Revisiting Incentive-Based Contracts.

Incentive-based pay is rational, intuitive, and popular. Agency theory tells us that a principal seeking to align its incentives with an agent's should be able to simply pay the agent to achieve the principal's desired results. Indeed, this strategy has long been used across diverse industries-from executive compensation to education, professional sports to public service-but with mixed results. Now a new convert to incentive compensation has appeared on the scene: the United States' behemoth health-care industry. In many ways, the incentive mismatch story is the same. Insurance companies and employers are concerned about constraining the cost of care, and patients are concerned about quality of care. Physicians lack an adequate financial incentive to pay attention to either. Health care's recent move away from the traditional fee-for-service compensation model to incentive pay is perhaps unsurprising. But there is a problem: mixed preliminary evidence and potential mal-effects on vulnerable third-party patients. This Article employs a new lens-the legal and behavioral literature on optimal contract specificity-to suggest why incentive pay is problematic and why the health-care experience will be no different than other industries. The use of incentive pay is a change in contractdrafting strategy, a decision to write a more detailed, control-based contract rather than one that relies on discretion. The contracts literature suggests that this strategy will only work well where simple compliance is the goal rather than creativity or innovation. The health industry will not succeed in implementing incentive pay better than other industries have. What it needs is to recognize the limits of incentive pay and implement it sparingly. The new Trump Administration may be particularly primed to heed this call.

The health equity mandate.

People of color and the poor die younger than the White and prosperous. And when they are alive, they are sicker. Health inequity is morally tragic. But it is also economically inefficient, raising the nation's healthcare bill and lowering productivity. The COVID pandemic only, albeit dramatically, highlights these pre-existing inequities. COVID sufferers of color die at twice the rate of Whites. The cause, in large part, is structural inequality and racism. Neither the popular nor the scholarly discussion of healthcare inequity, while robust, has translated into palpable and rapid progress. This article describes why health inequity has so far proven intractable. In the healthcare system, no one actor has both adequate incentive and adequate wherewithal to create progress. The healthcare system cannot solve the problem alone. To jumpstart reform, the article suggests a new regulatory approach, grounded in principles of democratic experimentalism and cooperative federalism. It draws inspiration from the examples that the Health Insurance Portability and Accountability Act (HIPAA) and the Clean Air Act provide. A federal health equity mandate, with funding and penalties for state non-compliance, will spur collaboration between federal, state, local, public, and private entities and start the USA on the path to remediating healthcare's inequities.

Pseudolymphoma evolving into diffuse large B-cell lymphoma.

A 46-year-old man presented with a 1-year history of asymptomatic papules on the right arm, without an antecedent event. Initial clinical and histopathologic features were consistent with a pseudolymphoma without gene rearrangements, and the patient was treated with intralesional glucocorticoids. Four months later, the patient developed additional papules and plaques on the right arm, and, at this time, clinical and histopathologic features were most consistent with a T-cell-rich, large B-cell lymphoma, with monoclonal immunoglobulin light chain gene rearrangement. Systemic evaluation showed no evidence of extracutaneous involvement. The transformation of a pseudolymphoma into a large B-cell lymphoma is a rare event. This patient's subtype, diffuse large B-cell lymphoma-other, carries an intermediate prognosis when compared to the more aggressive leg subtype and more indolent folliculocentric subtype. Potential therapeutic options include local radiotherapy, chemotherapy, and rituximab.