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For 165 million nonelderly Americans, employers provide health insurance either by purchasing a fully insured plan or through self-insurance. By self-insuring, employers bear the financial risk for enrollees' health care spending and are accountable for plan management, either directly or by contracting with a third-party administrator. Using National Association of Insurance Commissioners data, we demonstrate that insurers are deeply entrenched in the provision of administrative services only (ASO) contracts for self-insured employers. In 2022, insurers administered to nearly four times as many ASO enrollees as they covered in fully insured plans, with fifty-six insurer-based ASO contractors providing services for 118 million enrollees. The largest ASO contractors-CVS Group, Cigna Health Group, and Elevance Health Inc. Group-collectively served more than seventy million ASO enrollees and demonstrated less variable and stronger profitability relative to other ASO contractors. This study expands understanding of this increasingly important market for employer-sponsored insurance.

Radical cure of Plasmodium vivax malaria with 8-aminoquinolines (primaquine or tafenoquine) is complicated by haemolysis in individuals with glucose-6-phosphate dehydrogenase (G6PD) deficiency. G6PD heterozygous females, because of individual variation in the pattern of X-chromosome inactivation (Lyonisation) in erythroid cells, may have low G6PD activity in the majority of their erythrocytes, yet are usually reported as G6PD \"normal\" by current phenotypic screening tests. Their haemolytic risk when treated with 8-aminoquinolines has not been well characterized. In a cohort study nested within a randomised clinical trial that compared different treatment regimens for P. vivax malaria, patients with a normal standard NADPH fluorescent spot test result (≳30%-40% of normal G6PD activity) were randomised to receive 3 d of chloroquine or dihydroartemisinin-piperaquine in combination with primaquine, either the standard high dose of 0.5 mg base/kg/day for 14 d or a higher dose of 1 mg base/kg/d for 7 d. Patterns of haemolysis were compared between G6PD wild-type and G6PD heterozygous female participants. Between 21 February 2012 and 04 July 2014, 241 female participants were enrolled, of whom 34 were heterozygous for the G6PD Mahidol variant. Haemolysis was substantially greater and a larger proportion of participants reached the threshold of clinically significant haemolysis (fractional haematocrit reduction >25%) in G6PD heterozygotes taking the higher (7 d) primaquine dose (9/17 [53%]) compared with G6PD heterozygotes taking the standard high (14 d) dose (2/16 [13%]; p = 0.022). In heterozygotes, the mean fractional haematocrit reductions were correspondingly greater with the higher primaquine dose (7-d regimen): -20.4% (95% CI -26.0% to -14.8%) (nadir on day 5) compared with the standard high (14 d) dose: -13.1% (95% CI -17.6% to -8.6%) (nadir day 6). Two heterozygotes taking the higher (7 d) primaquine dose required blood transfusion. In wild-type participants, mean haematocrit reductions were clinically insignificant and similar with both doses: -5.8 (95% CI -7.2% to -4.4%) (nadir day 3) compared with -5.5% (95% CI -7.4% to -3.7%) (nadir day 4), respectively. Limitations to this nested cohort study are that the primary objective of the trial was designed to measure efficacy and not haemolysis in relation to G6PD genotype and that the heterozygote groups were small. Higher daily doses of primaquine have the potential to cause clinically significant haemolysis in G6PD heterozygous females who are reported as phenotypically normal with current point of care tests. ClinicalTrials.gov NCT01640574.

Insurance companies often follow highly correlated investment strategies. As major investors in corporate bonds, their investment commonalities subject investors to fire sale risk when regulatory restrictions prompt widespread divestment of a bond following a rating downgrade. Reflective of fire sale risk, the clustering of insurance companies in a bond has significant explanatory power for yield spreads, controlling for liquidity, credit risk, and other factors. The effect of insurer clustering on bond yield spreads is more evident for bonds held to a greater extent by capital-constrained insurance companies, those with ratings closer to National Association of Insurance Commissioners risk categories with larger capital requirements, and during the financial crisis.

The Patient Protection and Affordable Care Act (ACA) of 2010 has been one of the most controversial laws in decades. The ACA relies extensively on the cooperation of states for its implementation, offering opportunities for both local adaptation and political roadblocks. Health insurance exchanges are one of the most important components of the for achieving its goal of near-universal coverage. Despite significant financial support from the federal government, many governors and legislatures have taken actions that have blocked or delayed significant progress in developing their exchanges. However, many state commissioners of insurance have played constructive roles in moving states forward in exchange planning through their expertise, leadership, and pragmatism, sometimes in spite of strong political opposition to the from governors and legislatures.

Why are some countries more open to trade than others? Prominent explanations emphasize differences in the influence of voters as consumers. Consumers benefit from lower prices. Because governments in democracies are more responsive to voters, they should implement lower tariffs. We develop and evaluate an implication of this line of argument. If lower tariffs are a response to consumer interests, lower tariffs should be concentrated on products most relevant to consumers. Using data on consumption shares across product categories, we report evidence that consumer interests do not account for lower tariffs. Governments place higher tariffs on goods with higher consumption shares, and we find no evidence that this relationship attenuates under more democratic institutions. There may be a variety of reasons why more democratic states are engaged in higher levels of international trade. A larger concern for consumer interests, however, is likely not among them.

In the Southern U.S., timber is transported from harvest sites to mills by many small trucking companies. Few studies have examined the structure and challenges facing these businesses. This study involved interviews with 18 log truck owners operating in the state of Georgia, USA. Participants operated in all forested regions of Georgia and included wood dealers, contract haulers, logging businesses, logging and trucking businesses, and large, diversified trucking businesses. Fleet sizes ranged from zero trucks (recently ceased hauling) to more than 50 log trucks. Log trucks were driven an average of 127,324 km year−1 and delivered an average of 17,410 t year−1. Participants averaged 48% loaded km. Analysis suggests the current combination of average payload, percent-loaded km, and published haul rates make it difficult for log trucking companies to be profitable. The most important challenges faced by log truck owners were a shortage of qualified drivers and rising truck insurance premiums, which were identified as the greatest challenge by 44% and 39% of participants, respectively. Increasing percent-loaded km, reducing turn times at mills and harvest sites, providing driver training, and adopting technologies, such as global positioning system tracking and onboard cameras, could improve transportation efficiency and safety.

Background To ensure the provision of patient‐centred health care, it is essential that consumers are actively involved in the process of determining and implementing health‐care quality improvements. However, common strategies used to involve consumers in quality improvements, such as consumer membership on committees and collection of patient feedback via surveys, are ineffective and have a number of limitations, including: limited representativeness; tokenism; a lack of reliable and valid patient feedback data; infrequent assessment of patient feedback; delays in acquiring feedback; and how collected feedback is used to drive health‐care improvements. Objectives We propose a new active model of consumer engagement that aims to overcome these limitations. This model involves the following: (i) the development of a new measure of consumer perceptions; (ii) low cost and frequent electronic data collection of patient views of quality improvements; (iii) efficient feedback to the health‐care decision makers; and (iv) active involvement of consumers that fosters power to influence health system changes.

The Affordable Care Act (ACA) establishes essential health benefits as the coverage standard for health plans sold in the individual and small-group markets for all fifty states and the District of Columbia, including the health insurance Marketplaces. \"Pediatric services\" is one of the required classes of coverage under the ACA. However, other than oral health and vision care, neither the act nor the regulations for implementing it define what these services should be. We investigated how state benchmark plans-the base plan chosen in each state as the standard or benchmark of coverage in that state under ACA rules- address pediatric coverage in plans governed by the essential health benefits standard. Our review of summaries of all the state benchmark plans found that no state specified a distinct pediatric services benefit class. Furthermore, although benchmark plans explicitly included multiple pediatric conditions, many plans also specifically excluded services for children with special health care needs. The Department of Health and Human Services has made a commitment in the essential health benefits regulations to review its approach for the 2016 plan year. Thus, our findings have implications for future regulations regarding the essential health benefits standard for pediatric services.

States are introducing regulations to slow health care spending growth, but which of these successfully reduce spending growth remains unclear. We studied Rhode Island's 2010 affordability standards, which imposed price controls-particularly inflation caps and diagnosis-based payments-on contracts between commercial insurers and hospitals and clinics and required commercial insurers to increase their spending on primary care and care coordination services. Using a difference-in-differences design, we compared spending among 38,001 commercially insured adults in Rhode Island to that among 38,001 matched adults in other states in the period 2007-16. Relative to quarterly fee-for-service (FFS) spending among the control group, quarterly FFS spending among the Rhode Island group decreased by $76 per enrollee after implementation of the policy, or a decline of 8.1 percent from 2009 spending. Quarterly non-FFS primary care coordination spending increased by $21 per enrollee. Total spending growth decreased, driven by lower prices concordant with the adoption of price controls. Quality measures were unaffected or improved. The Rhode Island experience indicates that states may be able to slow total commercial health care spending growth through price controls while maintaining quality.

The Assistance Fund (TAF), a charity based in Orlando, Florida, will pay $4m (£3.1m; $3.6m) to settle claims that it served as a conduit for kickbacks from the drug manufacturers Teva, Biogen, and Novartis that aimed to encourage Medicare patients with multiple sclerosis to use their expensive products. The Anti-Kickback Statute, a federal law, bans drug manufacturers from covering copayments on patients’ behalf, as this could increase Medicare patients’ use of very expensive drugs, ultimately increasing the manufacturer’s profit. [...]the US Department of Justice has alleged that the Assistance Fund brought just such coordination and focus to its relationships with Teva, Biogen, and Novartis.