High-resolution land value maps reveal underestimation of conservation costs in the United States.

The justification and targeting of conservation policy rests on reliable measures of public and private benefits from competing land uses. Advances in Earth system observation and modeling permit the mapping of public ecosystem services at unprecedented scales and resolutions, prompting new proposals for land protection policies and priorities. Data on private benefits from land use are not available at similar scales and resolutions, resulting in a data mismatch with unknown consequences. Here I show that private benefits from land can be quantified at large scales and high resolutions, and that doing so can have important implications for conservation policy models. I developed high-resolution estimates of fair market value of private lands in the contiguous United States by training tree-based ensemble models on 6 million land sales. The resulting estimates predict conservation cost with up to 8.5 times greater accuracy than earlier proxies. Studies using coarser cost proxies underestimate conservation costs, especially at the expensive tail of the distribution. This has led to underestimations of policy budgets by factors of up to 37.5 in recent work. More accurate cost accounting will help policy makers acknowledge the full magnitude of contemporary conservation challenges and can help improve the targeting of public ecosystem service investments.

Extracorporeal photopheresis chargemasters show haphazard billing practices.

BACKGROUND: United States healthcare spending continues to outpace other developed nations although efforts are being made to increase cost-transparency. Recent legislation requires hospitals to publish a chargemaster, a list of all billable procedure codes together with prices. Chargemaster prices have been shown to be highly variable, if available, and are not typically paid, but contribute to negotiated rates. Extracorporeal photopheresis (ECP) is performed for a limited number of indications and could serve as a marker of this variability. We investigated the availability of chargemaster documentation for ECP procedures and the variability of pricing as assessed by institutional characteristics. STUDY DESIGN AND METHODS: A list of centers with photopheresis systems was obtained from the device manufacturer and the institutional websites were analyzed for chargemaster list prices. Multivariate linear regressions were performed to compare impact of facility variables on chargemaster pricing. RESULTS: There are 139 locations in the US which are listed as referral centers for ECP; and chargemaster prices were available in 66.2% of these centers. The range was $571.48-183,452.00, maximum price 321 times greater than minimum, and the median price, after outlier exclusion, was $8989.06 (SD = $4361.72). ECP cost did not correlate with hospital size, facility type, ownership, number of hospitals in the referral region, hospital care intensity index, academic status, or region (p ≥ .05). CONCLUSIONS: Chargemaster costs for ECP procedures are highly variable and nonuniform, and the current data available for patients undergoing these specialized apheresis procedures is insufficient to afford patients the ability to compare prices.

Availability, cost and affordability of selected antibiotics and antiviral medicines against infectious diseases from 2013 to 2019 in Nanjing, China.

OBJECTIVES: As economic globalisation develops in-depth, infectious diseases that occur in a country or region no longer remains a regional issue. Antibiotics and antiviral medicines are essential medicines for the therapy of infectious diseases. This study aims to evaluate their availability, cost and affordability of AaAMs against infectious diseases in 41 public hospitals from 2013 to 2019 in Nanjing, China. METHODS: Data on the availability and price of 17 antibiotics and 6 antiviral medicines in 41 public hospitals were obtained from the Jiangsu Institute of Medicine Information. We adopted the WHO/Health Action International method to measure the availability, cost and affordability of these medicines. RESULTS: The availability of selected medicines against infectious diseases was relatively low; the median availability of originator brands was near-zero and that of lowest-priced generics during the survey period less than 50%. The total availability of medicines was poor in primary hospitals as compared to secondary and tertiary hospitals. The median daily-defined dose cost of originator brands was expensive (range from 66.11 RMB to 107.83 RMB), whereas that of lowest price generics was fairly acceptable at < 8 RMB. The affordability of most surveyed medicines was reasonable, which showed significant improvement over time, but the daily cost of a few medicines for originator brands exceeded the average daily wage. CONCLUSIONS: In general, the affordability of medicines surveyed was acceptable, while the availability was too low. There should be a great concern for improving the reserve system of anti-infective medicines in healthcare institutions. Policy should focus on improving the availability of generic drugs in hospitals and encouraging preferentially prescribed.

Nationwide survey of the availability and affordability of asthma and COPD medicines in Nigeria.

OBJECTIVE(S): To determine the availability and affordability of asthma and COPD medicines across Nigeria. METHODS: This was a cross-sectional survey conducted in 128 pharmacies (51 in public sector hospitals, 51 private sector community pharmacies and 26 charity or big private hospitals) across the six geopolitical zones of Nigeria using the WHO/Health Action Initiative method. The proportion of pharmacies where medicines were available, the median retail prices of originator and generics and affordability were analysed. A medicine was available if found in ≥ 80% of surveyed pharmacies. Unaffordability was defined as paying> 1 day's wage (> US$1.68) for a standard 30-day supply of the medicine. RESULTS: The available medicines were oral corticosteroids and oral salbutamol which are not on the WHO Essential Medicine List. Medicines were found more frequently in private than public pharmacies and in the southern than northern zones. Inhalable corticosteroid was not available at any public pharmacy nationwide. None of the EML medicines were affordable. The least number of days' wages for a 30-day supply of any inhalable corticosteroid-containing medication was 3.5 days. CONCLUSIONS: There are very limited availability and affordability of recommended asthma and COPD medicines across Nigeria with disparity across regions. Medicines that were available and affordable are not recommended and are harmful for long-term use. This underpins the need for engagement of all stakeholders for the review of existing policies regarding access to asthma and COPD medicines to improve availability and affordability.

Trends in access to anti-malarial treatment in the formal private sector in Uganda: an assessment of availability and affordability of first-line anti-malarials and diagnostics between 2007 and 2018.

BACKGROUND: Malaria is the single largest cause of illness in Uganda. Since the year 2008, the Global Fund has rolled out several funding streams for malaria control in Uganda. Among these are mechanisms aimed at increasing the availability and affordability of artemisinin-based combination therapy (ACT). This paper examines the availability and affordability of first-line malaria treatment and diagnostics in the private sector, which is the preferred first point of contact for 61% of households in Uganda between 2007 and 2018. METHODS: Cross-sectional surveys were conducted between 2007 and 2018, based on a standardized World Health Organization/Health Action International (WHO/HAI) methodology adapted to assess availability, patient prices, and affordability of ACT medicines in private retail outlets. A minimum of 30 outlets were surveyed per year as prescribed by the standardized methodology co-developed by the WHO and Health Action International. Availability, patient prices, and affordability of malaria rapid diagnostic tests (RDTs) was also tracked from 2012 following the rollout of the test and treat policy in 2010. The median patient prices for the artemisinin-based combinations and RDTs was calculated in US dollars (USD). Affordability was assessed by computing the number of days' wages the lowest-paid government worker (LPGW) had to pay to purchase a treatment course for acute malaria. RESULTS: Availability of artemether/lumefantrine (A/L), the first-line ACT medicine, increased from 85 to100% in the private sector facilities during the study period. However, there was low availability of diagnostic tests in private sector facilities ranging between 13% (2012) and 37% (2018). There was a large reduction in patient prices for an adult treatment course of A/L from USD 8.8 in 2007 to USD 1.1 in 2018, while the price of diagnostics remained mostly stagnant at USD 0.5. The affordability of ACT medicines and RDTs was below one day's wages for LPGW. CONCLUSIONS: Availability of ACT medicines in the private sector medicines retail outlets increased to 100% while the availability of diagnostics remained low. Although malaria treatment was affordable, the price of diagnostics remained stagnant and increased the cumulative cost of malaria management. Malaria stakeholders should consolidate the gains made and consider the inclusion of diagnostic kits in the subsidy programme.

Budget Impact of Tyrosine Kinase Inhibitor Discontinuation in Chronic Myeloid Leukemia With Sustained Deep Molecular Response.

OBJECTIVES: Tyrosine kinase inhibitors (TKIs) account for the vast majority of healthcare expenditure on patients with chronic myeloid leukemia (CML), and it has been demonstrated that TKI discontinuation in patients in long-term deep molecular remission (DMR) is safe and improves quality of life. Our objective was to estimate the budget impact of TKI discontinuation in CML patients in long-term DMR from the perspective of the French healthcare system. METHODS: This analysis was conducted over a 5-year time horizon using a Markov model with cycles of 6 months. Transition probabilities were estimated through systematic reviews and meta-analyses. Costs were estimated from the French National Claims Database. Monte Carlo simulations were performed to take into account the uncertainty surrounding model parameters. Sensitivity analyses were carried out by varying the size of the target population and the cost of TKIs. RESULTS: Over a 5-year period and for a target population of 100 patients each year eligible and agreeing to stop TKI, the TKI discontinuation strategy would save €25.5 million (95% confidence interval -39.3 to 70.0). In this model, the probability that TKI discontinuation would be more expensive than TKI continuation was 12.0%. In sensitivity analyses, mean savings ranged from €14.9 million to €62.9 million. CONCLUSIONS: This study provides transparent, reproducible, and interpretable results for healthcare professionals and policy makers. Our results clearly show that innovative healthcare strategies can benefit both the healthcare system and patients. Savings from generalizing TKI discontinuation in CML patients in sustained DMR should yield health gains for other patients.

Understanding the strategies rural cancer patients and survivors use to manage financial toxicity and the broader implications on their lives.

PURPOSE: To explore strategies rural Australians use to cope with the financial consequences of their cancer diagnosis and how that impacts on their lives. METHODS: Twenty adult cancer patients/survivors residing in regional-remote areas of Australia were purposively sampled and participated in audio-recorded, semi-structured interviews. When data saturation was reached, thematic analysis was employed to analyse the data. RESULTS: Participants were 20-78 years (M=60), 70% female, 35% were undergoing treatment and the remaining 65% had finished treatment within the past 5 years. Three themes provide context to rural financial toxicity-related experiences (travelling to access cancer treatment away from home is expensive, being single or lacking family support exacerbates the financial strain, and no choice other than to adopt cost-saving strategies if wanted to access treatment). Strategies commonly employed to minimise financial toxicity include: accessing travel-related support, changes to lifestyle (buying cheaper food, saving on utilities), accessing savings and retirement funds, missing holidays and social activities, reduced car use and not taking a companion to cancer-related appointments at metropolitan treatment areas. Although cost-saving strategies can effectively increase the ability of rural people to cover cancer treatment-related and other costs, most have broader negative psychological, social and practical consequences for them and their families. CONCLUSIONS: Increasing rural cancer patients' and survivors' awareness of various cost-saving strategies and their impact (positive and negative) may decrease their risk of experiencing financial toxicity and unexpected unintended consequences of adopting cost-saving measures.

Health System Costs of Treating Latent Tuberculosis Infection With Four Months of Rifampin Versus Nine Months of Isoniazid in Different Settings.

BACKGROUND: Four months of rifampin treatment for latent tuberculosis infection is safer, has superior treatment completion rates, and is as effective as 9 months of isoniazid. However, daily medication costs are higher for a 4-month rifampin regimen than a 9-month isoniazid regimen. OBJECTIVE: To compare health care use and associated costs of 4 months of rifampin and 9 months of isoniazid. DESIGN: Health system cost comparison using all health care activities recorded during 2 randomized clinical trials. (ClinicalTrials.gov: NCT00931736 and NCT00170209). SETTING: High-income countries (Australia, Canada, Saudi Arabia, and South Korea), middle-income countries (Brazil and Indonesia), and African countries (Benin, Ghana, and Guinea). PARTICIPANTS: Adults and children with clinical or epidemiologic factors associated with increased risk for developing tuberculosis that warranted treatment for latent tuberculosis infection. MEASUREMENTS: Health system costs per participant. RESULTS: A total of 6012 adults and 829 children were included. In both adults and children, greater health system use and higher costs were observed with 9 months of isoniazid than with 4 months of rifampin. In adults, the ratios of costs of 4 months of rifampin versus 9 months of isoniazid were 0.76 (95% CI, 0.70 to 0.82) in high-income countries, 0.90 (CI, 0.85 to 0.96) in middle-income countries, and 0.80 (CI, 0.78 to 0.81) in African countries. Similar findings were observed in the pediatric population. LIMITATION: Costs may have been overestimated because the trial protocol required a minimum number of follow-up visits, although fewer than recommended by many authoritative guidelines. CONCLUSION: A 4-month rifampin regimen was safer and less expensive than 9 months of isoniazid in all settings. This regimen could be adopted by tuberculosis programs in many countries as first-line therapy for latent tuberculosis infection. PRIMARY FUNDING SOURCE: Canadian Institutes of Health Research.

Provider- and patient-level costs associated with providing antiretroviral therapy during the postpartum phase to women living with HIV in South Africa: A cost comparison of three postpartum models of care.

OBJECTIVE: To compare the unit and total costs of three models of ART care for mother-infant pairs during the postpartum phase from provider and patient's perspectives: (i) local standard of care with women in general ART services and infants at well-baby clinics; (ii) women and infants continue to receive care through an integrated maternal and child care approach during the postpartum breastfeeding period; and (iii) referral of women directly to community adherence clubs with their infants receiving care at well-baby clinics. METHODS: Capital and recurrent cost data (relating to buildings, furniture, equipment, personnel, overheads, maintenance, medication, diagnostic tests and immunisations) were collected from a provider's perspective at six sites in Cape Town, South Africa. Patient time, collected via time-and-motion observation and questionnaires, was used to estimate patient perspective costs and is comprised of lost productivity time, time spent travelling and the direct cost of travelling. RESULTS: The cost of postpartum ART visits under models I, II and III was US $13, US $10 and US $7 per visit for a mother-infant pair, respectively, in 2018 US$. The annual costs for the mother-infant pair utilising the average visit frequencies (a mean of 4.5, 6.9 and 6.7 visits postpartum for models I, II and III, respectively) including costs for infant immunisations, visits, medication and diagnostic tests for both mothers and infants were: I - US $222, II - US $335 and III - US $249. Sensitivity analysis to assess the impact of visit frequency on visit cost showed that Model I annual costs would be most costly if visit frequency was equalised. CONCLUSION: This comparative analysis of three models of care provides novel data on unit costs and insight into the costs to provide ART and care to mother-infant pairs during the delicate postpartum phase. These costs may be used to help make decisions around integrated services models and differentiated service delivery for postpartum WLH and their children.

OBJECTIF: Comparer le coût et unitaire et total de trois modèles de soins ART pour les paires mère-enfant pendant la phase post-partum selon les perspectives du fournisseur et du patient: (I) - normes locales des soins avec les femmes dans les services généraux de l'ART et les nourrissons dans les cliniques de bien-être pour bébés; (II) - les femmes et les nourrissons continuent de recevoir des soins via une approche intégrée de soins maternels et infantiles pendant la période d'allaitement post-partum; et (III) - orientation des femmes directement vers les clubs d'adhésion communautaires, leurs nourrissons recevant des soins dans les cliniques de bien-être pour bébés pour bébés. MÉTHODES: Les données sur les coûts d'investissement et les coûts récurrents (relatifs aux bâtiments, au mobilier, à l'équipement, au personnel, aux frais généraux, à l'entretien, aux médicaments, aux tests de diagnostic et aux vaccinations) ont été recueillies selon le point de vue du prestataire sur six sites à Cape Town, en Afrique du Sud. Le temps du patient, recueilli via l'observation du temps et des mouvements et des questionnaires, a été utilisé pour estimer les coûts selon le point de vue du patient, et comprend le temps de productivité perdu, le temps passé en déplacement et le coût direct du déplacement. RÉSULTATS: Le coût des visites ART post-partum dans les modèles I, II et III était respectivement de 13 USD, 10 USD et 7 USD par visite pour une paire mère-enfant en USD de 2018. Les coûts annuels pour la paire mère-enfant en utilisant la fréquence moyenne des visites (une moyenne de 4,5 ; 6,9 et 6,7 visites post-partum pour les modèles I, II et III respectivement), y compris les coûts des vaccinations infantiles, des visites, des médicaments et des tests diagnostiques pour les mères et les nourrissons étaient: I - 222 USD, II - 335 USD et III - 249 USD. L'analyse de sensibilité pour évaluer l'impact de la fréquence des visites sur le coût des visites a montré que les coûts annuels du modèle I seraient les plus élevés si la fréquence des visites était égalisée. CONCLUSIONS: Cette analyse comparative de trois modèles de soins fournit de nouvelles données sur les coûts unitaires et un aperçu des coûts de fourniture de l'ART et de soins aux paires mère-enfant pendant la phase délicate du post-partum. Ces coûts peuvent être utilisés pour aider à la prise des décisions concernant les modèles de services intégrés et la prestation de services différenciés pour les femmes en période de post-partum et leurs enfants.

A tale of two cities: the cost, price-differential and affordability of current and healthy diets in Sydney and Canberra, Australia.

BACKGROUND: The perception that healthy foods are more expensive than unhealthy foods has been reported widely to be a key barrier to healthy eating. However, assessment of the relative cost of healthy and unhealthy foods and diets is fraught methodologically. Standardised approaches to produce reliable data on the cost of total diets and different dietary patterns, rather than selected foods, are lacking globally to inform policy and practice. METHODS: This paper reports the first application, in randomly selected statistical areas stratified by socio-economic status in two Australian cities, of the Healthy Diets Australian Standardized Affordability and Pricing (ASAP) method protocols: diet pricing tools based on national nutrition survey data and dietary guidelines; store sampling and location; determination of household incomes; food price data collection; and analysis and reporting. The methods were developed by the International Network on Food and Obesity/NCD Research, Monitoring and Action Support (INFORMAS) as a prototype of an optimum approach to assess, compare and monitor the cost and affordability of diets across different geographical and socio-economic settings and times. RESULTS: Under current tax policy in Australia, healthy diets would be 15-17% less expensive than current (unhealthy) diets in all locations assessed. Nevertheless, healthy diets are likely to be unaffordable for low income households, costing more than 30% of disposable income in both cities surveyed. Households spent around 58% of their food budget on unhealthy food and drinks. Food costs were on average 4% higher in Canberra than Sydney, and tended to be higher in high socioeconomic locations. CONCLUSIONS: Health and fiscal policy actions to increase affordability of healthy diets for low income households are required urgently. Also, there is a need to counter perceptions that current, unhealthy diets must be less expensive than healthy diets. The Healthy Diets ASAP methods could be adapted to assess the cost and affordability of healthy and unhealthy diets elsewhere.

Pharmaceutical Products and Their Value: Lessons Learned and the Path Ahead.

Steep increases in prices and spending on prescription drugs in the United States have triggered public outrage and questions over their value. Value-based pricing has emerged as a preferred alternative to prices determined by what the market will bear. In response, manufacturers and health plans have begun to publicize their efforts to engage in outcomes-based contracts and long-term financing agreements, which they describe as value-based. Nevertheless, both contracting approaches perpetuate existing distortions in the financial incentives of supply chain and prescribing intermediaries, and fail to realign the prices of drugs to their value to patients, the healthcare system, or society. This commentary describes the challenges of managing drugs according to their value, and describes several alternatives that promise greater impact than contracting strategies.

Employee and Employer Benefits From a Migraine Management Program: Disease Outcomes and Cost Analysis.

OBJECTIVE: To assess the impact of a migraine management program offered as a complimentary service by a company within its corporate well-being program. BACKGROUND: Migraine imposes a substantial burden on patients, families, employers, and societies. As migraine primarily affects working-age adults, this has important implications for both employees and employers. Workplace educational and well-being programs positively contribute to employees' productivity, reduce costs related to absenteeism, and improve the quality of life of the employees living with migraine. METHODS: This was a non-interventional cohort study, which followed employees and their family members over time. Participants received 1 telemedicine consultation to determine migraine diagnosis or a high probability of having migraine and 6 sessions of individualized telecoaching from a specialized nurse via a specially developed smartphone application to optimize their migraine management leveraging all appropriate medical and lifestyle options. Participants were evaluated during the program and at 3 months after completion through a series of validated questionnaires including Migraine Disability Assessment (MIDAS), Patient Activation Measure (PAM), and satisfaction with the services offered. A cost analysis was also performed to determine the economic benefit of the program considering the number of completers, dropouts, their associated program costs, MIDAS data, average salary of a Swiss employee in the pharma sector, and working days per year. RESULTS: Of the 141 participants enrolled in the program, 79 completed 6-month and 42 completed 9-month assessments. The total MIDAS scores (mean, standard deviation [SD]) significantly improved from baseline by 54% at Month 6 (15.0 [13.6] vs 6.9 [8.2]; mean [SD] reduction: 8.1 [12.9], 95% confidence interval [CI]: 5.6-10.6; P < .0001) and by 64% at Month 9 (15.4 [14.7] vs 5.6 [6.0]; mean [SD] reduction: 9.8 [14.0], 95% CI: 6.6-13.0; P < .0001). The PAM scores also significantly improved from baseline by 8% at Month 6 (63.8 [10.9] vs 69.6 [12.8]; mean [SD] increase: 5.8 [12.8], 95% CI: 3.2-8.4; P = .003) and 11% at Month 9 (63.5 [10.7] vs 71.3 [12.2]; mean [SD] increase: 7.8 [11.0], 95% CI: 4.3-11.2; P = .003). At Month 6, common coaching lessons and respective action plans focused on progressive muscle relaxation, sleep, hydration, nutrition, general disease education, and stress management. The exit survey showed that the majority of the participants who completed the program had a meaningful and sustained improvement in their overall health and reported a high level of satisfaction with the program. The cost analysis revealed that on average participants gained 10.8 (95% CI: 9.3-12.3) working days/year that were previously lost due to migraine, resulting in a positive return on investment (ROI) of 490% (95% CI: 410%-570%), indicating a higher magnitude of savings that could be achieved by the implementation of such program. In addition to ROI and work productivity gained, participants also gained on average 13.6 (95% CI: 9.9-17.3) migraine-free days/year for their private and social life. CONCLUSION: The employer-sponsored disease management program provided a better understanding of migraine, promoted methods and approaches to improve management by combining medical and lifestyle options leading to significant improvements in migraine symptoms that sustained beyond the intervention, supporting prolonged effectiveness of such programs. The program also provided a high ROI to the employer, supporting that the systematic inclusion of such programs into corporate well-being initiatives can be of significant benefit not only to the impacted individuals but to the employers as well.

Patient-controlled sedation with propofol for endoscopic procedures-A cost analysis.

BACKGROUND: Patient-controlled sedation (PCS) with propofol accompanied by a bedside nurse anaesthetist is an alternative sedation method for endoscopic procedures compared with midazolam administered by a nurse or endoscopist. Increasing costs in health care demands an economic perspective when introducing alternative methods. We applied a hospital perspective on a cost analysis comparing different methods of sedation and the resource use that were expected to affect cost differences related to the sedation. METHODS: Based on two randomised previous studies, the direct costs were determined for different sedation methods during two advanced endoscopic procedures: endoscopic retrograde cholangiopancreatography (ERCP) and flexible bronchoscopy including endobronchial ultrasound. ERCP comparisons were made between midazolam sedation by the endoscopic team, PCS with a bedside nurse anaesthetist and propofol sedation administered by a nurse anaesthetist. Bronchoscopy comparisons were made between midazolam sedation by the endoscopic team and PCS with a bedside nurse anaesthetist, categorised by premedication morphine-scopolamine or glycopyrronium. RESULTS: Propofol PCS with a bedside nurse anaesthetist resulted in lower costs per patient for sedation for both ERCP (233 USD) and bronchoscopy (premedication morphine-scopolamine 267 USD, premedication glycopyrronium 269 USD) compared with midazolam (ERCP 425 USD, bronchoscopy 337 USD). Aborted procedures that needed to be repeated and prolonged hospital stays significantly increased the cost for the midazolam groups. CONCLUSION: Propofol PCS with a bedside nurse anaesthetist reduces the direct sedation costs for ERCP and bronchoscopy procedures compared with midazolam sedation.

Economic opportunities of using crossbreeding and sexing in Holstein dairy herds.

With the increasing availability of sexed semen, farms have the opportunity to select genetically superior dams to produce their replacement animals and to produce crossbred calves for beef production of higher economic value than the remainder of the herd. However, higher costs and reduced fertility of sexed semen complicate the decision of when and to what extent sexed semen should be applied in a herd. The objective of this study was to explore the economically optimal utilization of sexed semen and crossbreeding among North Rhine-Westphalian dairy farms in a holistic single-farm model. For the analysis, we derived a representative sample of farms from Latin Hypercube sampling based on the observed distribution of farm characteristics from official North Rhine-Westphalian Farm Structure Survey data. Market- and technology-related input parameters such as output prices and sexed semen accuracy and fertility were included in the sampling procedure. Modeling results of the systematic sensitivity analysis were evaluated in a statistical meta-model. We found that the profit-maximizing utilization of sexed semen and crossbreeding was highly heterogeneous among the farms. Farms with lower stocking densities, <2 livestock units (LU)/ha, were generally found to produce excess heifers for sale, whereas farms with stocking densities >2 LU/ha were producing crossbred calves and using sexed semen only to produce replacement animals. On average, female-sexed dairy semen was used on 25.3% of all inseminations. Beef semen (both sexed and conventional) for producing crossbred calves was used in an average of 21.5% of the inseminations. The combination of sexed semen and crossbreeding increased profits from €0 to €568 per cow per year, with an average of €79.42 per cow per year. Farms characterized by low stocking densities (<2 LU/ha) and above-average replacement rates (>40%) were found to have higher profit increases as a result of selling more heifers from the use of sexed semen. Overall, sexed semen and crossbreeding adoption were most sensitive to stocking density and average cow longevity, as well as to additional costs for sexed semen and sexed semen accuracy. Our results show the potential of modern breeding technologies to improve dairy farm profits and the need to judge their profitability in the light of farm-specific production settings.

The paralyzing legal costs of facial nerve injury in head and neck tumors.

PURPOSE: Facial nerve paralysis from head and neck tumors can result from disease progression or iatrogenic causes, leading to litigation. The aim of this study was to investigate lawsuits regarding facial paralysis as a consequence of these tumors to understand and better educate physicians behind the reasons for litigation. METHODS: Jury verdict reviews were obtained from the Westlaw database from 1985 to 2018. Gathered data, including verdicts, litigation reasons, defendant specialties, and amounts awarded, were analyzed via Statistical Package for the Social Sciences. RESULTS: Of the 26 lawsuits analyzed, the leading reason for litigation was failure to diagnose (53.8%), followed by iatrogenic injury (34.6%). The average award was $2,704,470. Otolaryngologists were the most common defendants. Defendants that included an otolaryngologist had shorter delays of diagnosis compared to those that did not (p < 0.05). CONCLUSION: Failure to diagnose parotid injury was the leading cause of litigation. In instances where the jury found for the plaintiff, the amount was material. There were equivalent incidences of cases in favor of plaintiffs and defendants.

Competition in Outpatient Procedure Markets.

BACKGROUND: More than half of all medical procedures performed in the United States occur in an outpatient setting, yet few studies have explored how competition among ambulatory surgery centers (ASCs) and hospitals affects prices for commercially insured outpatient services. OBJECTIVES: We examined the association between prices for commercially insured outpatient procedures and competition among ASCs and hospitals. RESEARCH DESIGN: Using claims from the Health Care Cost Institute for 2008-2012, we constructed county-level price indices for outpatient procedures in hospital outpatient departments and ASCs. Using regression analysis, we estimated the association between prices and ASC availability, outpatient and inpatient hospital competition, hospital/physician integration, and several other hospital market characteristics. Our estimates were identified from changes within counties over time. RESULTS: First, ASC availability was associated with decreases in overall outpatient procedure prices, mostly due to reductions in the prices paid to hospital outpatient departments. Second, competition among hospitals was also associated with decreases in outpatient procedure prices-and had an effect more than twice as large as the effect of ASC availability. Third, competition among ASCs was also associated with reductions in the prices paid to other ASCs. CONCLUSIONS: Our results suggest that competition from ASCs benefits consumers through lower prices for outpatient procedures. Any conclusions about the broader welfare implications of the rise in ASCs, however, must balance the price reductions that we found with the volume increases found in previous work, particularly the volume increases at physician-owned ASCs.

Payment Reform, Medication Use, and Costs: Can We Afford to Leave Out Drugs?

Medications are one of the fastest growing sources of costs in the health system and the cornerstone of disease management. Despite extensive attention around drug pricing, medications have largely been excluded from CMS-derived, value-based payment models. In this perspective, we synthesize evidence about the impact of three prominent models-primary care-based redesign, ACOs, and bundled payment programs-on medication use, adherence, and costs. We also examine the literature describing similar models implemented by private payors and their relationship with medication use and costs. The exclusion of drug costs from payment reform model design has led to missed opportunities for payors and providers to prioritize effective medication management strategies and has limited our learning about the effects on cost and quality. New CMS-based models are starting to allow greater flexibility in pharmacy benefit design and reward improved medication therapy management. Additionally, health plans, pharmacies, and pharmacy benefit managers are beginning to partner on collaborative value-based pharmacy initiatives. Taken together, these efforts encourage a paradigm shift around drug cost management that more deeply integrates pharmacy into payment and delivery reform with the goal of improving quality and reducing the total cost of care.

Prices, availability and affordability of insulin products: a cross-sectional survey in Shaanxi Province, western China.

OBJECTIVE: To evaluate price, availability and affordability of insulin products in Shaanxi Province, western China. METHODS: We used a simplified and adapted WHO/Health Action International method to obtain the availability and prices of insulin products and five oral anti-diabetic medicines as comparators in public general hospitals and private retail outlets. In addition, we investigated the price components of eight selected insulin products by tracing the supply chain. RESULTS: All three kinds of insulin products, prandial, basal and premixed insulin, are 100% available in public hospitals, and have fairly high availability in the private sector (62.5-68.8%). The prices of most insulin products were higher than international reference prices in both sectors (ranging from 0.95 times to 2.33 times). All insulin products were unaffordable as they would cost 3.5-17.1 days' wage of the lowest-paid government workers in Shaanxi. The manufacturer's markup (selling price), which comprised more than 60% of the final price of all insulin products surveyed, was the largest price component. CONCLUSIONS: Although availability of insulin products was high in public general hospitals and private retail pharmacies, their high price made them unaffordable to diabetes patients, especially low-income patients. The government should increase insurance compensation for those who need these life-saving medicines or decrease the cost of insulin products through negotiation with suppliers.

Enhanced recovery protocols in colonic surgery: retrospective cohort analysis of economic impact from an institutional point of view.

BACKGROUND: Despite increasing evidence supporting the beneficial effects of enhanced recovery protocols (ERPs), their accurate economic impact on institutions remains lacking. The aim of this study was to analyze ERP economic impact in a French center in order to further encourage implementation. METHODS: All patients who underwent elective laparoscopic right or left colectomy for benign or malignant pathology from 2014 to 2017 in a single center were retrospectively reviewed. ERP according to national recommendations was effective starting November 2015. Perioperative data and all direct costs borne by the institution were collected for each patient. Patients who underwent colectomy before and after ERP implementation were compared. RESULTS: Overall, 288 patients were included of which 144 received conventional perioperative care (CC) and 144 received ERP. There were 161 (56%) men, median age was 71 (28-92) years, and 242 (84%) patients underwent surgery for malignant disease. Operative time, intraoperative blood loss, and severe postoperative complications were similar between both groups. ERP was associated with reduced Clavien-Dindo I-II postoperative complications (15% vs. 28%, p = 0.010) and overall in-hospital stay (6 vs. 7 days, p = 0.003). Overall institutional costs were lower in the ERP group although difference was not statistically significant (7022 vs. 7501 euros, p = 0.098). Estimated savings per patient reached a mean of 480 euros. CONCLUSIONS: In a tertiary French center, ERP was associated with reduced postoperative morbidity and in-hospital stay resulting in considerable cost savings. Although not significant, ERP resulted in positive economic impact even in an early implementation phase.