A reprogrammable mechanical metamaterial with stable memory.

Metamaterials are designed to realize exotic physical properties through the geometric arrangement of their underlying structural layout1,2. Traditional mechanical metamaterials achieve functionalities such as a target Poisson's ratio3 or shape transformation4-6 through unit-cell optimization7-9, often with spatial heterogeneity10-12. These functionalities are programmed into the layout of the metamaterial in a way that cannot be altered. Although recent efforts have produced means of tuning such properties post-fabrication13-19, they have not demonstrated mechanical reprogrammability analogous to that of digital devices, such as hard disk drives, in which each unit can be written to or read from in real time as required. Here we overcome this challenge by using a design framework for a tileable mechanical metamaterial with stable memory at the unit-cell level. Our design comprises an array of physical binary elements (m-bits), analogous to digital bits, with clearly delineated writing and reading phases. Each m-bit can be independently and reversibly switched between two stable states (acting as memory) using magnetic actuation to move between the equilibria of a bistable shell20-25. Under deformation, each state is associated with a distinctly different mechanical response that is fully elastic and can be reversibly cycled until the system is reprogrammed. Encoding a set of binary instructions onto the tiled array yields markedly different mechanical properties; specifically, the stiffness and strength can be made to range over an order of magnitude. We expect that the stable memory and on-demand reprogrammability of mechanical properties in this design paradigm will facilitate the development of advanced forms of mechanical metamaterials.

Equity Investment in Physician Practices: What's All This Brouhaha?

There have been two waves of equity-based investment in physician practices. Both used a combination of public and private sources, but in different mixes. The first investment wave in the 1990s was led by public equity and physician practice management companies (PPMCs), with less involvement by private equity (PE). The second investment wave followed the Affordable Care Act (ACA 2010) and led by PE firms. It has generated concerns of wasteful spending, less cost-effective care, and initiatives harmful to patient welfare. This paper compares the two waves and asks if they are parallel in important ways. We describe the similarity in the players, driving forces, acquisition dynamics, spurs to consolidation, types of equity involved, models to organize physicians, and levels of market penetration achieved. The paper then tackles three unresolved issues. Does PE investment differ from other investment vehicles in concerning ways? Does PE possess capabilities that other investment vehicles lack and confer competitive advantage? Does physician practice investment offer opportunities for super-normal profits? The paper then discusses ongoing trends that may disrupt PE and curtail its practice investment. We conclude past may be prologue: what happened during the 1990s may well repeat, suggesting the PE threat is overblown.

Big Med's Spread.

Policy Points Hospital executives posit a number of rationales for system mergers which lack any basis in academic evidence. Decades of academic research question whether system combinations confer public benefits. Antitrust authorities need to continue to closely scrutinize these transactions. Recently, mergers of hospital systems that span different geographic markets are on the rise. Economists have alerted policymakers about the potential impacts such cross-market mergers may have on hospital prices. We suggest there are other reasons for concern that scholars have not often confonted. Cross-market mergers may be conducted for purely self-serving reasons of organizational growth that increases executive compensation. Combinations of sellers should have clear advantages to consumers. System executives and their boards should bear the burden of proof. Federal regulators and state attorney generals should be cognizant that rationales for cross-market systems advanced by merging parties are unlikely to be operative or dominant in merger decision making. Policymakers should be careful about passing legislation that encourages hospitals to consolidate. CONTEXT: There is a growing trend of combinations among hospital systems that operate in different geographic markets known as cross-market mergers. Economists have analyzed these broader systems in terms of their anticompetitive behavior and pricing power over insurers. This paper evaluates the benefits advanced by these new hospital systems that speak to a different set of issues not usually studied: increased efficiencies, new capabilities, operating synergies, and addressing health inequities. The paper thus "looks under the hood" of these emerging, cross-market systems to assess what value they might bestow and upon whom. METHODS: The paper examines recently announced cross-market mergers in terms of their supposed benefits, as expressed by the systems' executives as well as by industry consultants. These presumed benefits are then evaluated against existing evidence regarding hospital system outcomes. FINDINGS: Advocates of cross-market hospital mergers cite a host of benefits. Research suggests these benefits are nonexistent. Additional evidence suggests other motives may be at play in the formation of cross-market mergers that have nothing to do with efficiencies, synergies, or community benefits. Instead these mergers may be self-serving efforts by system chief executive officers (CEOs) to boost their compensation. CONCLUSIONS: Cross-market hospital mergers may yield no benefits to the hospitals involved or the communities in which they operate. The boards of hospital systems that engage in these cross-market mergers need to exercise greater diligence over the actions of their CEOs.

Externalities in the wildland-urban interface: Private decisions, collective action, and results from wildfire simulation models for California.

Property damage from wildfires occurs from spread into built-up areas, the wildland-urban interface. Fire spread occurs as embers from one burning structure ignite neighboring ones-but mitigation reduces the chances that fire spreads. In this study, we use a simulation model with realistic parameters for a neighborhood in California to illustrate patterns of marginal benefit from mitigation. We extend existing models of fire spread in two novel ways. We show how to describe the no-regulation equilibrium and social optimal levels of mitigation by incorporating data on a key factor, the distribution of house values in the community. We incorporate insurance in the model and show that it improves homeowner decision-making and insurance premium regulation. The fire spread simulations show that under plausible parameter values, there is a pattern in which mitigation's marginal benefit is low at low levels of community mitigation, rises to a maximum, and then falls quickly to a low level. We argue that the maximum marginal benefit is a guide to achieving optimal mitigation in a community. Owner mitigation decisions will depend on the distribution of house values in the neighborhood and other factors. In an illustration, we use the distribution of house values in a California community to illustrate the mitigation owners will choose under independent (Nash) investment decisions, and the efficiency-improving actions involving regulations or insurance premium subsidies that can lead to the social optimum.

Medical Complexity Mediates Healthcare Resource Use in the Socially Vulnerable.

GOAL: The objective of this retrospective, observational study was to assess the mediating effect of medical complexity on the relationship between social vulnerability and four acute care resource use outcomes-number of hospitalizations, emergency department (ED) visits, observation stays, and total visits. Such information may help healthcare managers better anticipate the effects of interventions targeted to the socially vulnerable in their patient population. METHODS: Electronic health records of 147,496 adults served by 27 primary care practices in one large health system from 2015 to 2017 were used. Descriptive statistics were applied to characterize patients and the primary care practices included in the study. Causal mediation analyses using a modified Baron and Kenny approach were performed. PRINCIPAL FINDINGS: Causal mediation analyses demonstrated that increased social vulnerability was associated with increased medical complexity (incidence rate ratio [IRR] = 1.57) and increased numbers of hospitalizations (IRR = 1.63), ED visits (IRR = 2.14), observation stays (IRR = 1.94), and total visits (IRR = 2.04). Effects remained significant, though attenuated, after adjusting for medical complexity (mediator), demographics, and medications (hospitalizations IRR = 1.44, ED visits IRR = 2.02, observation stays IRR = 1.74, total visits IRR = 1.86). Social vulnerability, given medical complexity, explained between 8% (ED visits) and 26% (hospitalizations) of the variation in outcomes. PRACTICAL APPLICATIONS: These findings reinforce the need to modify interventions for medically complex adults to address their social needs and, consequently, reduce costly health services. Health systems seeking to reduce costly care can use these results to estimate savings in the treatment of patients with high social vulnerability-before they get chronic conditions and later as they seek care.

Older Adult and Family Caregiver Perspectives on Engagement in Primary Care.

The purpose of the current in-depth qualitative study was to explore the experiences of older adults and family caregivers in primary care. Twenty patients and caregivers from six Comprehensive Primary Care Plus (CPC+) practices' Patient and Family Advisory Councils within a large academic health system participated in telephone interviews from December 2018 to May 2019. Participants were mostly women (60%), with an average age of 71 years and nine chronic conditions. Transcripts were coded using conventional content analysis. Two key themes emerged related to person-centered care (PCC): Engagement in Health Care and Patient-Provider Relationship. Engagement in health care was defined by participants as: being proactive, centering on patient goals in treatment discussions, adherence, and self-triaging. Approximately all participants discussed the importance of the relationship and interactions with their provider as influencing their engagement. The identified themes offer recommendations for further improvement of primary PCC. [Journal of Gerontological Nursing, 48(11), 7-13.].

Cost-Effectiveness Analysis of Branded Drugs With Market Demand and Insurance.

OBJECTIVES: Cost-effectiveness analysis of branded pharmaceuticals presumes that both cost (or price) and marginal effectiveness levels are exogenous. This assumption underlies most judgments of the cost-effectiveness of specific drugs. In this study, we show the theoretical implications of letting both factors be endogenous by modeling pharmaceutical price setting with and without health insurance, along with patient response to the prices that depend on marginal effectiveness. We then explore the implications of these models for cost-effectiveness ratios. METHODS: We used simple textbook models of patient demand and pricing behavior of drug firms to predict market equilibria in the drug and insurance markets and to generate calculations of the cost-effectiveness ratios in those settings. RESULTS: We found that ratios in market settings can be much different from those calculated in cost-effectiveness studies based on exogenous prices and treatment of all patients at risk rather than those who would demand treatment in a market setting. We also found that there may be considerable similarity in these market cost-effectiveness ratios across different products because drug firms with market power set profit-maximizing prices. CONCLUSIONS: We found that market cost-effectiveness ratios will always indicate an excess of benefits over cost. Insurance will lead to less favorable ratios than without insurance, but when insurers bargain with drug firms, rather than taking their prices as given, cost-effectiveness ratios will be more favorable.

Policy Flight Simulators: Accelerating Decisions to Adopt Evidence-Based Health Interventions.

EXECUTIVE SUMMARY: In this study, the authors used simulation to explore factors that might influence hospitals' decisions to adopt evidence-based interventions. Specifically, they developed a simulation model to examine the extent to which hospitals would benefit economically from the transitional care model (TCM). The TCM is designed to transition high-risk older adults from hospitals back to communities using interventions focused on preventing readmissions.The authors used qualitative methods to identify and validate simulation facets. Four simulation experiments explored the economic impact of the TCM on more than 3,000 U.S. hospitals: (1) magnitude of readmission penalty, (2) application to specific diagnosis-related groups, (3) level of cost sharing between payer and provider, and (4) capitated versus fee-for-service payments. The simulator projected hospital-specific economic effects. The authors used Monte Carlo methods for the simulations, which were parameterized with public data sets from the Centers for Medicare & Medicaid Services (CMS) and TCM data from randomized controlled trials and comparative effectiveness studies.Under current conditions, the simulation indicated that only 10 of more than 3,000 Medicare-certified hospitals would benefit financially from the TCM. If current readmission penalties were doubled, the number of hospitals projected to benefit would increase to 300. Targeting selected diagnosis cohorts would also increase the number of hospitals to 300. If payers reimbursed providers for 100% of the TCM costs, 2,000 hospitals would benefit financially. Under a capitated payment model, 1,500 hospitals would benefit from the TCM.Current CMS penalties-or reasonable increases-have little economic effect on the TCM. In the current environment, two strategies are likely to facilitate adoption: (1) persuading payers to reimburse TCM costs and (2) focusing on hospitals with higher bed occupancies and higher revenue patients.

Transformation of the Health Care Industry: Curb Your Enthusiasm?

Policy Points: Policymakers seek to transform the US health care system along two dimensions simultaneously: alternative payment models and new models of provider organization. This transformation is supposed to transfer risk to providers and make them more accountable for health care costs and quality. The transformation in payment and provider organization is neither happening quickly nor shifting risk to providers. The impact on health care cost and quality is also weak or nonexistent. In the longer run, decision makers should be prepared to accept the limits on transformation and carefully consider whether to advocate solutions not yet supported by evidence. CONTEXT: There is a widespread belief that the US health care system needs to move "from volume to value." This transformation to value (eg, quality divided by cost) is conceptualized as a two-fold movement: (1) from fee-for-service to alternative payment models; and (2) from solo practice and freestanding hospitals to medical homes, accountable care organizations, large hospital systems, and organized clinics like Kaiser Permanente. METHODS: We evaluate whether this transformation is happening quickly, shifting risk to providers, lowering costs, and improving quality. We draw on recent evidence on provider payment and organization and their effects on cost and quality. FINDINGS: Data suggest a low prevalence of provider risk payment models and slow movement toward new payment and organizational models. Evidence suggests the impact of both on cost and quality is weak. CONCLUSIONS: We need to be patient in expecting system improvements from ongoing changes in provider payment and organization. We also may need to look for improvements in other areas of the economy or to accept and accommodate prospects of modest improvements over time.

Objectives, Budgets, Thresholds, and Opportunity Costs-A Health Economics Approach: An ISPOR Special Task Force Report [4].

The fourth section of our Special Task Force report focuses on a health plan or payer's technology adoption or reimbursement decision, given the array of technologies, on the basis of their different values and costs. We discuss the role of budgets, thresholds, opportunity costs, and affordability in making decisions. First, we discuss the use of budgets and thresholds in private and public health plans, their interdependence, and connection to opportunity cost. Essentially, each payer should adopt a decision rule about what is good value for money given their budget; consistent use of a cost-per-quality-adjusted life-year threshold will ensure the maximum health gain for the budget. In the United States, different public and private insurance programs could use different thresholds, reflecting the differing generosity of their budgets and implying different levels of access to technologies. In addition, different insurance plans could consider different additional elements to the quality-adjusted life-year metric discussed elsewhere in our Special Task Force report. We then define affordability and discuss approaches to deal with it, including consideration of disinvestment and related adjustment costs, the impact of delaying new technologies, and comparative cost effectiveness of technologies. Over time, the availability of new technologies may increase the amount that populations want to spend on health care. We then discuss potential modifiers to thresholds, including uncertainty about the evidence used in the decision-making process. This article concludes by discussing the application of these concepts in the context of the pluralistic US health care system, as well as the "excess burden" of tax-financed public programs versus private programs.

An Overview of Value, Perspective, and Decision Context-A Health Economics Approach: An ISPOR Special Task Force Report [2].

The second section of our Special Task Force builds on the discussion of value and perspective in the previous article of the report by 1) defining a health economics approach to the concept of value in health care systems; 2) discussing the relationship of value to perspective and decision context, that is, how recently proposed value frameworks vary by the types of decisions being made and by the stakeholders involved; 3) describing the patient perspective on value because the patient is a key stakeholder, but one also wearing the hat of a health insurance purchaser; and 4) discussing how value is relevant in the market-based US system of mixed private and public insurance, and differs from its use in single-payer systems. The five recent value frameworks that motivated this report vary in the types of decisions they intend to inform, ranging from coverage, access, and pricing decisions to those defining appropriate clinical pathways and to supporting provider-clinician shared decision making. Each of these value frameworks must be evaluated in its own decision context for its own objectives. Existing guidelines for cost-effectiveness analysis emphasize the importance of clearly specifying the perspective from which the analysis is undertaken. Relevant perspectives may include, among others, 1) the health plan enrollee, 2) the patient, 3) the health plan manager, 4) the provider, 5) the technology manufacturer, 6) the specialty society, 7) government regulators, or 8) society as a whole. A valid and informative cost-effectiveness analysis could be conducted from the perspective of any of these stakeholders, depending on the decision context.

A Health Economics Approach to US Value Assessment Frameworks-Summary and Recommendations of the ISPOR Special Task Force Report [7].

This summary section first lists key points from each of the six sections of the report, followed by six key recommendations. The Special Task Force chose to take a health economics approach to the question of whether a health plan should cover and reimburse a specific technology, beginning with the view that the conventional cost-per-quality-adjusted life-year metric has both strengths as a starting point and recognized limitations. This report calls for the development of a more comprehensive economic evaluation that could include novel elements of value (e.g., insurance value and equity) as part of either an "augmented" cost-effectiveness analysis or a multicriteria decision analysis. Given an aggregation of elements to a measure of value, consistent use of a cost-effectiveness threshold can help ensure the maximization of health gain and well-being for a given budget. These decisions can benefit from the use of deliberative processes. The six recommendations are to: 1) be explicit about decision context and perspective in value assessment frameworks; 2) base health plan coverage and reimbursement decisions on an evaluation of the incremental costs and benefits of health care technologies as is provided by cost-effectiveness analysis; 3) develop value thresholds to serve as one important input to help guide coverage and reimbursement decisions; 4) manage budget constraints and affordability on the basis of cost-effectiveness principles; 5) test and consider using structured deliberative processes for health plan coverage and reimbursement decisions; and 6) explore and test novel elements of benefit to improve value measures that reflect the perspectives of both plan members and patients.

The Questionable Economic Case for Value-Based Drug Pricing in Market Health Systems.

This article investigates the economic theory and interpretation of the concept of "value-based pricing" for new breakthrough drugs with no close substitutes in a context (such as the United States) in which a drug firm with market power sells its product to various buyers. The interpretation is different from that in a country that evaluates medicines for a single public health insurance plan or a set of heavily regulated plans. It is shown that there will not ordinarily be a single value-based price but rather a schedule of prices with different volumes of buyers at each price. Hence, it is incorrect to term a particular price the value-based price, or to argue that the profit-maximizing monopoly price is too high relative to some hypothesized value-based price. When effectiveness of treatment or value of health is heterogeneous, the profit-maximizing price can be higher than that associated with assumed values of quality-adjusted life-years. If the firm sets a price higher than the value-based price for a set of potential buyers, the optimal strategy of the buyers is to decline to purchase that drug. The profit-maximizing price will come closer to a unique value-based price if demand is less heterogeneous.

Effects of the ACA on Health Care Cost Containment.

This brief reviews the evidence on how key ACA provisions have affected the growth of health care costs. Coverage expansions produced a predictable jump in health care spending, amidst a slowdown that began a decade ago. Although we have not returned to the double-digit increases of the past, the authors find little evidence that ACA cost containment provisions produced changes necessary to "bend the cost curve." Cost control will likely play a prominent role in the next round of health reform and will be critical to sustaining coverage gains in the long term.

Cost-effectiveness analysis and insurance coverage: solving a puzzle.

The conventional model for the use of cost-effectiveness analysis for health programs involves determining whether the cost per unit of effectiveness of the program is lower than some socially determined maximum acceptable cost per unit of effectiveness. If a program is better by this criterion, the policy implication is that it should be implemented by full coverage of its cost by insurance; if not, the program should not be implemented. This paper examines the unanswered question of how cost-effectiveness analysis should be performed and interpreted when insurance coverage may involve cost sharing. It explores the question of how cost sharing should be related to the magnitude of a cost-effectiveness ratio. A common view that cost sharing should vary inversely with program cost-effectiveness is shown to be incorrect. A key issue in correct analysis is whether there is heterogeneity in marginal effectiveness of care that cannot be perceived by the social planner but is known by the demander. It is possible that some programs that would fail the social efficiency test at full coverage will be acceptable with positive cost sharing. Combining individual and social preferences affects both the choice of programs and the extent of cost sharing.

Time savings--realized and potential--and fair compensation for community health workers in Kenyan health facilities: a mixed-methods approach.

BACKGROUND: Sub-Saharan Africa faces a severe health worker shortage, which community health workers (CHWs) may fill. This study describes tasks shifted from clinicians to CHWs in Kenya, places monetary valuations on CHWs' efforts, and models effects of further task shifting on time demands of clinicians and CHWs. METHODS: Mixed methods were used for this study. Interviews were conducted with 28 CHWs and 19 clinicians in 17 health facilities throughout Kenya focusing on task shifting involving CHWs, time savings for clinicians as a result of task shifting, barriers and enabling factors to CHWs' work, and appropriate CHW compensation. Twenty CHWs completed task diaries over a 14-day period to examine current CHW tasks and the amount of time spent performing them. A modeling exercise was conducted examining a current task-shifting example and another scenario in which additional task shifting to CHWs has occurred. RESULTS: CHWs worked an average of 5.3 hours per day and spent 36% of their time performing tasks shifted from clinicians. We estimated a monthly valuation of US$ 117 per CHW. The modeling exercise demonstrated that further task shifting would reduce the number of clinicians needed while maintaining clinic productivity by significantly increasing the number of CHWs. CONCLUSIONS: CHWs are an important component of healthcare delivery in Kenya. Our monetary estimates of current CHW contributions provide starting points for further discussion, research and planning regarding CHW compensation and programs. Additional task shifting to CHWs may further offload overworked clinicians while maintaining overall productivity.

Continuity of Care: The Transitional Care Model.

Older adults with multiple chronic conditions complicated by other risk factors, such as deficits in activities of daily living or social barriers, experience multiple challenges in managing their healthcare needs, especially during episodes of acute illness. Identifying effective strategies to improve care transitions and outcomes for this population is essential. One rigorously tested model that has consistently demonstrated effectiveness in addressing the needs of this complex population while reducing healthcare costs is the Transitional Care Model (TCM). The TCM is a nurse-led intervention targeting older adults at risk for poor outcomes as they move across healthcare settings and between clinicians. This article provides a detailed summary of the evidence base for the TCM and the model's nine core components. We also discuss measuring the TCM's core components and the overall impact of this evidence-based care management approach.