EXAMPLES

1.Please read the article below. Using economic theorydiscuss the implications for the vaccine market, should the Supreme Court allow the vaccine manufacturers to be sued outside of ‘vaccine court’.

Supreme Court Considers Vaccine Injury Case

By Emily P. Walker, Washington Correspondent, MedPageToday

Published: October 12, 2010

WASHINGTON -- The U.S. Supreme Court heard arguments today in a case seeking to sue vaccine maker Wyeth outside the special forum established to assure continued availability of vaccines.

Congress created the so-called "vaccine court" in 1986 to address safety claims in an attempt to ease the threat of lawsuits in state courts against pharmaceutical companies lest they pull out of what they claim is an unprofitable vaccine marketplace completely.

The case under consideration was brought by the parents of Hannah Bruesewitz, now 18, and charges that she developed a seizure disorder after receiving her third dose of the diphtheria-tetanus-pertussis (DTP) vaccine when she was six months old. She has suffered developmental problems ever since, and will likely require medical attention for the rest of her life, her parents say.

The dose of the vaccine in question, TRI-IMMUNOL, came from a lot that generated 65 reports of adverse reactions, including 39 emergency room visits, six hospitalizations, and two deaths, according to documents from the U.S. appeals court that heard the case last year.

The Bruesewitz suit argues that the vaccine had a flawed design, contained toxins that caused their daughter's seizures, and that Wyeth could have manufactured a safer vaccine but chose not to. The flawed-design concept, the family alleges, takes the case out of the jurisdiction of the vaccine court, which was set up to compensate injuries from unavoidable side effects.

The vaccine court turned down the Bruesewitz claim and the family then sought to bring a case in state court.

Although the current case does not involve autism, the outcome could have important implications for the hundreds of lawsuits filed against vaccine makers by people who allege the shots caused their children to develop autism. Numerous courts have ruled in the past year that there is no link between common childhood vaccines and autism.

A number of groups, including the American Association for Justice and the National Vaccine Information Center, have filed briefs on behalf of the Bruesewitz family, arguing that Congress intended to allow lawsuits hinging on vaccine defects.

Meanwhile, the Solicitor General of the United States, the Chamber of Commerce, and several medical groups including the American Academy of Pediatrics have filed briefs stating that the 1986 law meant to block the Bruesewitz type of vaccine lawsuit.

Several lower courts have ruled that the law creating the vaccine court preempts design-defect claims.

2.

Please read the article below. Using economic theory discuss the implications of tax deduction provision for self-employed on the bottom line of small firms.

Smart Answers October 12, 2010, 9:44AM EST

Health-Care Tax Relief for the Self-Employed

This year a new law will let solo business owners fully deduct health insurance premiums for the first time. Here's how it works

By Karen E. Klein

I heard that I can deduct my health insurance costs because I run my own business. Is this part of the health-care reform bill? How does it work?

—P.J., Pasadena, Calif.

If you are self-employed and your business is a sole proprietorship, single-member LLC, or sole-owner S-corp, you can indeed deduct your health insurance expenses for 2010. This one-year provision is not a part of the health-care reform bill that passed in March, however. It was included in the Small Business Jobs and Credit Act that President Barack Obama signed into law just last month.

"In this economic climate, any kind of bottom line tax savings is helpful," says Kristie Arslan, executive director of the National Association for the Self-Employed, a Washington-based lobbying group. "This is one of the few small business provisions that's been passed where business owners will actually see lower taxes on Apr. 15, 2011."

Her organization has championed the deduction for more than eight years and unsuccessfully tried to get it included in the health-care reform law.

The new provision corrects what Arslan calls a fundamental unfairness: Self-employed individuals cannot deduct the full cost of health insurance premiums as a business expense on their payroll taxes, as other business entities can do.

Although the new law authorizes the deduction only for 2010,Arslan says it's "a foot in the door" for self-employed individuals, who pay both the employer and employee portions of the payroll tax—a self-employment tax totaling 15.3 percent. Employees typically pay half that amount (7.65 percent) and their employers cover the other half as part of their payroll taxes. The new deduction exempts solo business owners from paying self-employment tax on the portion of their income that they spend on health premiums. "This is a step in the right direction. We're hoping to extend it and make it permanent," Arslan says.

Make sure to ask your tax preparer about taking the deduction when you file your tax returns next year. In order to take advantage of it, you must buy your own insurance (rather than relying on a spouse's coverage or being uninsured) and you must pay self-employment tax on business income (rather than declaring a business loss). The deduction phases out above a $106,800 annual income limit. The provision is specifically geared for those who file a 1040 Schedule C business income tax form or a Schedule E earned income tax form, Arslan says.

Another important caveat: The new deduction does not apply to health insurance coverage that you may provide for any employees you have. There is a small business health-care tax credit, part of the health-care reform legislation, that you may be able to claim for that expense. More information on that tax credit is available at the IRS website.

Karen E. Klein is a Los Angeles-based writer who covers entrepreneurship and small-business issues.

©2010 Bloomberg L.P. All Rights Reserved.

3.

Please read the article below. Using economic theory discuss the implication of excessive expenditure in medical care that denies availability of resources to investments in public health, education, public safety, safety-net, and community development programs andtherefore on life-expectancy in the U.S.

U.S. Still Lags in Life Expectancy

By Joyce Frieden, News Editor, MedPage Today

Published: October 07, 2010

Americans' 15-year survival rates in comparison to those of other countries has been declining despite increases in health spending, researchers have found.

"Even as relative health care spending has increased in the United States, the nation has fallen behind 12 comparison countries with respect to 15-year survival for men and women ages 45 and 65 during the past three decades," according to Peter A. Muennig, MD, MPH, and Sherry A. Glied, PhD, both of the Mailman School of Public Health at Columbia University in New York City.

"The findings undercut critics who might argue that the U.S. healthcare system is not in need of major changes," they wrote in the November 2010 issue of Health Affairs.

In 1950, the U.S. was fifth among the leading industrialized nations with respect to female life expectancy at birth, the authors noted. But the most recent numbers put the country at 46th in the world. And, for male and female life expectancy combined, the U.S. is ranked 49th.

Meanwhile, per-capita health spending increased at nearly twice the rate in other wealthy nations between 1970 and 2002. The U.S. now spends far more on health than any other country as a percentage of its gross domestic product.

To explore the issue further, the investigators examined health costs and 15-year survival from 1975 to 2005. They focused on 45- and 65-year-old men and women, and measured costs as healthcare spending per capita. They also examined relative changes in smoking and obesity over time.

They used international data on obesity and health system costs from the Organization for Economic Cooperation and Development. They also looked at data for U.S. non-Hispanic whites from the CDC and at International Mortality and Smoking Statistics data to examine smoking statistics.

In 1975, the United States was in last place with respect to 15-year survival at age 45 for people of both sexes. However, it ranked high for those at age 65. At that time, per-capita U.S. health care costs were above the mean for other nations but were comparable to those in some of the nations studied.

Between 1975 and 2005, survival probabilities and health costs increased for all groups in all nations.

However, by 2005, "not only were 15-year survival rates for 45-year-old U.S. white women lower than in all comparison countries, but they had not even surpassed 1975 15-year survival rates for Swiss, Swedish, Dutch, or Japanese women," the investigators wrote.

In addition, 65-year-old U.S. white women in particular also showed large relative declines in 15-year survival.

One possible explanation for the U.S.'s poor showing is its population diversity, the researchers noted. "According to this argument, lower health status or lower survival gains for ethnic or racial minorities would tend to depress overall health outcomes for Americans relative to the residents of other countries."

But that does not appear to be the case. For instance, relative gains in survival for non-Hispanic whites in the U.S. between 1995 and 2005 were the lowest among nations in each age category, while men and women in Austria and Australia experienced some of the largest gains.

"Contrary to the diversity hypothesis, including the experience of diverse groups in the U.S. data improves the comparative performance of the United States, since the superior survival gains of other Americans relative to non-Hispanic whites boosts the overall performance of the United States relative to that of other countries," the authors wrote.

In terms of smoking, the current smoking rate in the U.S. is generally lower than in the 12 comparison nations. In 2006, the U.S. smoking rate was 15% for women and 19% for men, whilethe comparison-country smoking rates ranged from a low of 14% for Japanese women to a high of 41.3% for Japanese men.

As for obesity, the U.S. population is much heavier, on average, than the populations of other countries; however, "there is nothing new about this pattern: In 1975, U.S. obesity rates were also much higher than those in other countries," the authors noted.

Other causes of death, such as homicides and traffic accidents, aren't borne out as possible causes either, they continued.

Rather, Glied and Muennig suggested, rising U.S. health spending may be the reason.

"First, as health spending rises, so, too, does the number of people with inadequate health insurance," the authors wrote. "Higher spending could be reducing survival by decreasing the number of insured people."

In addition, rising health spending may be decreasing public funding on more important life-saving programs, and "investments in public health, education, public safety, safety-net, and community development programs may be more efficient at increasing survival than further investments in medical care."

Finally, unregulated fee-for-service reimbursement and an emphasis on specialty care may contribute to high U.S. health spending because it leads to unneeded procedures and fragmented care.

"Unneeded procedures may be associated with secondary complications. Fragmentation of care leads to poor communication between providers, sometimes conflicting instructions for patients, and higher rates of medical errors. For example, two separate physicians are probably more likely than a single primary care provider to prescribe two incompatible drugs to a single patient."

However, how much this affects population health is uncertain, the authors admitted.

"We speculate that the nature of our health care system -- specifically, its reliance on unregulated fee-for-service and specialty care -- may explain both the increased spending and the relative deterioration in survival that we observed. If so, meaningful reform may not only save money over the long term, it may also save lives."

The study was funded by a grant from the Commonwealth Fund.

Glied is currently on leave from the Department of Health and Human Services (HHS); the study was written prior to her appointment at HHS and does not reflect the official views ofHHS. No other information on conflicts of interest was provided.

Please answer ANY TWO questions below. Emphasis should be on building economic model(s) that captures the central point of each question with short paragraphs explaining the assumptions you have made to construct the model(s). 

1.Clearly and without reservation identify the good or service that is at the heart of the question. Failure to do so may cause problems such as drifting into other markets and products that are not at the center of the article.

2.Establish the initial market condition in terms demand and supply curves and initial equilibrium prices and quantity exchanged in the market. Remember that there should be separate market model for each good/service considered. Vertical axis is prices and not cost. Cost is built into the supply curve. What market observes is price and not cost of production.

3.Make certain that you incorporate Elasticities of demand and supply in the initial model if applicable. If consumers are price insensitive at initial state, them demand curve is more steep than otherwise. If production of the product is complicated and expanding output by suppliers (producers) is costly, then supply curve is steeper than otherwise. For example, supply curve of neurosurgery is considerably steeper than supply of primary care provided by a nurse practitioner. If you do not see any reason to make assumptions about demand and/or supply Elasticities, then use a generic 45 degree curve(s).

4.Work into the model dynamic of the issue… that is how consumer demand or producer supply curve changes due to some exogenous forces. For example, increase in consumer taste or need for a good/service will shift the demand for the product and may become even less price sensitive (steeper). Adverse supply shocks such as problems with production, lack of inputs, backfired technology or management decisions all can shift the supply curve to the left and even make it more steep reflecting higher cost of production.

5.Identify the conclusions reached after dynamic of the issue is incorporated into the model

6.Label your model clearly and carefully.

7.You may hand draw the model(s). 

8.Finally, AVOID restating or rephrasing the content of the article as a way of analyzing the issue. You should take the real world scenario discussed in the article and use the economic tools, concepts, theories and models to unravel the content.

Questions

1.In the article below, once again, allegations of improper link between the pharmaceutical industry and the FDA/NIH that result in favorable outcomes for the industry has been raised. Using economic theory discuss the implications of such practices on public health.

FDA and Pharma: Emails Raise Pay-for-Play Concerns

Published: Oct 7, 2013

By John Fauber, Reporter, Milwaukee Journal Sentinel/MedPage Today

For more than a decade representatives of some of the nation's leading pharmaceutical companies paid entry fees running into the tens of thousands of dollars to attend invitation only conferences with FDA and NIH officials, according to a trove of emails provided to the Milwaukee Journal Sentinel/MedPageToday.

The Email Trail

The emails, most of which track correspondence among founders of an organization called IMMPACT, academics, NIH researchers, and FDA officials, raise serious questions about the way in which federal regulators interact with the pharmaceutical companies they regulate.

Entry to these meetings was secured by annual fees that ranged as high as $35,000. The drug companies that paid those fees were guaranteed the right to send a representative to the annual meetings of the organization known as IMMPACT, meetings that were also attended by officials from the FDA and other federal agencies..

The IMMPACT web site, states that the organization's goal is to improve the design of clinical trials conducted to develop new pain treatments.

But the emails raise concerns about a possible pay-for-play arrangement in which drug companies were able to buy access to invitation-only meetings where they could meet with FDA officials and possibly influence FDApolicy regarding approval and regulation of analgesics, said Michael Carome, MD, director of the health research group of the watchdog group, Public Citizen.

"The whole picture is a troubling one and it warrants an independent investigation," said Carome, who has seen the emails.

Powerful Strategy or Shortcut to Disaster?

As an example of an initiative that sprung from the IMMPACTmeetings, Carome singled out the FDA's new "enriched enrollment" guidance for conducting pivotal trials of drugs. Enriched enrollment allows drug companies to weed outnonresponders or subjects who have adverse reactions to the drug from enrollment in clinical trials.

Experts say that approach makes it much more likely a drug will prove effective and possibly win FDA approval. It's also cheaper for drug companies to conduct such trials.

However, the approach has drawn criticism because it essentially stacks the deck in favor of the drug. More importantly, experts say, drugs tested that way are not likely to reflect what will happen when a drug gets on the market and is prescribed for large numbers of people.

"It's in fact cheating," said Patrick McGrath, PhD, a pediatric pain expert at the Dalhousie University in Halifax, Nova Scotia.

On its web site, the FDA says that enriched enrollment is potentially powerful strategy for the pharmaceutical industry because when used appropriately it can result in smaller studies, shortened drug development time and lower development costs.

"While enrichment won't save a drug that doesn't work, it will help find one that will," Bob Temple, MD, the agency's deputy director for clinical science, wrote in a piece posted on the FDA's web site last December.

Behind Closed Doors

The emails represent another example of how drug company money has influenced the practice of American medicine, a concern that has been raised in ongoing investigative reports in the Journal Sentinel/MedPage Today over the last 4 years.

Several of those stories revealed how companies that make opioid analgesics funded various nonprofit organizations that advocated for expanded use of opioids, particularly in treating chronic pain.

That increased use of opioids over more than a decade has been linked to an epidemic of overdose deaths and addiction.

Last year, the U.S. Senate Committee on Finance, citing reports in the Journal Sentinel/MedPage Today , opened an investigation into those financial relationships.

The IMMPACT emails, which run for 409 pages, were obtained through a public records request by Craig Mayton, a Columbus, Ohio attorney who has made claims against drug companies in cases where people have died of opioid overdoses. The emails were provided to Mayton by the University of Washington where, Dennis Turk, PhD, one of the founders of the organization, works as a professor of anesthesiology and pain medicine.

Mayton gave the emails to the Journal Sentinel/MedPage Today.

In an email response to questions about the emails, FDA spokesman Steven Immergut, said the agency was aware of concerns raised about the agency's involvement in theIMMPACT organization and "we take these concerns very seriously. We are unaware of any improprieties..."

In an interview, Douglas Throckmorton, MD, the FDA's deputy director for regulatory programs, said FDA officials who attended the organization's meetings were listening to scientists, not setting policy.

"Pay-for-play is just not the way the FDA operates," Throckmorton said. "That's not part of the culture of the FDA."

He said that while enriched enrollment may have been discussed at the organization's meetings, the FDA's decision to endorse of the concept did not come entirely from the meetings.

The emails paint a picture of another way in which drug companies can exert influence on the practice of medicine.

In a 2003 email, Raymond Dionne, an official with the National Institutes of Health, raised a concern about the closed, invitation-only nature of the organization's meetings and suggested open meeting on the NIH campus.

"The major advantage of having the meeting on the NIH campus would be the ability to open the meeting to all interested parties and avoid the stigma that this initiative is a 'pay to play'process," Dionne wrote.

A day later, Dionne wrote in an email that IMMPACT was inviting criticism that is it "paid for by a few large pharmaceutical firms who are assumed to be influencing the outcomes."

Brown Bagging It

In another email about 2 weeks later, Dionne tells IMMPACTthat he and other federal officials "if they play by the book" should not accept dinners for meetings at the Four Seasons Hotel.

"I may even bring a brown bag," Dionne says.

In response, Robert Dworkin, PhD, the other co-founder ofIMMPACT, told Dionne that, if he wished, the organization would order "inexpensive sandwiches for lunch for the government folks."

"The rest of us undoubtedly will feel guilty, but we will probably resist the temptation to have tuna fish in respect for your plight," added Dworkin, a professor at the University ofRochester Medical Center.

Renate Myles, a spokeswoman for NIH, said that because of the federal government shut down she could not provide a response for this story.

Many of the academics invited to the organization's meetings were offered payments of about $3,000 to attend. In a 2002 letter from Turk, the University of Washington professor who is a co-founder ofIMMPACT, a $3,000 honorarium was offered to Robert Rappaport, MD, who heads the FDA division that regulates analgesics, to attend an IMMPACT meeting in Annapolis, Md., The FDA said the payment was not accepted.

In an interview Turk, acknowledged that, dating back to 2002, drug companies paid between $20,000 and $35,000 each to be able to send one representative to the 16 meetings held by the group.

Nearly all the meetings were held over 2 days at high-end hotels in the Washington, D.C. area., Turk said.

Between 25 and 50 people, including regulators, academic researchers and drug company representatives attended each event.

"There was no attempt to do anything more than answer some questions," Turk said.

After the meetings, consensus papers that listed drug company officials, federal health officials and academics as the co-authors were published in various medical journals.

Dworkin, said no more than than one person from any one drug company was allowed to attend the meetings and it was encouraged that companies send researchers, not marketing people.

Dworkin acknowledged that the emails might raise ethical concerns.

"Yes, some of the emails that Dennis and I sent back and forth ... looked problematic on the surface, but the fact of the matter is it was a model that worked that no one complained about," saidDworkin, a professor and pain expert at the University of Rochester Medical Center.

The organization's website lists 11 drug company sponsors, including several that make narcotic painkillers.

In an email, James Heins, a spokesman for Purdue Pharma, the company that makes the narcotic painkiller, OxyContin, said the pharmaceutical industry has been an important participant in the organization's program.

"Our experience conducting clinical trials is valuable to academia and the FDA, especially in improving clinical trial design for analgesics," Heins said.

In an email, Greg Panico, a spokesman for the Janssen Research & Development, said it funded the organization to help improve clinical trials involving pain drugs. Janssen's, parent, Johnson & Johnson, is listed as a corporate sponsor on the organization's web site.

"Our company believes in working collaboratively in public-private efforts to pursue scientific innovation," Panico said

2. In the article below, out-of-pocket spending for millions of currently uninsured citizens will decrease while the overall expenditure for the same group will increase as they purchasemedical insurance. Using economic theory (models) show the impact of reduction in out-of-pocket spending on 1. Medical care services market and 2. Public health.

Washington-Watch

Out-of-Pocket Costs Projected to Fall Under ACA

Published: Oct 3, 2013

By David Pittman, Washington Correspondent, MedPage Today

WASHINGTON -- Most Americans flocking to HealthCare.govthis week to sign up for health coverage under the Affordable Care Act (ACA) will see their out-of-pocket costs fall with expanded insurance options, an analysis found.

"Decreases in out-of-pocket spending will be largest for those who would otherwise be uninsured," a study from the RAND Corporation found. "In some cases, these reductions will be dramatic."

However, total health spending -- which includes out-of-pocket costs and spending on health insurance premiums -- will increase for many newly insured people, except those who will be covered by Medicaid.

In the report, "Effects of the Affordable Care Act on Consumer Health Care Spending and Risk of Catastrophic Health Costs," RAND researchers sought to understand how the 2010 health law would impact consumer spending by using amicrosimulation model for newly insured consumers and those who change their source of coverage.

Out-of-Pocket Costs Predicted to Drop ...

The lowest-income individuals receiving coverage in the ACA'sindividual market -- those making between 100% and 138% of the federal poverty level -- are expected to see their out-of-pocket costs drop from about $1,446 in 2016 without the ACAto $506 with the law. The 11.4 million people making between 138% and 400% of poverty will have their out-of-pocket costs drop from about $1,969 to $1,224.

Those making above 400% of poverty will see their out-of-pocket spending fall from an estimated $5,368 to $1,227, according to the report. "We note that this group has particularly high out-of-pocket costs without the ACA because many of these individuals are denied coverage on the individual market without guaranteed issue due to their health status," the authors stated.

Low-income uninsured people who are living in states that don't expand their Medicaid programs -- Texas and Florida, for example -- and who are ineligible for federal assistance will spend an average of $1,831 out-of-pocket, compared to $28 if they were covered by Medicaid.

However, people who gain coverage in an expanded Medicaid program are predicted to have their annual out-of-pocket medical costs fall from $1,463 to $34. In states that elect to expand, the ACA has the federal government pay most or all coverage for those making up to 138% of poverty.

"Because the consumers in this group will pay no premiums, the decreases in out-of-pocket spending for those transitioning from uninsured status to Medicaid will be identical to the decreases in overall health care spending," the RAND study stated.

... But Total Health Spending Expected to Increase

However, total health spending will increase for most groupsunder the ACA.

Consumers who become newly insured on the individual market and make too much money to qualify for the ACA's subsidies are expected to pay more ($7,202) in 2016 compared to if the law wasn't in place ($5,368), according to the report.

"This increase is explained largely by the fact that newly insured consumers are paying premiums for the first time -- and for those with incomes above 400 percent of the [federal poverty level], these premiums are not subsidized by the government -- and thus their total spending on healthcare will increase even though their out-of-pocket spending will go down," the report stated.

The ACA's exchanges or marketplaces that have launched this week, catching much attention and crashing from heavy traffic, are open to those without affordable health options, but the premium tax credits are only available for those making between 100% and 400% of poverty.

Of the 16.5 million who would be uninsured without the ACA, the RAND study expects 3.3 million people nationwide to make too much to receive the subsidies.

Consumers with incomes below 138% of poverty will spend a total of $2,005 in 2016, an increase of $559. Those making between 138% and 400% of poverty will spend $3,536, an increase of $1,567.

"Our results show that despite decreases in out-of-pocket spending for those who transition from being uninsured to having coverage in the individual market, total consumer health care spending will increase for this group because these people, who previously opted not to or were ineligible to buy insurance, will be paying premiums for the first time," the study showed.

Finally, RAND estimated that by 2016, 11.5 million people will have gained coverage from Medicaid. Those newly covered people will see their risk of spending at least 10% of their income on medical costs drop from 45% to 5%.

3.In the article below, reminders and communication has been identified as methods by which primary care providers may reduce patient no-shows. Using economic model(s) show the impacting of reducing no-shows on the market for medical care.

Reminders, Clarity Help Cut Office No-Shows

Published: Oct 4, 2013

By Chris Kaiser

Interventions focused on forgetfulness and miscommunication might help decrease missed primary care appointments, researchers suggested.

Two-thirds of those who missed an appointment said it was either because they had forgotten (35%) or there was a miscommunication (31.5%), according to Emma Kaplan-Lewis, MD, a resident primary care physician, and Sanja Percac-Lima, MD, a primary care physician, both at Massachusetts General Hospital (MGH) Chelsea HealthCare Center.

Patients who missed appointments were more likely to be younger than those who showed up; those ages 18-40 made up about 38% of those who showed up, but comprised more than half (54%) of the no-shows, researchers reported in the latest edition of the Journal of Primary Care & Community Health. On the other hand, patients between 40-64, and patients 65 and over, were more likely to honor their scheduled appointments compared with those under 40 (both P<0.001).

The no-shows also were more likely to be Hispanic (P<0.001), black (P=0.0423), and have Medicaid, self-insurance, or no known insurance (P<0.001).

Other reasons for missing an appointment, in order of greatest percentage to least (starting at 5.1%), were:

•Too sick

•Late

•Other obligation

•Away

•Work

•Hospitalized

•Transportation issues

•Health insurance

Interestingly, only three patients reported insurance as a barrier to making scheduled appointments. Kaplan-Lewis and Percac-Lima suggested that positive note may be because of the health insurance mandate in Massachusetts.

Also, the seven patients who claimed hospitalization prevented them from making their appointment was"notable" because MGH Chelsea has an electronic system that notifies schedulers and primary care physicians when someone is hospitalized. Researchers suggested that the patients have been at nonaffiliated facilities, and that a solution could entail having a better system of coordination among Boston area hospitals.

There was no difference in gender between those who came to their appointments and those who did not, nor was there a difference related to primary language spoken.

Other studies have found language to be a barrier to keeping appointments, but MGH Chelsea has 16 interpreters/outreach workers on site covering 13 languages, researchers pointed out.

For the study, Kaplan-Lewis and Percac-Lima retrospectively reviewed records at a community health center serving a predominantly Latino, immigrant, and low-income population.

They identified adults who did not show to primary care appointments from March 23, 2012 to September 4, 2012.

Of 5,604 appointments, 16.5% were no-shows. A total of 37% of them were interviewed for this study.

Forgetfulness has been noted in previous studies as a predominant reason for missing appointments with primary care clinics.

A study by Richard D. Neal, MB, ChB, and colleagues in the United Kingdom, for example, found thatover 40% of those who missed an appointment had simply forgotten. However, 25% said they tried very hard to cancel the appointment.

Similar to the current study, Neal and colleagues found that younger patients were more likely to miss appointments.

Missed primary care appointments lead to poor disease control and later presentation to care. What strategies do you employ to help patients keep their appointments? -- Sanjay Gupta, MD

This study was supported by a Harvard Medical School Center for Primary Care Academic Innovations Collaborative Grant.

The authors declared no potential conflicts of interest with respect to the study.

4.In the article below the number of diagnostic codes will jump from 1700 to 150,000. Using economic theory (models) discuss the implications on physician services.

Docs Urged to Start Prepping Now for ICD-10

Published: Oct 2, 2013

By David Pittman, Washington Correspondent, MedPage Today

WASHINGTON -- Come the first week of October next year, the number of codes to document, say, an angioplasty will go from one to 854. The number of pressure ulcer codes will jump from nine to 125. Asthma will need to be classified as "mild," "mild intermittent," "mild persistent," "moderate persistent," or "severe."

Yes, this week brought the opening of the Affordable Care Act's health insurance exchanges, but Oct. 1, 2014 will usher in another revolution for physician offices: the International Classification of Diseases, version 10 -- ICD-10.

And the date is one that the Centers for Medicare and Medicaid Services has stood firm on after granting a 1-year delay.

The much-dreaded update to the coding system that determines how much physicians will be paid increases the number of procedure and diagnostic codes from roughly 17,000 to nearly 150,000 and requires much greater detail on location of ailments, cause and type, and complications or manifestations compared with ICD-9.

While ICD-9 codes are three to five numbers long, ICD-10 codes are up to seven digits long and include numbers and letters.

And reimbursement will depend on getting them all right.

Several health information technology experts advise physician offices to start testing systems and workflow practices now -- if they haven't already -- to prepare for the transition.

Deepak Sadagopan, general manager of clinical solutions at the Bellevue, Wash., health IT companyEdifecs, said providers should expect multiple disruptions to offices, involving reimbursement, contracts with payers, and worker productivity.

"There are multiple impacts that could potentially ripple through the organization," Sadagopan said on a webinar Tuesday. "Some of these impacts are going to be with your organizations for some time."

A computer-assisted coding system may help smooth workflow, he said. But Sadagopan said providers also must improve the specificity of documentation in order to meet ICD-10's increased billing demands.

Nearly two-thirds of clinical documentation doesn't contain enough information for coders to use for billing under ICD-10, according to a survey from AAPC, a medical coding society based in Salt Lake City, Utah.

AAPC gives a number of tips for physicians:

•

Review contracts with health plans and see what additional information they need or what will be changing

•

Test systems and procedures before October 2014 to make sure your office is ready to go

•

Budget for the costs of the change

•

Train and educate clinicians and other staff members on the changes they need to make

•

Update forms, documentation, and internal processes

CMS has produced a number of tip sheets, handbooks, and other content to aid providers on the transition. The agency also hosts periodic teleconferences and sends updates via email. Checklists and tip sheets also vary by small, medium, and large practices and hospitals.

Along with links to its resources, the agency suggests that practices:

•

Have a transition plan in place and make sure it documents the steps being followed and the dates that milestones will be achieved to comply with ICD-10 requirements

•

Include vendor tasks in the plan and time line, and make sure to communicate with your practice management system and/or electronic health record (EHR) vendors regularly about ICD-10

•

Establish an emergency fund to cover unexpected costs and possible reimbursement delays

CMS recommends providers not focus on the more than 100,000 codes in ICD-10, but home in on thehandful that are most applicable to their practice and specialty.

Doctors note that ICD-10 comes with a wave of other health IT transformations, including "meaningful use" mandates for EHRs and e-prescribing.

Physician advocates, including the American Medical Association and the Medical Group Management Association (MGMA), have pushed for greater flexibility in the program, given the many IT mandates coming.

MGMA has specifically has urged CMS to conduct "end-to-end testing" between the agency and physician practices, a move CMS has declined to take.

5.Please view the video (link below). What economic theory discussed is relevant in understanding the central theme of the lecture. Discuss with graph(s).

http://www.ted.com/talks/barry_schwartz_on_the_paradox_of_choice.html