New evidence on the impacts of cross-market hospital mergers on commercial prices and measures of quality.

OBJECTIVE: To examine the impact of "cross-market" hospital mergers on prices and quality and the extent to which serial acquisitions contribute to any measured effects. DATA SOURCES: 2009-2017 commercial claims from the Health Care Cost Institute (HCCI) and quality measures from Hospital Compare. STUDY DESIGN: Event study models in which the treated group consisted of hospitals that acquired hospitals further than 50 miles, and the control group was hospitals that were not part of any merger activity (as a target or acquirer) during the study period. DATA EXTRACTION METHODS: We extracted data for 214 treated hospitals and 955 control hospitals. PRINCIPAL FINDINGS: Six years after acquisition, cross-market hospital mergers had increased acquirer prices by 12.9% (CI: 0.6%-26.6%) relative to control hospitals, but had no discernible impact on mortality and readmission rates for heart failure, heart attacks and pneumonia. For serial acquirers, the price effect increased to 16.3% (CI: 4.8%-29.1%). For all acquisitions, the price effect was 21.8% (CI: 4.6%-41.7%) when the target's market share was greater than the acquirer's market share versus 9.7% (CI: -0.5% to 20.9%) when the opposite was true. The magnitude of the price effect was similar for out-of-state and in-state cross-market mergers. CONCLUSIONS: Additional evidence on the price and quality effects of cross-market mergers is needed at a time when over half of recent hospital mergers have been cross-market. To date, no hospital mergers have been challenged by the Federal Trade Commission on cross-market grounds. Our study is the third to find a positive price effect associated with cross-market mergers and the first to show no quality effect and how serial acquisitions contribute to the price effect. More research is needed to identify the mechanism behind the price effects we observe and analyze price effect heterogeneity.

GNSS visibility and performance implications for the GENESIS mission.

The GENESIS mission prepared for launch in 2027 integrates the four space-geodetic techniques on a single spaceborne platform in medium Earth orbit. With its unique observations and alternative tie concepts, the mission aims to contribute to an improved accuracy and homogeneity of future terrestrial reference system realizations. To assess the expected contribution of Global Navigation Satellite System (GNSS) tracking, a comprehensive GNSS coverage analysis is performed based on detailed link-budget simulations, taking into account the best available gain patterns and signal-specific transmit power estimates derived for this work from measurements of a high-gain dish antenna. The benefit of different receiver antenna concepts for the GENESIS spacecraft is assessed, and it is demonstrated that a single-antenna system with either a nadir-looking or side-looking boresight is a viable alternative to the dual-antenna configuration considered in initial mission studies. Compared to terrestrial users and missions in low Earth orbit, GENESIS will collect GNSS signals transmitted at up to two times larger off-boresight angles. Only limited information on the actual transmit antenna phase patterns is presently available in this region, which hampers a quantitative assessment of the expected measurement and orbit determination accuracy. As such, a comprehensive release of manufacturer calibrations is encouraged for all blocks of GPS and Galileo satellites. In parallel, a need for in-flight characterization and calibration of the GNSS transmit antennas for off-boresight angles of up to 30∘ using observations of the GENESIS mission itself is expected. The impact of such calibrations on the overall quality of terrestrial reference frame parameters will need to be assessed in comprehensive simulations of global GNSS network solutions with joint processing of terrestrial and GENESIS GNSS observations.

Active Surface Flows Accelerate the Coarsening of Lipid Membrane Domains.

Phase separation of multicomponent lipid membranes is characterized by the nucleation and coarsening of circular membrane domains that grow slowly in time as ∼t^{1/3}, following classical theories of coalescence and Ostwald ripening. In this Letter, we study the coarsening kinetics of phase-separating lipid membranes subjected to nonequilibrium forces and flows transmitted by motor-driven gliding actin filaments. We experimentally observe that the activity-induced surface flows trigger rapid coarsening of noncircular membrane domains that grow as ∼t^{2/3}, a 2x acceleration in the growth exponent compared to passive coalescence and Ostwald ripening. We analyze these results by developing analytical theories based on the Smoluchowski coagulation model and the phase field model to predict the domain growth in the presence of active flows. Our Letter demonstrates that active matter forces may be used to control the growth and morphology of membrane domains driven out of equilibrium.

Reprocessed precise science orbits and gravity field recovery for the entire GOCE mission.

ESA's Gravity field and steady-state Ocean Circulation Explorer (GOCE) orbited the Earth between 2009 and 2013 for the determination of the static part of Earth's gravity field. The GPS-derived precise science orbits (PSOs) were operationally generated by the Astronomical Institute of the University of Bern (AIUB). Due to a significantly improved understanding of remaining artifacts after the end of the GOCE mission (especially in the GOCE gradiometry data), ESA initiated a reprocessing of the entire GOCE Level 1b data in 2018. In this framework, AIUB was commissioned to recompute the GOCE reduced-dynamic and kinematic PSOs. In this paper, we report on the employed precise orbit determination methods, with a focus on measures undertaken to mitigate ionosphere-induced artifacts in the kinematic orbits and thereof derived gravity field models. With respect to the PSOs computed during the operational phase of GOCE, the reprocessed PSOs show in average a 8-9% better consistency with GPS data, 31% smaller 3-dimensional reduced-dynamic orbit overlaps, an 8% better 3-dimensional consistency between reduced-dynamic and kinematic orbits, and a 3-7% reduction of satellite laser ranging residuals. In the second part of the paper, we present results from GPS-based gravity field determinations that highlight the strong benefit of the GOCE reprocessed kinematic PSOs. Due to the applied data weighting strategy, a substantially improved quality of gravity field coefficients between degree 10 and 40 is achieved, corresponding to a remarkable reduction of ionosphere-induced artifacts along the geomagnetic equator. For a static gravity field solution covering the entire mission period, geoid height differences with respect to a superior inter-satellite ranging solution are markedly reduced (43% in terms of global RMS, compared to previous GOCE GPS-based gravity fields). Furthermore, we demonstrate that the reprocessed GOCE PSOs allow to recover long-wavelength time-variable gravity field signals (up to degree 10), comparable to information derived from GPS data of dedicated satellite missions. To this end, it is essential to take into account the GOCE common-mode accelerometer data in the gravity field recovery.

Bio-enabled Engineering of Multifunctional "Living" Surfaces.

Through the magic of "active matter"─matter that converts chemical energy into mechanical work to drive emergent properties─biology solves a myriad of seemingly enormous physical challenges. Using active matter surfaces, for example, our lungs clear an astronomically large number of particulate contaminants that accompany each of the 10,000 L of air we respire per day, thus ensuring that the lungs' gas exchange surfaces remain functional. In this Perspective, we describe our efforts to engineer artificial active surfaces that mimic active matter surfaces in biology. Specifically, we seek to assemble the basic active matter components─mechanical motor, driven constituent, and energy source─to design surfaces that support the continuous operation of molecular sensing, recognition, and exchange. The successful realization of this technology would generate multifunctional, "living" surfaces that combine the dynamic programmability of active matter and the molecular specificity of biological surfaces and apply them to applications in biosensors, chemical diagnostics, and other surface transport and catalytic processes. We describe our recent efforts in bio-enabled engineering of living surfaces through the design of molecular probes to understand and integrate native biological membranes into synthetic materials.

Antibody binding reports spatial heterogeneities in cell membrane organization.

The spatial organization of cell membrane glycoproteins and glycolipids is critical for mediating the binding of ligands, receptors, and macromolecules on the plasma membrane. However, we currently do not have the methods to quantify the spatial heterogeneities of macromolecular crowding on live cell surfaces. In this work, we combine experiment and simulation to report crowding heterogeneities on reconstituted membranes and live cell membranes with nanometer spatial resolution. By quantifying the effective binding affinity of IgG monoclonal antibodies to engineered antigen sensors, we discover sharp gradients in crowding within a few nanometers of the crowded membrane surface. Our measurements on human cancer cells support the hypothesis that raft-like membrane domains exclude bulky membrane proteins and glycoproteins. Our facile and high-throughput method to quantify spatial crowding heterogeneities on live cell membranes may facilitate monoclonal antibody design and provide a mechanistic understanding of plasma membrane biophysical organization.

Association Between a Capitated, Low-cost, County-Based Public Health Insurance Option and Affordable Care Act Premium Growth in California.

Importance: Empirical evidence is needed on how a capitated, risk-based county plan performs as a viable public option in the Affordable Care Act (ACA) Marketplace in California. Objective: To estimate whether LA Care-a capitated, county-based public option and California's largest public insurer-was associated with health insurance premium growth in the Los Angeles (LA) regions of Covered California (CC), the ACA exchange in California. Design, Setting, and Participants: This economic evaluation used ACA silver plan premium data within the 19 CC regions. Difference-in-differences and event study models used data on plan-level premiums from Health Insurance Exchange Compare for years 2014 to 2022 to estimate the association between LA Care and ACA premium growth in LA. Exposures: The intervention was LA Care becoming the lowest-cost health plan on the ACA exchange in 2018. The treatment group included the East and West LA regions, and the control group included the remaining 17 CC regions. Main Outcomes and Measures: The main outcome variable was annual premium growth of plans on CC from 2014 to 2022. Results: Using 504 plan-level observations for 2014 to 2022, ACA premium growth in LA declined by 4.8% after LA Care became the lowest-cost health plan on the exchange in 2018 (coefficient estimate, -0.048; SE, 0.022; 95% CI, -0.093 to -0.002). Savings due to lower premium growth from 2019 to 2022 were calculated to be $345 million, with approximately 70% of the savings ($242 million) going to the federal government. Conclusions and Relevance: In this economic evaluation, LA Care was associated with lower premium growth of other health insurance plans in the LA regions of CC, with the majority of savings going to the federal government. California could have captured these savings if it had applied for and received a State Innovation Waiver under section 1332 of the ACA. LA Care may be a viable public option with the potential to be expanded across California through the state's 16 other county-based health plans.

GAN River-I: A process-based low NTG meandering reservoir model dataset for machine learning studies.

The GAN River-I data set is designed to provide a stern test for machine learning and geostatistical tools that wish to recreate the complex geometries of realistic facies distributions in subsurface reservoirs. It provides more complex, non-stationary facies distributions than previous open data sets, some of which have modelled channels but do not include the number and complex association of facies types of this data set. GAN River-I is a dataset of 2D layers of 3D facies models produced from a process-based simulator of a meandering fluvial system. The data set contains 25 simulated 3D cubes, converted into three datasets consisting of 16,000 2D models/images, each representing the increasing complexity of the modelled facies. The number of facies decreases between the three data sets, with nine facies, seven facies and three facies, respectively. The facies reduction is carried out by amalgamating similar facies in terms of their likely permeability and sedimentary relationships to represent flowing units in a subsurface reservoir. The data is therefore provided to allow users to increase the model complexity in a manageable and comparable way between groups using the data. GAN River-I covers a range of low NTG meandering patterns with varied avulsion rates. Each dataset comprises an ensemble of meandering models representing various plausible patterns and, therefore, can be used as a geologically plausible benchmark for testing generative models' performance. We provide three data file formats, including image, Ndarray and GSLIB, to adapt to different researchers' preferences.

The Rise Of Cross-Market Hospital Systems And Their Market Power In The US.

Although hospital consolidation within markets has been well documented, consolidation across markets has not, even though economic theory predicts-and evidence is emerging-that cross-market hospital systems raise prices by exerting market power across markets when negotiating with common customers (primarily insurers). This study analyzes hospital systems using the American Hospital Association Annual Survey Database and defines hospital geographic markets as commuting zones that link workers to places of employment. The share of community hospitals in the US that were part of hospital systems increased from 10 percent in 1970 to 67 percent in 2019, resulting in 3,436 hospitals within 368 systems in 2019. Of these systems, 216 (59 percent) owned hospitals in multiple commuting zones, in part because 55 percent of the 1,500 hospitals targeted for a merger or acquisition between 2010 and 2019 were located in a different commuting zone than the acquirer. Based on market-power differences among hospitals in systems, the number of systems in urban commuting zones that could potentially exert enhanced cross-market power increased from thirty-seven systems in 2009 to fifty-seven systems in 2019, an increase of 54 percent. The increase in cross-market hospital systems warrants concern and scrutiny because of the potential anticompetitive impact of hospital systems exerting market power across markets in negotiations with common customers.

Homophilic Interaction Between Transmembrane-JAM-A and Soluble JAM-A Regulates Thrombo-Inflammation: Implications for Coronary Artery Disease.

Genetic predisposition through F11R-single-nucleotide variation (SNV) influences circulatory soluble junctional adhesion molecule-A (sJAM-A) levels in coronary artery disease (CAD) patients. Homozygous carriers of the minor alleles (F11R-SNVs rs2774276, rs790056) show enhanced levels of thrombo-inflammatory sJAM-A. Both F11R-SNVs and sJAM-A are associated with worse prognosis for recurrent myocardial infarction in CAD patients. Platelet surface-associated JAM-A correlate with platelet activation markers in CAD patients. Activated platelets shed transmembrane-JAM-A, generating proinflammatory sJAM-A and JAM-A-bearing microparticles. Platelet transmembrane-JAM-A and sJAM-A as homophilic interaction partners exaggerate thrombotic and thrombo-inflammatory platelet monocyte interactions. Therapeutic strategies interfering with this homophilic interface may regulate thrombotic and thrombo-inflammatory platelet response in cardiovascular pathologies where circulatory sJAM-A levels are elevated.

Conductive Ink with Circular Life Cycle for Printed Electronics.

Electronic waste carries energetic costs and an environmental burden rivaling that of plastic waste due to the rarity and toxicity of the heavy-metal components. Recyclable conductive composites are introduced for printed circuits formulated with polycaprolactone (PCL), conductive fillers, and enzyme/protectant nanoclusters. Circuits can be printed with flexibility (breaking strain ≈80%) and conductivity (≈2.1 × 104 S m-1 ). These composites are degraded at the end of life by immersion in warm water with programmable latency. Approximately 94% of the functional fillers can be recycled and reused with similar device performance. The printed circuits remain functional and degradable after shelf storage for at least 7 months at room temperature and one month of continuous operation under electrical voltage. The present studies provide composite design toward recyclable and easily disposable printed electronics for applications such as wearable electronics, biosensors, and soft robotics.

SMS reminders to improve the uptake and timeliness of the primary immunisation series in infants: a multi-centre randomised controlled trial.

Background: Immunisation timeliness continues to present challenges to achieving optimal vaccine coverage in infancy, particularly in disadvantaged groups and Australian First Nations infants. We aimed to determine whether a tailored, educational SMS reminder improves the timeliness of immunisation in infants up to seven months of age. Methods: A pragmatic, three-arm, parallel-group, randomised controlled trial of immunisation reminders was conducted in two First-Nations-specific primary health care centres and two public hospital antenatal clinics in South East Queensland, Australia. Live-born infants of mothers enrolled during pregnancy were randomised at birth and followed to eight months of age. One group received a simple SMS reminder at two weeks before, the week of, and two weeks after the due date for immunisation at two, four and six months of age. The second group received a tailored SMS with an educational message at two weeks before and on the date immunisations were due; those not immunised two weeks following the due date were offered support to immunise the baby. Controls received no intervention or contact until the baby turned seven months of age. The primary outcome was the proportion of infants age-appropriately vaccinated at seven months of age as recorded on the Australian Immunisation Register. Secondary outcomes included vaccination status at three and five months of age. Results: Between 30 May 2016 and 24 May 2018, one hundred and ninety-six infants (31% First Nations infants) were randomised. At seven months of age, 54/65 (83.1%) infants in the educational SMS ± additional support group (ESMS±S) were age-appropriately immunised, compared to 45/64 (70.3%) in the simple SMS group and 45/67 (67.2%) in controls. Differences were most marked at five months of age: ESMS±S 95.5%; simple SMS 73.4%; controls 75.8%. The difference between the ESMS±S group and the other two groups at seven months of age was no longer apparent when those who received additional support beyond the SMS were assumed to have not been vaccinated if that support had not been received. Discussion: A tailored SMS reminder system using an educational message and with provision of additional support to mothers is more effective in improving immunisation timeliness in infants at three and five months of age than a simple message and no intervention. The additional support was required at seven months of age in order to achieve higher coverage in the ESMS±S group.

Do State Bans of Most-Favored-Nation Contract Clauses Restrain Price Growth? Evidence From Hospital Prices.

Policy Points Looking for a way to curtail market power abuses in health care and rein in prices, 20 states have restricted most-favored-nation (MFN) clauses in some health care contracts. Little is known as to whether restrictions on MFN clauses slow health care price growth. Banning MFN clauses between insurers and hospitals in highly concentrated insurer markets seems to improve competition and lead to lower hospital prices. CONTEXT: Most-favored-nation (MFN) contract clauses have recently garnered attention from both Congress and state legislatures looking for ways to curtail market power abuses in health care and rein in prices. In health care, a typical MFN contract clause is stipulated by the insurer and requires a health care provider to grant the insurer the lowest (i.e., the most-favored) price among the insurers it contracts with. As of August 2020, 20 states restrict the use of MFN clauses in health care contracts (19 states ban their use in at least some health care contracts), with 8 states prohibiting their use between 2010 and 2016. METHODS: Using event study and difference-in-differences research designs, we compared prices for a standardized hospital admission in states that banned MFN clauses between 2010 and 2016 with standardized hospital admission prices in states without MFN bans. FINDINGS: Our results show that bans on MFN clauses reduced hospital price growth in metropolitan statistical areas (MSAs) with highly concentrated insurer markets. Specifically, we found that mean hospital prices in MSAs with highly concentrated insurer markets would have been $472 (2.8%) lower in 2016 had the MSAs been in states that banned MFN clauses in 2010. In 2016, the population in our sample that resided in MSAs with highly concentrated insurer markets was just under 75 million (23% of the US population). Hence, banning MFN clauses in all MSAs in our sample with highly concentrated insurer markets in 2010 would have generated savings on hospital expenditures in the range of $2.4 billion per year. CONCLUSIONS: Our empirical findings suggest banning MFN clauses between insurers and providers in highly concentrated insurer markets would improve competition and lead to lower prices and expenditures.

Standardized Vaccine-Hesitant Patients in the Assessment of the Effectiveness of Vaccine Communication Training.

OBJECTIVES: To determine if training residents in a structured communication method elicits specific behaviors in a laboratory model of interaction with vaccine-hesitant parents. STUDY DESIGN: Standardized patients portraying vaccine-hesitant parents were used to assess the effectiveness of training in the Announce, Inquire, Mirror, Secure (AIMS) Method for Healthy Conversations. Blinded pediatric residents were pseudorandomized to receive AIMS or control training and underwent pre- and post-training encounters with blinded standardized patients. Encounters were assessed by blinded raters using a novel tool. Participant confidence and standardized patient evaluations of the participants' general communication skills were assessed. RESULTS: Ratings were available for 27 AIMS and 26 control participants. Statistically significant increases in post-training scores (maximum = 30) were detected in AIMS, but not in control, participants (median, 21.3 [IQR, 19.8-24.8] vs 18.8 [IQR, 16.9-20.9]; P < .001). Elements (maximum score = 6) with significant increases were Inquire (0.67 [IQR, 0-1.76] vs -0.33 [IQR, -0.67 to 0.33]; P < .001); Mirror (1.33 [IQR, 0 to 2] vs -0.33 [IQR, -0.92 to 0]; P < .001) and Secure (0.33 [IQR, 0 to 1.67] vs -0.17 [IQR, -0.67 to 0.33]; P = .017). Self-confidence increased equally in both groups. Standardized patients did not detect a difference in communication skills after training and between groups. Internal consistency and inter-rater reliability of the assessment tool were modest. CONCLUSIONS: Standardized patients proved useful in studying the effectiveness of structured communication training, but may have been limited in their ability to perceive a difference between groups owing to the predetermined encounter outcome of vaccine refusal. AIMS training should be studied in real-world scenarios to determine if it impacts vaccine acceptance.

Predictors of the Development of Protracted Bacterial Bronchitis following Presentation to Healthcare for an Acute Respiratory Illness with Cough: Analysis of Three Cohort Studies.

We describe the prevalence and risk factors for protracted bacterial bronchitis (PBB) following healthcare presentation for an acute cough illness in children. Data from three studies of the development of chronic cough (CC) in children were combined. PBB was defined as a wet cough of at least 4-weeks duration with no identified specific cause of cough that resolved following 2-4 weeks of appropriate antibiotics. Anterior nasal swabs were tested for 17 viruses and bacteria by polymerase chain reaction. The study included 903 children. Childcare attendance (adjusted relative risk (aRR) = 2.32, 95% CI 1.48-3.63), prior history of chronic cough (aRR = 2.63, 95% CI 1.72-4.01) and age <2-years (<12-months: aRR = 4.31, 95% CI 1.42-13.10; 12-<24 months: aRR = 2.00, 95% CI 1.35-2.96) increased risk of PBB. Baseline diagnoses of asthma/reactive airways disease (aRR = 0.30, 95% CI 0.26-0.35) or bronchiolitis (aRR = 0.15, 95% CI 0.06-0.38) decreased risk. M. catarrhalis was the most common organism (52.4%) identified in all children (PBB = 72.1%; no PBB = 50.2%, p < 0.001). We provide the first data on risks for PBB in children following acute illness and a hypothesis for studies to further investigate the relationship with wheeze-related illnesses. Clinicians and parents/guardians should be aware of these risks and seek early review if a wet cough lasting more than 4-weeks develops the post-acute illness.

Burden of Care for Children with Bronchiectasis from Parents/Carers Perspective.

Bronchiectasis is a neglected chronic respiratory condition. In children optimal appropriate management can halt the disease process, and in some cases reverse the radiological abnormality. This requires many facets, including parental/carer bronchiectasis-specific knowledge, for which there is currently no such published data. Further, the importance of patient voices in guiding clinical research is becoming increasingly appreciated. To address these issues, we aimed to describe the voices of parents of children with bronchiectasis relating to (a) burden of illness and quality of life (QoL), (b) their major worries/concerns and (c) understanding/management of exacerbations. The parents of 152 children with bronchiectasis (median age = 5.8 years, range 3.5-8.4) recruited from the Queensland Children's Hospital (Australia) completed questionnaires, including a parent-proxy cough-specific QoL. We found that parents of children with bronchiectasis had impaired QoL (median 4.38, range 3.13-5.63) and a high disease burden with median 7.0 (range 4.0-10.0) doctor visits in 12-months. Parental knowledge varied with only 41% understanding appropriate management of an exacerbation. The highest worry/concern expressed were long-term effects (n = 42, 29.8%) and perceived declining health (n = 36, 25.5%). Our study has highlighted the need for improved education, high parental burden and areas of concern/worry which may inform development of a bronchiectasis-specific paediatric QoL tool.

States' Merger Review Authority Is Associated With States Challenging Hospital Mergers, But Prices Continue To Increase.

States can challenge proposed hospital mergers by using antitrust laws to prevent anticompetitive harms. This observational study examined additional state laws-principally charitable trust, nonprofit corporation, health and safety, and certificate-of-need laws-that can serve as complements and substitutes for antitrust laws by empowering states to be notified of, review, and challenge proposed hospital mergers through administrative processes. During the period 2010-19, 862 hospital mergers were proposed, but only forty-two (4.9 percent) were challenged by states, including thirty-five by states without federal involvement, of which twenty-five (71.4 percent) originated in the eight states with the most robust merger review authority. The twenty-five challenges resulted in two mergers being blocked; three being abandoned; and twenty being approved with conditions, including seven with competitive-impact conditions. Hospital market concentration and prices increased at similar rates in these eight states versus other states, potentially because most challenges allowed mergers to proceed with conditions that did not adequately address competitive concerns. Although these findings do not reveal an optimal state framework, elements of advanced state merger review authority may have the potential to improve poorly functioning hospital markets.

Physician Compensation In Physician-Owned And Hospital-Owned Practices.

Physician practices are increasingly being acquired by hospitals and health systems. Despite evidence that this type of vertical integration is profitable for hospitals, the association between these acquisitions and the incomes of physicians in the acquired practices is unknown. We combined national survey data on physician practice ownership with data on physician income to examine whether hospital or health system ownership of physician practices was associated with differences in physician income during 2014-18. During the study period, hospital and health system ownership of physician practices increased by 89.2 percent, from 24.1 percent to 45.6 percent of all physicians in our sample. Among physician practices overall, vertical integration with hospitals or health systems was associated with, on average, 0.8 percent lower income compared with independent physicians after multivariable adjustment. In analyses by physician specialty, vertical integration of physician practices with hospitals or health systems was associated with lower income for nonsurgical specialists, no difference in income for primary care physicians, and slightly higher income for surgical specialists. Although vertical integration of physician practices is a rapidly growing trend, physicians might not directly benefit financially.

Bandwidth correction of Swarm GPS carrier phase observations for improved orbit and gravity field determination.

Gravity fields derived from GPS tracking of the three Swarm satellites have shown artifacts near the geomagnetic equator, where the carrier phase tracking on the L2 frequency is unable to follow rapid ionospheric path delay changes due to a limited tracking loop bandwidth of only 0.25 Hz in the early years of the mission. Based on the knowledge of the loop filter design, an analytical approach is developed to recover the original L2 signal from the observed carrier phase through inversion of the loop transfer function. Precise orbit determination and gravity field solutions are used to assess the quality of the correction. We show that the a posteriori RMS of the ionosphere-free GPS phase observations for a reduced-dynamic orbit determination can be reduced from 3 to 2 mm while keeping up to 7% more data in the outlier screening compared to uncorrected observations. We also show that artifacts in the kinematic orbit and gravity field solution near the geomagnetic equator can be substantially reduced. The analytical correction is able to mitigate the equatorial artifacts. However, the analytical correction is not as successful compared to the down-weighting of problematic GPS data used in earlier studies. In contrast to the weighting approaches, up to 9-10% more kinematic positions can be retained for the heavily disturbed month March 2015 and also stronger signals for gravity field estimation in the equatorial regions are obtained, as can be seen in the reduced error degree variances of the gravity field estimation. The presented approach may also be applied to other low earth orbit missions, provided that the GPS receivers offer a sufficiently high data rate compared to the tracking loop bandwidth, and provided that the basic loop-filter parameters are known.

The Association between Hospital-Physician Vertical Integration and Outpatient Physician Prices Paid by Commercial Insurers: New Evidence.

This study assessed the relationship between hospital ownership of physician organizations (known as hospital-physician vertical integration) and facility fees billed to commercial insurers and physician service prices. Healthcare claims came from the IBM® MarketScan® Commercial Database (2012-2016, N = 30,716,800 office visit claims [CPT codes 99211-99215]), and hospital-physician vertical integration measures were from SK&A Office Based Physicians Database provided by IQVIA. Multi-variate, fixed-effect models were used to regress prices on market-level hospital-physician vertical integration; models included geographic market and year fixed effects, claim-level variables, and time-varying market-level variables. Analyses did not find that market-level hospital-physician vertical integration was associated with the billing of facility fees for office visits. However, vertical integration was associated with office visit physician prices for some specialties. A 10-percentage-point increase in vertical integration was associated with a 1.0% price increase for primary care, a 0.6% increase for orthopedics, and a 0.5% increase for cardiology; no such association was found for obstetrics/gynecology or oncology. When comparing metropolitan statistical areas (MSAs) in the bottom quartile of changes in vertical integration from 2012 to 2016 to MSAs in the top quartile, we found the following relative price increases based on predicted values for claims in the top quartile: $1.64 (1.9% of mean 2012 predicted price) for primary care to $2.30 (3.1%) for orthopedics to $3.13 (3.4%) for cardiology. Differences in predicted price accounted for an estimated $45.8 million in additional expenditure on primary care office visits in the top quartile of MSAs in 2016. In summary, market-level hospital-physician vertical integration was positively associated with physician prices for select specialties, but was not associated with changes in the use of facility-fee billing. More evidence on the quality effects of hospital-physician vertical integration is needed, as price increases that are not accompanied by measurable quality improvements should be part of any regulatory review.