Monday, September 21, 2015

Drug Pricing and Externalities

I bet a few companies are not too happy about what Turing Pharmaceuticals just did.

Turing acquired rights to the drug Daraprim and pretty much right away increased its price from $13.50 a tablet to $750.  The NYT has the story.

Well, that created quite an uproar.  Hillary Clinton tweeted, "Price gouging like this in the specialty drug market is outrageous. Tomorrow I'll lay out a plan to take it on. -H"

Today the biotech sector had a bad day on Wall Street.


Now what was Turing up to?  Maybe the previous owner, Impax Laboratories, was simply mispricing it?  Maybe there is a difference in opinion as to the price elasticity of demand?

Or maybe there is a difference in time horizon/discount rate between the old owner and the new owner, with the new owner caring more about cash in the present than a lower but longer annuity?

Saturday, September 19, 2015

Competition for Vermont's Hospitals?

I am always intrigued by how some people think they can calculate exactly how many doctors, beds, hospitals, or procedures a population "needs."  And the implicit or explicit conclusion is that it would be wasteful to have more supply than what is the calculated need.

The latest comes from a proposal by an investor group that wants to open an independent (from hospitals) surgery center in Vermont -- see this article for more.

Cases like this are great for seeing the tension between alternative views of efficiency and performance of the health care market.

The proposed center would do outpatient surgeries and procedures only -- colonoscopies, endoscopies, hernia repairs, steroid injections.

It is of course running into opposition by the incumbents.

Amazingly, for Medicare patients, the proposed center would receive only 56% of the payment that a hospital would receive for the same service.  For an umbilical hernia repair, for example, the facility charge for the new center would be $1,417 while a hospital would receive $2,531.  And the proposed center would be profitable at those rates, according to their plan!

Do we think that maybe the Medicare fees are a bit off?

As for the opposition,
"But the project has opponents. They argue that a freestanding for-profit surgical center would threaten the financial health of hospitals and add to the cost of health care in Vermont by duplicating facilities and services. The Vermont Association of Hospitals and Health Systems, which represents all 16 nonprofit hospitals in the state, and Northwestern Medical Center in St. Albans both have been granted interested-party status in the case."
And a VP at Northwestern Medical Center in St. Albans refers to the opening of a similar independent eye surgery center in 2008, saying, "...and we still think the eye center wasn't needed..."From our perspective, it isn't meeting a need."

The President and CEO of the VT Hospitals Association says, "They (such surgery centers) syphon off services that help hospitals maintain a bottom line."

Both the hospital association and the NW Medical Center have "interested party" standing in the decision on the new center.

Here are some questions I would pose:

Is there any place for the process of creative destruction in health care?   
If we aren't prepared to see some duplication of facilities, how do we expect to get any of the benefits of competition? 
Are we prepared at all to see some organizations and facilities become "stranded assets" just like coal plants are becoming in the energy sector? 
Think what would happen if anytime a new auto maker wanted to build a new plant, we did a calculation on whether existing capacity was sufficient -- with the incumbents doing the calculation? 
Or if we had a commission that determined how many seat-miles we needed as capacity in the airline industry? 
How about we let existing universities decide if we need any online competitors?  (And this is my own industry!) 
Or if the Federal Reserve determined how many financial planners we need? 
How will anyone assess relative quality of alternative providers if there are no alternatives?

I know the responses I am going to get:  Health care is different.  Hospitals provide care to the indigent and uninsured, and therefore we need to let them make money in any areas to cover those losses.  This center is just cherry-picking the most profitable Medicare DRGs.  These independent surgery centers have low quality.

While there is certainly plenty of room for debate on these issues, here are some of my thoughts.

As to the indigent and uninsured, that is what we have the ACA for.  Medicaid and subsidized insurance are available in VT.  That issue is now off the table -- that's the beauty of the ACA.

As for cherry picking, if an entrant can get prices at 56% of what a hospital receives and make money, then we have a bigger problem.  It is time to think critically about the "bundling" implicit in Medicare and Medicaid prices. But the inability of Medicare (or Medicaid) to set reasonable prices should not be a license to stop competition.

As for quality of such centers, look at this:

(As a last note, since some of the investors are doctors, the new center could not be an inpatient facility with overnight beds -- the Affordable Care Act bans new physician-owned hospitals and expansion of existing ones.  See here.  How much sense does that make?)

Tuesday, March 03, 2015

Boomers Beware: Pay More for Your Dating Service!

In a classic case of price discrimination, the dating service Tinder will charge those under the age of thirty $9.99 per month and those over the hill of thirty will pay $19.99.

Is marginal cost higher for those over 30?  Or is it that demand is more inelastic for the old-timers?  Tinder hints at what they think:

Tinder says it spent several months researching different price points around the world before it introduced the service. "Lots of products offer differentiated price tiers by age, like Spotify does for students, for example," Rosette Pambakian, a spokeswoman for Tinder, wrote in an e-mail. "Tinder is no different; during our testing we’ve learned, not surprisingly, that younger users are just as excited about Tinder Plus, but are more budget constrained, and need a lower price to pull the trigger."

Excellent.  Next time I teach price discrimination I have a new example.

King v. Burwell Tomorrow!

Tomorrow the Supreme Court will hear the King v. Burwell case.  Plaintiffs in this case argue that the Affordable Care Act's language authorizes Federal subsidies for the purchase of health insurance only on State-established health insurance exchanges, not on Federal exchanges established in states that declined to establish their own exchange.  The issue turns on how language in a statute is to be interpreted.

Prof. Laurence Tribe has an editorial on the matter in today's Boston Globe.  Interestingly, he cites a Supreme Court decision from last week, wherein the Court ruled that a fish is not a "tangible object" as that phrase is used in  18 U. S. C. §1519, which is actually part of the Sarbanes-Oxley Act, put in place after the Enron case to help restore trust in financial markets.

In this case, a fisherman was caught for throwing undersized fish overboard ostensibly to destroy evidence of a crime (shameful, for sure!).  The Section of the law in question states more fully,
“Whoever knowingly alters, destroys, mutilates, conceals, covers up, falsifies, or makes a false entry in any record, document, or tangible object with the intent to impede, obstruct, or influence the investigation or proper administration of any matter..."
Prof. Tribe notes that the majority, with the opinion written by Ruth Bader Ginsburg, declined to interpret a fish as a tangible object -- thereby showing how the language of a statute must be interpreted in the overall context of the statute and the language around the phrase or word in question.

True enough.  But I think Prof. Tribe fails to completely note that Justice Kagan delivered a strong dissent, in which she pretty much argued that the language of the statute is real clear and a fish is clearly a tangible object:

"In my view, conventional tools of statutory construction all lead to a more conventional result: A “tangible object” is an object that’s tangible. I would apply the statute that Congress enacted and affirm the judgment below."

"Apply the statute that Congress enacted.."  Hmmmm.....  and Scalia, Kennedy and Thomas joined with the dissent, making the opposition four.

And while Alito joined the majority, he begins his concurring opinion with,
This case can and should be resolved on narrow grounds. And though the question is close, traditional tools of statutory construction confirm that John Yates has the better of the argument. Three features of 18 U. S. C. §1519 stand out to me: the statute’s list of nouns, its list of verbs, and its title. Although perhaps none of these features by itself would tip the case in favor of Yates, the three combined do so.

Note the phrase, "...the question is close."  Four plus one makes a majority.

In my humble opinion, the same applies to King v. Burwell.  The question is indeed close.


Sunday, February 08, 2015

ACA Subsidies Threatened?: Thoughts on King v. Burwell

This March, the Supreme Court will hold a hearing on the King v. Burwell case.  The tone of that hearing and how different justices behave will cause a million words to be written, but we won't know for sure how the Court will rule until later this summer.

Here are a couple thoughts on the case.

Recall that the basic claim of the plaintiffs (King et al.) is that the Affordable Care Act specifies that subsidies for purchase of health insurance are only available for policies bought on exchanges created by a State -- with a State being defined as one of the fifty states plus the District of Columbia.

The respondents -- Sylvia Burwell et al. -- reply that this is much too narrow a reading of the Act and that there can be no doubt that the overall intent of the Act was to give subsidies to anyone who met the income eligibility requirements, no matter whether the policy was bought on an exchange established by a State or on an exchange established by the Federal government, in the cases where States did not establish their own exchanges.

I think there is a good chance that the Supreme Court will side with King, but that is my opinion.  Also let me say that I have always held the concept of subsidies for health insurance for low income persons one of the best parts of the ACA (although the subsidies could be implemented much better!).

For now, let me point out just two arguments that I find interesting.

1.  There is this idea out there that the part of the ACA where it says that subsidies are only for State exchanges is a minor out-of-the-way clause -- in fact, §36B(c)(2)(A)(i), which is defining what a "coverage month" is.  Here is the actual text, courtesy of Cornell's legal site:
(2) Coverage month 
For purposes of this subsection—
(A) In general 
The term “coverage month” means, with respect to an applicable taxpayer, any month if—
(i) as of the first day of such month the taxpayer, the taxpayer’s spouse, or any dependent of the taxpayer is covered by a qualified health plan described in subsection (b)(2)(A) that was enrolled in through an Exchange established by the State under section 1311 of the Patient Protection and Affordable Care Act, and
(ii) the premium for coverage under such plan for such month is paid by the taxpayer (or through advance payment of the credit under subsection (a) under section 1412 of the Patient Protection and Affordable Care Act).
But as the Brief for the plaintiffs argues (see page 29 of plaintiffs' brief), this is also the  place where the Act tells us that  health plans bought through insurers or brokers will NOT be eligible for subsidies (through the language at issue, saying that only plans bought on State exchanges qualify).  Now that is an extremely important part of ACA (one I don't understand though), that plans bought directly from insurers do not qualify for subsidy.  But there it is, buried in an obscure clause of the law.  Welcome to Federal law -- read it carefully, including the footnotes!  We all know the footnotes are the most important parts of any good paper!

2.  There is this claim by the respondents that the text must be read to include Federal exchanges as qualifying for subsidies, because otherwise the whole Act would fall down.  How could they have written a law with such a self-destructing clause inherent?

Well, this is not really accurate either.  The restriction of subsidies to State exchanges does not by itself imply the house of cards must fall down.  It is also necessary that some States -- many States -- do not establish their own exchanges.  The Congress could easily have thought that States would establish exchanges, and therefore this clause would never be important.  It only became important when State failed to act in the way that Congress thought they would.  The clause is not, therefor, directly destructive of the intent of the overall Act.  The intent could well have been achieved with that clause in it, if only States had not been so damn stubborn, or if it had not proved so difficult to create working exchanges (see Vermont).

Friday, January 16, 2015

Invest all at once or gradually: Risk, random walks and "dollar cost averaging"

I have been thinking a bit about my last post on whether if one has a bundle of cash and wants to put it into the stock market, you should invest all at once or more gradually.  For instance, suppose you have $1 million in cash; you could put it into an equity index fund all at once, or do 1/12 each month for the next year.  Bottom line for me is leaning very strongly towards all at once.

As to be expected, I was not the first one in history to pose this question and there is a fair amount written about it.  The phrase "dollar cost averaging" or DCA is sometimes used to refer to the idea of investing a lump sum gradually, although DCA is also used for other investment policies (such as just investing a fixed amount each month).

Wikipedia has an entry, dollar cost averaging, which starts out good but doesn't really solve the problem.  The references however are pretty good, including a 1979 paper by George Constantinides, "A Note on the Suboptimality of Dollar Cost Averaging as an Investment Policy."

The company Wealthfront, an online financial advisory service, has an entry in their FAQ section that addresses the question and gives a link to a paper published by Vanguard.  This is the same paper referenced by a commenter on my earlier post -- see here.

Both Wealthfront and Vanguard give pretty good reasons for investing all at once.  Vanguard even does a study using historical data to test DCA against all-at-once.

I liked the Constantinides paper because it is the most analytical and because it provides a reference to an even more analytical paper, a 1971 piece in Management Science by Gordon Pye, "Minimax Policies for Selling an Asset and Dollar Averaging."

The answer that many give to my question is along these lines:  If you have decided your optimal asset allocation, 80/20 stocks/bonds or whatever, you should just get to it right away.  If you like the risk/return profile of that asset allocation, then why would you not get to it right away?  If that is your optimal allocation in 12 months, why isn't it your optimal allocation right now?

That is pretty well said and convincing, if I do say so myself.

However, I had the following idea that caused me to consider seriously the gradual policy.  By investing gradually over a year, you end up investing at the average price during the year -- 1/12 each month at the price of that month is the same as putting all the money in at the average of the 12 months' prices.

Putting a statistical hat on, I then thought that the variance of that average price would be lower than the variance of any individual price, and therefore that going in gradually would get me to my optimal allocation in a less risky fashion.

Or put it this way.  Suppose I am going to put my money into the stock market tomorrow.  You give me a choice:  I can put in my order and take whatever the market price of the index is at that time, or you will let me buy in at the average index level during the day.  Again, I thought that I should prefer the average price by the compelling (seemingly) logic that the variance of an average is less than the variance of a single draw from a distribution.

There is a serious flaw in this line of reasoning, though, and it is the Constantinides paper that made me see it -- actually the reference to the Pye article because Pye deals with this problem.

My reasoning about the variance of the average being lower is true if the prices are independent random draws from a distribution.  That was the model of stock prices I implicitly had in my mind.

But probably a better model of stock prices is that they are a random walk.  That means, roughly, that the next price is the current price plus a random shock:

     p(t) = p(t-1) + e

where e is a random variable with mean zero and some variance.

In this case, if you do a little math, you find out that the variance of prices increases over time, and the variance of the average price over a period is not less than the variance of any one price.  Just to do a little math, suppose we have 5 periods.  Then we have

p1 = e1
p2 = p1 + e2
p3 = p2 + e3
p4 = p3 + e4
p5 = p4 + e5

Then doing some substitutions, you can write

p5 = e1+e2+e3+e4+e5

So you can see what is going on -- the end of period price is the sum of all the random shocks to that point.  Its variance is going to be higher than the variance of any of the previous prices -- the random walk is causing variance to increase with time.  That is one of the key ideas of a random walk -- the meandering in the future can be pretty far off course!

And in this case, the variance of the average of the five prices is not lower than the variance of just p1.  I will spare the math here, but it is pretty straightforward:  write out the formula for the average price given the five equations above, and calculate its variance.

So my early intuition was based on one model of stock prices -- that prices are fluctuating randomly around a mean -- rather than what is a better model, that of a random walk.

Now there are some reasons why you might still reasonably want a gradual policy.  One pretty good reason is based on a different kind of utility function, one that has a "regret" characteristic.  You can read the Constantinides paper and see also that he comes up with some reasonable situations where a gradual investment policy does make sense.  If you really think that the market is over-valued now, well then you should wait, but that is market timing which in practice is very difficult to do.  My intuition on why gradualism might be good was not based on market timing, just on the idea that maybe I could reduce the volatility of my wealth (at an acceptable price of lower return).

But in most cases, all at once will be the rational, utility maximizing policy.  Just be ready to face the prospect that you will see prices decline after you go all-in.  Such is the world.

Saturday, January 10, 2015

Buy stock all at once or over time?

Questions involving finance and financial markets can be tough.  Often one's intuition is misleading, and all kinds of priors and biases can get tangled up in decision-making.

With defined contribution pension plans, college tuition plans, annuities, health savings accounts, etc. it is all the more important for everyone to be able to make good financial decisions.

Here is a very practical issue, with a question that I am pondering.  I have intuition on it, but some lingering concerns as well.  I will put it out there for others to think about.

So suppose you all of a sudden come upon $1 million.  You would like to invest this in the stock market, using just one low cost index fund.  Your time horizon is long, say 15 years at least.

Should you put all the $1 million in at once, or should you do something like spread it out over 12 months, putting an equal amount in each month?

Thursday, January 08, 2015

Climate Hypocrisy

It was -14 F this morning in Hanover, -26 C.

Why is it me, rather skeptical of much of climate policy, who has to go around Tuck getting storm windows to be shut for winter?  The heat is just pouring out of the windows while the steam plant burns #2 fuel oil to compensate.

Or why is it me who in the little burb of Hanover immediately goes to the block-away parking lot where a spot is 99% probability rather than drive around and around waiting for someone to leave?  A town of liberal climate-change believers and you would not believe how everyone wastes fuel looking for the closest spot.

Ah, the hypocrisy in this world will kill you if you let it.