Out-of-Pocket Costs and Payments in Autologous and Implant-Based Breast Reconstruction: A Nationwide Analysis.

BACKGROUND: Many factors influence a patient's decision to undergo autologous versus implant-based breast reconstruction, including medical, social, and financial considerations. This study aims to investigate differences in out-of-pocket and total spending for patients undergoing autologous and implant-based breast reconstruction. METHODS: The IBM MarketScan Commercial Databases were queried to extract all patients who underwent inpatient autologous or implant-based breast reconstruction from 2017 to 2021. Financial variables included gross payments to the provider (facility and/or physician) and out-of-pocket costs (total of coinsurance, deductible, and copayments). Univariate regressions assessed differences between autologous and implant-based reconstruction procedures. Mixed-effects linear regression was used to analyze parametric contributions to total gross and out-of-pocket costs. RESULTS: The sample identified 2079 autologous breast reconstruction and 1475 implant-based breast reconstruction episodes. Median out-of-pocket costs were significantly higher for autologous reconstruction than implant-based reconstruction ($597 vs $250, P < 0.001) as were total payments ($63,667 vs $31,472, P < 0.001). Type of insurance plan and region contributed to variable out-of-pocket costs (P < 0.001). Regression analysis revealed that autologous reconstruction contributes significantly to increasing out-of-pocket costs (B = $597, P = 0.025) and increasing total costs (B = $74,507, P = 0.006). CONCLUSION: The US national data demonstrate that autologous breast reconstruction has higher out-of-pocket costs and higher gross payments than implant-based reconstruction. More study is needed to determine the extent to which these financial differences affect patient decision-making.

Shifting from techno-economic to socio-ecological priorities: Incorporating landscape preferences and ecosystem services into the siting of renewable energy infrastructure.

This study examines the siting scenarios for renewable energy installations (REI) in a mountainous region of Europe (Switzerland), incorporating the external costs of ecosystem services and, innovatively, social preferences. This approach challenges the prevalent techno-economic siting paradigm, which often overlooks these externalities. To minimize the external costs of the scenarios while maximizing energy yield, Marxan, an optimization software, was employed. The energy target for all scenarios is set at 25 TWh/a, stemming from the energy gap anticipated due to the phase-out of Swiss nuclear reactors by 2050. This target is met using renewable energy infrastructure such as wind, roof-mounted photovoltaic, and ground-mounted photovoltaic systems. By integrating social preferences into the optimization, this study showcases a promising implementation that transcends the software's intended applications. It complements techno-economic approaches and offers alternative decision-making avenues. The conventional "roof first" strategy proved ineffective in preventing extensive land use for the development of new renewable energy infrastructure. Strategies incorporating ground-mounted photovoltaic infrastructure were more spatially, ecologically, and socially efficient than those without. The strategy optimized for energy yield exhibited the highest spatial efficiency but incurred significant ecosystem service costs and, surprisingly, had low social costs. In contrast, the strategy prioritizing ecosystem services was the most efficient in terms of ecosystem service costs but had elevated social costs and was spatially less efficient than other strategies. The strategy optimized for social preferences incurred the lowest social costs and excelled in spatial efficiency and ecosystem service costs. Notably, this strategy employed a limited number of planning units linked to both high ecosystem service and social costs. The findings underscore that incorporating social preferences significantly enhances the evaluation of siting options. This inclusion allows for the social acceptance of investments to be factored into costs, facilitating more informed and inclusive decisions.

Mapping the global geography of cybercrime with the World Cybercrime Index.

Cybercrime is a major challenge facing the world, with estimated costs ranging from the hundreds of millions to the trillions. Despite the threat it poses, cybercrime is somewhat an invisible phenomenon. In carrying out their virtual attacks, offenders often mask their physical locations by hiding behind online nicknames and technical protections. This means technical data are not well suited to establishing the true location of offenders and scholarly knowledge of cybercrime geography is limited. This paper proposes a solution: an expert survey. From March to October 2021 we invited leading experts in cybercrime intelligence/investigations from across the world to participate in an anonymized online survey on the geographical location of cybercrime offenders. The survey asked participants to consider five major categories of cybercrime, nominate the countries that they consider to be the most significant sources of each of these types of cybercrimes, and then rank each nominated country according to the impact, professionalism, and technical skill of its offenders. The outcome of the survey is the World Cybercrime Index, a global metric of cybercriminality organised around five types of cybercrime. The results indicate that a relatively small number of countries house the greatest cybercriminal threats. These findings partially remove the veil of anonymity around cybercriminal offenders, may aid law enforcement and policymakers in fighting this threat, and contribute to the study of cybercrime as a local phenomenon.

Online Tools to Decrease Out-of-Pocket Prescription Costs for Patients: A Practical Guide for Urologists.

INTRODUCTION: Patients who seek urologic care have recently reported a high degree of financial toxicity from prescription medications, including management for nephrolithiasis, urinary incontinence, and urological oncology. Estimating out-of-pocket costs can be challenging for urologists in the US because of variable insurance coverage, local pharmacy distributions, and complicated prescription pricing schemes. This article discusses resources that urologists can adopt into their practice and share with patients to help lower out-of-pocket spending for prescription medications. METHODS: We identify 4 online tools that are designed to direct patients toward more affordable prescription medication options: the Medicare Part D Plan Finder, GoodRx, Amazon, and the Mark Cuban Cost Plus Drug Company. A brief historical overview and summary for patients and clinicians are provided for each online resource. A patient-centered framework is provided to help navigate these 4 available tools in clinic. RESULTS: Among the 4 tools we identify, there are multiples tradeoffs to consider as financial savings and features can vary. First, patients insured by Medicare should explore the Part D Plan Finder each year to compare drug plans. Second, patients who need to urgently refill a prescription at a local pharmacy should visit GoodRx. Third, patients who are prescribed recurrent generic prescriptions for chronic conditions can utilize the Mark Cuban Cost Plus Drug Company. Finally, patients who are prescribed 3 or more chronic medications can benefit from subscribing to Amazon RxPass. CONCLUSIONS: Prescription medications for urologic conditions can be expensive. This article includes 4 online resources that can help patients access medications at their most affordable costs. Urologists can provide this framework to their patients to help support lowering out-of-pocket drug costs.

Association of food insecurity with health, access to care, affordability of care, financial burden of care, and financial hardships among US adults during the COVID-19 pandemic.

OBJECTIVES: To examine the associations between food insecurity and health, access to care, affordability of care, financial burden of care, and financial hardships among US adults during the COVID-19 pandemic and examine whether the associations were less pronounced among adults with safety nets. STUDY DESIGN: We conducted a retrospective longitudinal cohort study using the 2020-2021 Medical Expenditure Panel Survey. METHODS: Linear probability models were used to assess the associations between food insecurity in one year and the outcomes of interest in the following year while adjusting for baseline characteristics. We performed the analyses for the entire population and then conducted stratified analyses for adults with and without Supplemental Nutrition Assistance Program (SNAP) benefits or Medicaid coverage. RESULTS: Compared with food-secure adults, food-insecure adults were 9.1 percentage points less likely to report life satisfaction and 9.9, 10.2, and 13.2 percentage points more likely to experience delays in getting medical care, postpone or forgo medical care because of cost, and struggle with paying medical bills. Food-insecure adults were 30.4, 27.2, and 23.5 percentage points more likely to face challenges in affording necessities, paying utility bills, and meeting rent or mortgage payments on time than food-secure adults. Notably, the strengths of these associations were attenuated among adults with SNAP benefits or Medicaid coverage. CONCLUSIONS: Food insecurity was associated with poor health, limited access to and affordability of care, and a greater financial burden of care among US adults during the pandemic. Nevertheless, safety net programs can play a critical role in alleviating adverse consequences.

The increasing costs of medicines and their implications for patients, physicians and the health system.

Most new medicines entering the market are high-cost speciality drugs. These drugs can cost tens to hundreds of thousands of dollars per course of treatment and in some cases millions of dollars per dose. Approximately half of all spending on medicines is projected to target only 2-3% of patients, raising important questions about resource allocation. While there is no doubt that breakthrough innovations have transformed clinical care in some disciplines, it is also true that cost is becoming one of the primary barriers to treatment access and that many new medicines do not provide value commensurate with their prices. This article examines pricing trends, the reasons for high prices and their implications for access and clinical practice.

Modeling and simulating the multi-generation product sales, production and inventory system within the context of quality upgrades.

The rapid development of science and technology has led to an increasing number of high-tech enterprises offering new products through successive generations of product upgrades. This trend presents a new challenge for the sustainable operations of enterprises. Based on the Norton-Bass model, this study begins by constructing a multi-generation product diffusion model within a single enterprise in the context of a monopoly under the quality upgrade scenario. Subsequently, a supply model is established based on this foundation, and these two models are seamlessly integrated using product sales volume as an interface, culminating in a comprehensive sales-supply system. This study analyzes the effects of new-product pricing, quality levels, initial stock, and production capacity on the performance of this system. The system dynamics (SD) method was used to simulate and solve the system in the decentralized and centralized decision-making modes, and the two decision-making modes were compared and analyzed. The research reveals several key findings. i) Comprehensive decision optimization yields enhanced profitability through joint optimization calculation of the multi-generation product diffusion system and the supply adjustment system. ii) consumer price sensitivity significantly affects product quality upgrades and profits. A negative correlation exists between consumer price sensitivity and both factors. The upgrades of product quality should be carefully traded off with consideration of pricing and quality costs. iii) Maximizing profits by maintaining a certain order level of backlog or stock shortage is beneficial for overall enterprise profitability. Additionally, optimal production capacity has been identified as a crucial element in efficient operational inventory management. This study expands the multi-generation product diffusion operational theory and provides valuable theoretical support and decision-making foundations for the sustainable management of enterprises.

Optimal power-heat-carbon scheduling strategy for interconnected heterogeneous multi-microgrid considering hydrogen fuel cell vehicles.

The scale of multi-microgrid (MMG) and hydrogen fuel cell vehicles (HFCVs) is increasing dramatically with the increase in the new energy penetration ratio, and developing an integrated energy system containing a multi-microgrid for hydrogen fuel vehicles brings great challenges to power grid operation. Focusing on the difficulties of the access of multiple microgrids for the low-carbon and economic operation of the system, this paper proposes an optimal interconnected heterogeneous multi-microgrid power-heat-carbon scheduling strategy for hydrogen-fueled vehicles. Firstly, an HFCV model is established, and then an optimal scheduling model is constructed for the cooperative trading of power-heat-carbon in a multi-microgrid, on the basis of which the low-carbon economic operation of the multi-microgrid is realized. The results of the case study show that the scheduling strategy in this paper reduces carbon emissions by about 7.12% and costs by about 3.41% compared with the independent operation of the multi-microgrid. The degrees of interaction of each multi-microgrid are also analyzed under different HFCV penetration rates.

Access to essential medicines for diabetes care: availability, price, and affordability in central Ethiopia.

BACKGROUND: Diabetes is a major global public health burden. Effective diabetes management is highly dependent on the availability of affordable and quality-assured essential medicines (EMs) which is a challenge especially in low-and-middle-income countries such as Ethiopia. This study aimed to assess the accessibility of EMs used for diabetes care in central Ethiopia's public and private medicine outlets with respect to availability and affordability parameters. METHODS: A cross-sectional study was conducted in 60 selected public and private medicine outlets in central Ethiopia from January to February 2022 using the World Health Organization/Health Action International (WHO/HAI) standard tool to assess access to EMs. We included EMs that lower glucose, blood pressure, and cholesterol as these are all critical for diabetes care. Availability was determined as the percentage of surveyed outlets per sector in which the selected lowest-priced generic (LPG) and originator brand (OB) products were found. The number of days' wages required by the lowest paid government worker (LPGW) to purchase a one month's supply of medicines was used to measure affordability while median price was determined to assess patient price and price markup difference between public procurement and retail prices. RESULTS: Across all facilities, availability of LPG and OB medicines were 34.6% and 2.5% respectively. Only two glucose-lowering (glibenclamide 5 mg and metformin 500 mg) and two blood pressure-lowering medications (nifedipine 20 mg and hydrochlorothiazide 25 mg) surpassed the WHO's target of 80% availability. The median price based on the least measurable unit of LPG diabetes EMs was 1.6 ETB (0.033 USD) in public and 4.65 ETB (0.095 USD) in private outlets. The cost of one month's supply of diabetes EMs was equivalent to 0.3 to 3.1 days wages in public and 1.0 to 11.0 days wages in private outlets, respectively, for a typical LPGW. Thus, 58.8% and 84.6% of LPG diabetes EMs included in the price analysis were unaffordable in private and public outlets, respectively. CONCLUSIONS: There are big gaps in availability and affordability of EMs used for diabetes in central Ethiopia. Policy makers should work to improve access to diabetes EMs. It is recommended to increase government attention to availing affordable EMs for diabetes care including at the primary healthcare levels which are more accessible to the majority of the population. Similar studies are also recommended to be conducted in different parts of Ethiopia.

3D Printing Technology: Role in Safeguarding Food Security.

The rising threats to food security include several factors, such as population growth, low agricultural investment, and poor distribution systems. Consequently, food insecurity results from a confluence of issues, including diseases, processing limitations, and distribution deficiencies. Food insecurity usually occurs in vulnerable areas where certain technologies and traditional food safety testing are not a viable solution for foodborne disease detection. In this regard, 3D printing technologies and 3D printed sensors open the platform to produce portable, accurate, and low-cost sensors that address the gaps and challenges in food security. In this paper, we discuss the perspective role of 3D printed sensors in food security in terms of food safety and food quality monitoring to provide reliable access to nutritious, affordable food. In each section, we highlight the advantages of 3D printing technology in terms of cost-effectiveness, accuracy, accessibility, and reproducibility compared to traditional manufacturing methodologies. Recent developments in robotic technologies for mechanization, such as food handling with soft grippers, are also discussed. Lastly, we delve into the applications of advanced 3D printing technologies in agricultural monitoring, particularly the future of plant wearables, environmental sensing, and overall plant health monitoring.

Pricing decision and channel selection of fresh agricultural products dual-channel supply chain based on blockchain.

The application of blockchain can effectively improve the efficiency of fresh agricultural product circulation and consumer trust, but it can also increase investment costs. In this context, this paper introduces parameters such as blockchain unit variable cost, the level of blockchain technology investment, and consumer channel preference in two dual-channel supply chain systems dominated by fresh agricultural product manufacturers: online direct sales and distribution. It compares and analyzes pricing and channel selection strategies in both cases of not using and using blockchain. The research shows that when blockchain is used, manufacturer profits are higher in the direct sales model than in the distribution model. Traditional retailers' profits are lower in the direct sales model than in the distribution model. Total supply chain profits are higher in the direct sales model than in the distribution model, and they exhibit an inverted "U" shape as the level of blockchain investment increases. In the online direct sales model, if the blockchain technology unit variable cost is within a certain threshold range, manufacturer profits, traditional retailer profits, and total supply chain profits are all higher than when blockchain technology is not used. In the online distribution model, when the blockchain variable cost and blockchain usage level meet certain conditions, manufacturers, traditional retailers, and online distributors all have higher profits when using blockchain technology than when not using it. This study provides theoretical guidance for the practical application of blockchain technology in dual-channel fresh agricultural product supply chains.

Tobacco use among in-school young adolescents in Indonesia: Exploring availability, affordability, and accessibility.

The research on Indonesian adolescents' perception of tobacco control in schools is limited. This study aimed to explore the availability, affordability, and accessibility of tobacco among young adolescents in Yogyakarta Municipality, Indonesia, with a focus on advocating for school teenagers. Focus groups, comprising participants from diverse backgrounds and stakeholders, were conducted in Yogyakarta, Indonesia, to systematically collect varied data. The subsequent analysis employed a robust thematic approach, combining both inductive and deductive processes to ensure a nuanced exploration of emerging patterns and pre-existing frameworks. In addition to focus group data, the study incorporated insights from extensive field observations and research group discussions. The multifaceted approach enhanced the depth of analysis but also facilitated a comprehensive understanding of the complex dynamics. The findings of this study revealed that young adolescents found it extremely easy to purchase cigarettes from local markets. The smoking prevalence among young adolescents was relatively low, with only 10% of the respondents admitting to smoking. Although the Indonesian government has increased surveillance and regulations regarding smoking among young individuals, the actual implementation and effectiveness of these measures remain questionable. The existing anti-smoking approaches in Indonesia have been unsuccessful in curbing smoking among Indonesian school students. The study argues that it is crucial to recognize and value students' perceptions of smoking, as their knowledge of smoking is actively constructed. To address this issue, future anti-smoking education in schools should incorporate interactive sessions rather than solely relying on didactic approaches that highlight the harms of smoking. By engaging students in interactive discussions, they can actively participate in constructing their understanding of the consequences of smoking. Additionally, efforts should be made to enhance the implementation of tobacco control measures within schools and extend the reach of these measures to off-campus environments.

Selection of presale models for innovative products considering channel preferences and valuation differences.

To reduce financial pressure and operational risk, and improve match between supply and demand, an increasing number of enterprises are adopting presales to launch new products. In this context, this paper investigates three presale models for innovative products, namely, the no-presale model, the manufacturer presale model and the retailer presale model. A Hotelling model is used to describe the impact of channel preferences and valuation differences on the two-stage competition between innovative products. Aiming at evaluating the purchase behavior of consumers under three presale modes, a game optimization model is established to analyze the presale decision problem for innovative products under different presale entities. The research shows that: (1) Compared with no-presale, presales can help enterprises obtain more profits. The overall profit of the supply chain is optimal under the retailer presale mode. (2) When the difference in channel preferences is small, the manufacturer obtains the greatest profit by choosing the direct presale model. In contrast, the selection of different presale entities has a significant impact on product sales and supply chain enterprise profits. At this point, the manufacturer should choose the retailer presale model. (3) When the product valuation discount is high, the manufacturer can increase the spot and wholesale prices to induce consumers to choose the presale method to purchase the product. In the opposite situation, the manufacturer should lower the presale price to improve the presale utility of consumers and encourage them to participate in the presale. These conclusions provide more targeted suggestions for enterprises to formulate presale strategies, which can help them grasp market demand and improve market competitiveness.

Patient Out-of-Pocket Costs for Biologic Drugs After Biosimilar Competition.

Importance: Biologic drugs account for a growing share of US pharmaceutical spending. Competition from follow-on biosimilar products (subsequent versions that have no clinically meaningful differences from the original biologic) has led to modest reductions in US health care spending, but these savings may not translate to lower out-of-pocket (OOP) costs for patients. Objective: To investigate whether biosimilar competition is associated with lower OOP spending for patients using biologics. Design, Setting, and Participants: This cohort study used a national commercial claims database (Optum Clinformatics Data Mart) to identify outpatient claims for 1 of 7 clinician-administered biologics (filgrastim, infliximab, pegfilgrastim, epoetin alfa, bevacizumab, rituximab, and trastuzumab) from January 2009 through March 2022. Claims by commercially insured patients younger than 65 years were included. Exposure: Year relative to first biosimilar availability and use of original or biosimilar version. Main Outcomes and Measures: Patients' annual OOP spending on biologics for each calendar year was determined, and OOP spending per claim between reference biologic and biosimilar versions was compared. Two-part regression models assessed for differences in OOP spending, adjusting for patient and clinical characteristics (age, sex, US Census region, health plan type, diagnosis, and place of service) and year relative to initial biosimilar entry. Results: Over 1.7 million claims from 190 364 individuals (median [IQR] age, 53 [42-59] years; 58.3% females) who used at least 1 of the 7 biologics between 2009 and 2022 were included in the analysis. Over 251 566 patient-years of observation, annual OOP costs increased before and after biosimilar availability. Two years after the start of biosimilar competition, the adjusted odds ratio of nonzero annual OOP spending was 1.08 (95% CI, 1.04-1.12; P < .001) and average nonzero annual spending was 12% higher (95% CI, 10%-14%; P < .001) compared with the year before biosimilar competition. After biosimilars became available, claims for biosimilars were more likely than reference biologics to have nonzero OOP costs (adjusted odds ratio, 1.13 [95% CI, 1.11-1.16]; P < .001) but had 8% lower mean nonzero OOP costs (adjusted mean ratio, 0.92 [95% CI, 0.90-0.93; P < .001). Findings varied by drug. Conclusions and Relevance: Findings of this cohort study suggest that biosimilar competition was not consistently associated with lower OOP costs for commercially insured outpatients, highlighting the need for targeted policy interventions to ensure that the savings generated from biosimilar competition translate into increased affordability for patients who need biologics.