early January 1996, though the case was ultimately dismissed, according to a police report and court documents.

That witness:

The Santa Monica, Calif., police report says that Bannon’s then-wife claimed he pulled at her neck and wrist during an altercation over their finances, and an officer reported witnessing red marks on her neck and wrist to bolster her account. Bannon also reportedly smashed the phone when she tried to call the police.

The details get uglier:

Bannon then got his lawyer on the case, who allegedly “threatened” Piccard and told her she “would have no money [and] no way to support the children” if the case went to trial.

Bannon then told Piccard to skip town.

He said “that if I wasn’t in town they couldn’t serve me and I wouldn’t have to go to court,” she claimed in the document.

Piccard left for two weeks before Bannon’s attorney said she could return, according to the declaration.

“Because I was not present at the trial, the case was dismissed,” she said in the documents.

That second quote is from The New York Post. That would be the Rupert Murdoch-owned Post, which is an added twist to this tale.  What is the true state of Trump-Murdoch relations?

But leave aside that kind of political inside baseball.  The most compelling element to the story of Bannon’s thuggery is that it is an unexpected, deep look into his character.  Through it we can discover what kind of person Donald Trump — a major party nominee for President, with a genuine, non-zero chance of achieving that office — thinks is one of  “the best people.”

It ain’t pretty.  The Post‘s coverage continues:

Bannon had allegedly also earlier told Picccard, who was then his girlfriend and the expectant mother of their twin girls, that he would only agree to marry her if the kids were “normal.”

He married her on April 14, 1995, three days before the twins were born.

George_Romney_-_Mother_and_Child_-_Google_Art_Project_(2220591)

Worst of all — at least it seems to me — Bannon is a man who would do this:

Piccard alleged in another document that Bannon believed in corporal punishment for the girls, even though he rarely saw them.

She cited as one example that Bannon allegedly spanked one of his toddler daughters to try to stop her from hitting her head against the crib.

Piccard claimed that when she intervened, he exploded, calling her “f—ing crazy” and saying if he hadn’t been interrupted, “she wouldn’t be banging her head anymore.”

Beating any adult is reprehensible.  Whacking on a child, a toddler? (And no, I don’t think “spanking” in this context is likely to have been a gentle swat on the bum.)  There are special circles of hell for those folks.

I left out the last half of the Trump quote at top.  In full, it reads “My motto is ‘Hire the best people, and don’t trust them.’”

As none should him.

Images:  John Sell Cotman, Ruined House betw. 1807 and 1810.

George Romney, Mother and Childundated, before 1802.



APTC Hacks – buggering the competitors

On the whole I want as many insurers and states to engage in a Silver Gap strategies.  However there are situations where it can be used offensively to bugger and beggar competitors.  Let’s walk though an example.

The scenario needs one insurer that actually wants to cover people in a county.  It also needs an insurer that for political/strategic/publicity reasons wants to be on Exchange while selling as few policies as possible.  I can think of at least one situation where that is an accurate assessment of the pricing configuration.  The way that a company stays on Exchange but does not sell many policies is to offer a plan design that meets minimum requirements but is a horrendous value proposition while being priced very high compared to its competing plans.

Silver Spamming strategies by the active insurer enable this sit out and wait strategy by the passive/avoiding insurer.  Mild Silver Gapping strategies where the active carrier offers a low price narrow network Silver and then a broader network plan priced 12% higher as the benchmark Silver when the passive Silver is priced 80% above the benchmark will also allow for a passive presence with low enrollment.

However if the active carrier decides that it wants to screw its competitor it can by embracing an extreme Silver Gap strategy.  It would offer its low cost narrow network plan only.  All of the sudden, the passive carrier’s Silver is now the #2 Benchmark Silver.  The #1 Silver by the active carrier has extremely low post-premium prices so it will suck in all of the healthy risk in the market.  The plan that was supposed to be a placeholder gets significant membership that the offering carrier was not anticipating and it is higher risk membership.

So in odd corner cases like this, the Silver Gap strategy can be deployed offensively.



APTC Hacks, Non subsidized plans and choice revelation

Advanced Premium Tax Credits (APTC) are only relevant for people who buy policies on the Exchanges.  However the subsidized universe is only about half of the entire individual market.  The non-subsidized and off-Exchange universes will help us determine how carriers embark on their Silver pricing strategies.

If an individual would have qualified for an APTC but buys an off-Exchange policy for whatever reason, they do not get any subsidy to help offset the premium.  They pay full price.  There are some non-subsidized buyers on the Exchanges.  A common case will be people with variable incomes who are not sure if they are subsidy eligible.  They may overestimate their income so they don’t have to pay the APTC back but if they have a bad year, they can collect the Premium Tax Credit the following year when they file for their tax refund.  People who know that they can not qualify for the Exchange have no reason to shop on Exchange.  Indeed, they have a mild incentive to look off-Exchange.

Policies that are sold on Exchange must be offered off-Exchange.  However carriers can offer policy and plan designs off-Exchange that they do not offer on Exchange.  Mayhew Insurance did that in 2014 with an experimental product as we needed data to see if our hunch was right (we weren’t).  Carriers can decide to only participate off-Exchange if they wish to do so.  The advantage of selling off-Exchange is that the population is a bit higher income and that tends to correlate with two things; better health and more stability in paying bills.  Even though policies are offered off Exchange, the on and off-Exchange policies in a single metal band in a state are in a common risk pool for risk adjustment purposes.

Off Exchange has a typical policy buying decision maker earning over 400% Federal Poverty Level (FPL).  On Exchange, subsidized buyers have a median policy decision maker earning around 200% FPL.  These are very different market segments.  And those differences can feed some insight into why a carrier that has the ability to capture the #1 and #2 Silver positions would engage in either a Silver Spamming or Silver Gapping strategy.

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Sunday Morning Open Thread


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All-American koan:


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What’s on the agenda as we wrap up the weekend?