Selection of pallet management strategies from the perspective of supply chain cost with Anylogic software.

Pallet is a very important innovation in logistics industry. Pallets are so widely used that we can find them in nearly every logistical operation scenario. In order to manage pallets efficiently, researchers have developed several pallet management strategies (PMS). The most common and widely accepted PMS includes extensive management of pallets (EMP), transfer of pallet's ownership (TPO), and pallet rent (PR). This paper addresses mainly on how to help pallet managers choose a certain kind of PMS from the perspective of supply chain cost. Firstly, cost models of three kinds of PMS are presented. Secondly, all parameters involved in the models are valued based on data that is collected from industry survey. The results show that the cost of PR is constantly lower than EMP, and also lower than TPO when the operation period is no more than 37 months. Finally, the effect of several important parameters on the cost is studied by sensitivity analysis. The selection strategies of PMS are proposed based on the results.

Perspectives on Implementation Considerations and Costs of Malaria Case Management Supportive Supervision.

Between 2012 and 2017, the U.S. President's Malaria Initiative-funded MalariaCare project supported national malaria control programs in sub-Saharan Africa to implement a case management quality assurance (QA) system for malaria and other febrile illnesses. A major component of the system was outreach training and supportive supervision (OTSS), whereby trained government health personnel visited health facilities to observe health-care practices using a standard checklist, to provide individualized feedback to staff, and to develop health facility-wide action plans based on observation and review of facility registers. Based on MalariaCare's experience, facilitating visits to more than 5,600 health facilities in nine countries, we found that programs seeking to implement similar supportive supervision schemes should consider ensuring the following: 1) develop a practical checklist that balances information gathering and mentorship; 2) establish basic competency criteria for supervisors and periodically assess supervisor performance in the field; 3) conduct both technical skills training and supervision skills training; 4) establish criteria for selecting facilities to conduct OTSS and determine the appropriate frequency of visits; and 5) use electronic data collection systems where possible. Cost will also be a significant consideration: the average cost per OTSS visit ranged from $44 to $333. Significant variation in costs was due to factors such as travel time, allowances for government personnel, length of the visit, and involvement of central level officials. Because the cost of conducting supportive supervision prohibits regularly visiting all health facilities, internal QA measures could also be considered as alternative or complementary activities to supportive supervision.

Chimeric antigen receptor-T cell therapy manufacturing: modelling the effect of offshore production on aggregate cost of goods.

Cell and gene therapies have demonstrated excellent clinical results across a range of indications with chimeric antigen receptor (CAR)-T cell therapies among the first to reach market. Although these therapies are currently manufactured using patient-derived cells, therapies using healthy donor cells are in development, potentially offering avenues toward process improvement and patient access. An allogeneic model could significantly reduce aggregate cost of goods (COGs), potentially improving market penetration of these life-saving treatments. Furthermore, the shift toward offshore production may help reduce manufacturing costs. In this article, we examine production costs of an allogeneic CAR-T cell process and the potential differential manufacturing costs between regions. Two offshore locations are compared with regions within the United States. The critical findings of this article identify the COGs challenges facing manufacturing of allogeneic CAR-T immunotherapies, how these may evolve as production is sent offshore and the wider implication this trend could have.

The Complexity Of Billing And Paying For Physician Care.

The administrative costs of providing health insurance in the US are very high, but their determinants are poorly understood. We advance the nascent literature in this field by developing new measures of billing complexity for physician care across insurers and over time, and by estimating them using a large sample of detailed insurance "remittance data" for the period 2013-15. We found dramatic variation across different types of insurance. Fee-for-service Medicaid is the most challenging type of insurer to bill, with a claim denial rate that is 17.8 percentage points higher than that for fee-for-service Medicare. The denial rate for Medicaid managed care was 6 percentage points higher than that for fee-for-service Medicare, while the rate for private insurance appeared similar to that of Medicare Advantage. Based on conservative assumptions, we estimated that the health care sector deals with $11 billion in challenged revenue annually, but this number could be as high as $54 billion. These costs have significant implications for analyses of health insurance reforms.

Prospective observational study of predicted usage of intravenous cannulas inserted in a tertiary paediatric emergency department.

OBJECTIVES: To determine the proportion of unused peripheral intravenous cannulas (PIVCs) inserted in a paediatric emergency department (PED) and to assess clinicians' abilities to predict future usage of PIVC. METHODS: Prospective concealed observational study in a tertiary PED. Healthcare workers (HCWs) completed questionnaires upon insertion and removal of PIVC with review of patient notes if required. The primary outcome was the number of unused, unnecessary PIVCs. Secondary outcomes included demographic factors affecting unused cannulas, a clinician's ability to predict PIVC use and the incidence of complications from PIVC insertion. RESULTS: From 806 returned questionnaires, 719 patients were recruited. Twenty-two per cent of PIVCs remained unused after initial insertion for all patients. There was no significant difference in the rate of unused cannulas among any age or sex category, with the lowest rate of unused PIVCs in triage category 2 patients. HCW seniority when deciding to insert a PIVC did not affect usage rates. Likert scale analyses showed that HCWs could correctly predict ongoing use of PIVCs in 90% of cases. The overall rate of PIVCs removed for infected or inflamed insertion sites was low at 0.8%. CONCLUSION: This study is consistent with the idle PIVC rates observed in PEDs but there is potential to further reduce this rate with targeted insertion. The paediatric clinicians' reliability in predicting PIVC use has been demonstrated for the first time and we have identified four groups where targeted phlebotomy rather than i.v. cannulation would reduce unused cannulas.

Costing analysis and anthropological assessment of the vaccine supply chain system redesign in the Comé District (Benin).

OBJECTIVE: At the end of 2013, a pilot experiment was carried out in Comé health zone (HZ) in an attempt to optimize the vaccine supply chain. Four commune vaccine storage facilities were replaced by one central HZ facility. This study evaluated the incremental financial needs for the establishment of the new system; compared the economic cost of the supply chain in the Comé HZ before and after the system redesign; and analyzed the changes induced by the pilot project in immunization logistics management. METHOD: The purposive sampling method was used to draw a sample from 37 health facilities in the zone for costing evaluation. Data on inputs and prices were collected retrospectively for 2013 and 2014. The analysis used an ingredient-based approach. In addition, 44 semi-structured interviews with health workers for anthropological analysis were completed in 2014. RESULTS: The incremental financial costs amounted to US$55,148, including US$50,605 for upfront capital investment and US$4543 for ongoing recurrent costs. Annual economic cost per dose administered (including all vaccines distributed through the Expanded Program on Immunization (EPI)) in the Comé HZ increased from US$0.09 before system redesign to US$0.15 after implementation, mainly due to a high initial investment and the operational cost of HZ mobile warehouse. Interviews with health workers suggested that the redesigned system was associated with improvements in motivation and professional awareness due to training, supportive supervision, and improved work conditions. CONCLUSIONS: The system redesign involved a considerable investment at HZ level. Benefits were found in the reduction of transportation costs to health posts (HP) and commune health center (CHC) levels, and the strengthening of health workers professional skills at all levels in Comé. The redesigned system contributed to a decrease in funding needs at HP and CHC levels. The benefits of the investment need to be examined after the introduction of new vaccines and after a longer period.

Eradicating polio in Pakistan: an analysis of the challenges and solutions to this security and health issue.

Since the launch of the Global Polio Eradication Initiative (GPEI) in 1988 the global incidence of poliomyelitis has fallen by nearly 99 %. From a situation where wild type poliovirus was endemic in 125 countries across five continents, transmission is now limited to regions of just three countries - Pakistan, Afghanistan and Nigeria. A sharp increase in Pakistan's poliomyelitis cases in 2014 prompted the International Health Regulations Emergency Committee to declare the situation a 'public health emergency of international concern'. Global polio eradication hinges on Pakistan's ability to address the religious, political and socioeconomic barriers to immunisation; including discrepancies in vaccine coverage, a poor health infrastructure, and conflict in polio-endemic regions of the country. This analysis provides an overview of the GPEI, focusing on the historical and contemporary challenges facing Pakistan's polio eradication programme and the impact of conflict and insecurity, and sheds light on strategies to combat vaccine hesitancy, engage local communities and build on recent progress towards polio eradication in Pakistan.

True care coordination essential to achieve best outcomes in a value-based system.

I've been meeting with physicians nationwide about their planned, ongoing and potential transitions from fee-for-service to value-based reimbursement. It's certainly a work in progress.

Evaluating the effect of a proposed logistics fee cap on pharmaceuticals in South Africa--a pre and post analysis.

BACKGROUND: South Africa has proposed the implementation of a maximum logistics fee paid by pharmaceutical manufacturers to wholesalers and distributors. However very little knowledge exists of the effects, unintended or otherwise, of the implementation of these proposed regulations, which are required to guide further policy development and implementation. The objectives of this study was to therefore evaluate the effects of the proposed logistics fee cap on different pharmaceuticals and different dosage forms, as well as to observe the logistics fee contribution to the Single Exit Price. METHODS: Private sector medicine prices were sourced from the South African Medicine Price Registry as at 20 December 2013. For each medicine the maximum logistics fee was calculated based on the 2012 proposed government guidelines. The logistics fee as a percentage of the final Single Exit Price was calculated, as part of the analysis of results. RESULTS: Out of the 47 medicines in the overall sample from the current study, only 16 medicines showed a decrease in the Single Exit Price with the application of the maximum logistics fee cap. CONCLUSION: This study reveals the need for greater transparency of the mark ups along the distribution chain as well as further research with regards to the costing of logistics fees of similar pharmaceuticals.

Test de la figura compleja de Taylor: administración y corrección según un proceso de normalización y estandarización en población española / Taylor Complex Figure test: administration and correction according to a normalization and standardization process in Spanish population

Introducción. La figura compleja de Taylor (FCT) fue creada como alternativa a la figura compleja de Rey-Osterrieth. Aunque ambas figuras son instrumentos ampliamente utilizados, no se ha realizado hasta la fecha la normalización de la FCT para población española. Objetivo. Normalizar y estandarizar la FCT, considerando las características sociodemográficas de la población española. Sujetos y métodos. El presente estudio se enmarca dentro del proyecto Normacog. Se seleccionaron 700 participantes (rango: 18-90 años), y se evaluaron la capacidad visuoconstructiva y la memoria visual inmediata mediante la FCT. Se analizaron el efecto de la edad, el nivel educativo y el sexo sobre el rendimiento de la FCT, y se crearon los percentiles, las puntuaciones escalares para ocho rangos de edad y la puntuación escalar ajustada por el nivel educativo. Resultados. Los resultados muestran un efecto significativo de la edad y el nivel educativo sobre el rendimiento en copia y memoria de la FCT, mientras que el sexo no influyó significativamente. La edad y la educación explicaban el 25,3-35,7% de la varianza en la FCT. A mayor edad y menor nivel educativo, peor era el rendimiento obtenido en la FCT. Se obtienen los percentiles, las puntuaciones escalares para cada rango de edad y la puntuación escalar individual ajustada por el nivel educativo. Conclusión. Se aportan los materiales para la administración y corrección del test de FCT, así como los datos normativos de la FCT teniendo en cuenta las características sociodemográficas españolas para todo el rango adulto en nuestro país (AU)

Introduction. The Taylor Complex Figure (TCF) was created as an alternate form for the Rey-Osterrieth Complex Figure. Although both figures are widely used, to date, it has not been carried out the normalization of the TCF for Spanish population. Aim. To normalize and standardize the TCF taking into account the sociodemographic characteristics of the Spanish population. Subjects and methods. The present study is part of the Normacog Project. Seven hundred participants were recruited (18-90 years old), assessing the visuo-constructive ability and immediate visual memory by TCF. The effect of age, level of education and gender was analyzed on the performance of TCF and percentiles and scalar score for eight ranges of age and scalar score adjusted by the level of education. Results. Results showed a significant effect of age and level of education on the performance in copy and memory of TCF, whereas gender was not significant. Age and education explained from 25.3% to 35.7% of the variance of TCF performance. The older and less educated, the worse performance shown in TCF. Percentiles, scalar score for each range of age and scalar score adjusted by the level of education were obtained. Conclusion. Administration instructions, scoring and the normative data of the TCF are provided taking into account the Spanish sociodemographic characteristics for adults in our country (AU)

Lost opportunity. Fairly assigning value to physician administrative services.

The Resource-Based Relative Value System sets values for physician services that can be used to estimate the value of time spent on administrative tasks. This methodology assigns an appropriate place-of-service qualifier and the appropriate percentage of Medicare rates to the time being spent on administrative tasks. A variation of this methodology allows for a rate to be determined for an entire physician group or specialty.

Outsourcing vaccine logistics to the private sector: The evidence and lessons learned from the Western Cape Province in South-Africa.

With few exceptions, immunization supply chains in developing countries continue to face chronic difficulties in providing uninterrupted availability of potent vaccines up to service delivery levels, and in the most efficient manner possible. As these countries struggle to keep pace with an ever growing number of vaccines, more and more Ministries of Health are considering options of engaging the private sector to manage vaccine storage, handling and distribution on their behalf. Despite this emerging trend, there is limited evidence on the benefits or challenges of this option to improve public supply chain performance for national immunization programmes. To bridge this knowledge gap, this study aims to shed light on the value proposition of outsourcing by documenting the specific experience of the Western Cape Province of South Africa. The methodology for this review rested on conducting two key supply chain assessments which allowed juxtaposing the performance of the government managed segments of the vaccine supply chain against those managed by the private sector. In particular, measures of effective vaccine management best practice and temperature control in the cold chain were analysed. In addition, the costs of engaging the private sector were analysed to get a better understanding of the economics underpinning outsourcing vaccine logistics. The results from this analysis confirmed some of the theoretical benefits of outsourcing to the private sector. Yet, if the experience in the Western Cape can be deemed a successful one, there are several policy and practice implications that developing countries should be mindful of when considering engaging the private sector. While outsourcing can help improve the performance of the vaccine supply chain, it has the potential to do the reverse if done incorrectly. The findings and lessons learnt from the Western Cape experience can serve as a step towards understanding the role of the private sector in immunization supply chain and logistics systems for developing countries.

Metodología para documentar y estabilizar los procesos / Methodology for process documentation and stabilization

OBJETIVO: La metodología para implantar la gestión por procesos consta de cuatro fases con sus correspondientes etapas: la primera consiste en movilizar a la organización y ganar el apoyo del equipo directivo del centro, así como a las personas que van a constituir el equipo de trabajo. La segunda fase, una vez identificados y clasificados los procesos, consiste en documentarlos e implantarlos con su revisión efectuada. Implantado el proceso, al tiempo, se somete a una tercera fase que consiste en su control de gestión que termina con la evaluación. Evaluados los procesos tanto desde el punto de vista interno como comparativo con otras organizaciones con la misma misión clínica, cabe dos posibilidades: someterlos a una mejora gradual o sostenida o, en su caso, a una mejora radical, porque se advierta una falta de rendimiento o calidad. En este artículo se describen las dos primeras fases de la implantación, las cuales son clave para documentar y estabilizar los procesos de una organización

OBJECTIVES: The methodology for process management implantation consists of four phases with their corresponding stages.: The first consists of mobilizing the organization and gaining support of the executive board of the center, as well as the people that will conform the working team. The second phase, once the processes have been identified and classified, is o document and implement them with their review performed. Once the process has been implanted, with time, there is a third phase that consists of its management control that ends with the evaluation. Once the processes are evaluated, both from the internal point of view and comparatively with other organizations with the same clinical mission, there are two possibilities: to put them in a gradual or sustained improvement or to a radical improvement if a lack of performance or quality is noticed. In this article we describe the first two phases of implantation that are fundamental for organizational processes documentation and stabilization

Definición y estabilización de los procesos II. Procesos clínicos en un Servicio de Urología / Definition and stabilization of processes II. Management processes and support in a Urology Department

Los nuevos modelos de gestión clínica persiguen una práctica clínica basada en la calidad, la eficacia y la eficiencia evitando la variabilidad y la improvisación. En este trabajo, hemos desarrollado uno de los procesos clínicos más frecuentes en nuestra especialidad: el basado en el GRD 311 o procedimentos transuretrales sin complicaciones. A lo largo del mismo describiremos sus componentes: el formulario de estabilización, la trayectoría clínica, el cálculo de costes, y finalmente el diagrama de flujo del proceso

New models in clinical management seek a clinical practice based on quality, efficacy and efficiency, avoiding variability and improvisation. In this paper we have developed one of the most frequent clinical processes in our speciality, the process based on DRG 311 or transurethral procedures without complications. Along it we will describe its components: Stabilization form, clinical trajectory, cost calculation, and finally the process flowchart

Adecuación de Servicios de Urología en un Modelo Asistencial de Red de Hospitales / Adequacy of Urology Departments in a Health Care Model of Hospitals Network

El modelo sanitario tradicional se enfrenta actualmente a nuevas demandas de salud. La implantación de un sistema integrado de salud urológica puede ser una de las posibles soluciones a estas necesidades. Se requiere, por tanto, desarrollar e implementar un nuevo modelo asistencial, que incluya cambios a nivel estructural y organizativo. La adecuación de los Servicios de Urología de la Red hospitalaria idcsalud-Madrid, construyendo UroRed, constituye un nuevo sistema que se adapta a dichos cambios del entorno, para incrementar su profesionalidad y mejorar la calidad asistencial. Objectivos: Describir la gestión clínica de un Servicio de Urología corporativo (UroRed en idcsalud, Madrid) dentro de un modelo asistencial de Red de hospitales RISS (Red Integrada en Servicios de Salud). Métodos: En el período comprendido entre Noviembre de 2007 a Octubre de 2014, el Servicio de UROLOGIA del Grupo idcsalud Madrid, ha ido modelando un sistema organizativo constituido por 4 hospitales, con un equipo actual de 27 urólogos. Cada centro, ofrece y presta una determinada cartera de servicios especializados, compartiendo prestaciones y recursos humanos. Los diferentes equipos están gobernados por una misma línea de actuación. Resultados: El modelo ofrece una atención urológica integral y uniforme, dirigida a una población de 811.390 habitantes (Censo poblacional 2012), con capacidad concreta para la resolución de patologías específicas y continuidad clínica y asistencial. Conclusiones: Pertenecer a un modelo asistencial en red implica una modificación, un cambio de actitud. Conlleva un cambio organizacional basado en los procesos y los resultados que permitan controlar la gestión analíticamente, permitiendo detectar los puntos que requieren ser optimizados así como aquellos que resulten satisfactorios. Implica, por tanto, desarrollar una cultura de aprendizaje y cooperación para que los procesos sean fluidos y de calidad; crear proyectos clínicos y tecnológicos a favor de nuevas investigaciones generando recursos en base a las necesidades de la gestión conjunta del hospital. La complejidad de este modelo, requiere un trabajo centrado en las personas, sus inquietudes y su capacidad de coordinar acciones para obtener resultados en términos de calidad y profesionalidad asistencial

The traditional health care model is currently facing new health requirements. The implementation of integrated urologic health systems can be one of the possible solutions to these needs. It is mandatory to explore a new health care model, which includes structural and organizational changes. The adequacy of the urology departments of IDCsalud-Madrid network hospitals, creating URORed, is a new system adaptable to constant changes, in order to offer professionalism and quality health care. Objective: To describe the administrative/clinic management in the urology service of a health care model of Hospitals network (URORed at IDCsalud. Madrid), that has been included in a model of an Integrated network in a health care service. Methods: In the period between November 2007 to October 2014, the urology departments of IDCsalud Madrid Group, have been included in a new organizational system, including 4 hospitals, currently with 27 urologists. Each center offers specific urologic services, sharing benefits and human resources. The same directive line leads all centers. Results: The model offers an integrated and uniform urologic service to a specific population of 811.390 habitants (Population Census 2012), with capability to treat specific urologic diseases and to perform a correct clinical follow-up. Conclusions: Belonging to a health care model in network involves a change of attitude. It creates an organizational change, based on the processes and the results, which enables control of the management analytically, detecting the points that need to be optimized as well as those that are satisfactory. It implies developing a culture of learning and cooperation, so that the processes are fluent and have quality, to create clinical and technological projects in favor of new resource-generating research, based on the needs of the joint management of the hospitals network. The complexity of this model requires a work focused on the human resources, their concerns and their ability to coordinate actions to get results in terms of quality health care and professionalism

Modelo de innovación inversa en la consulta de enfermería de Servicios de Urología / Inverse innovation models in the nurse clinic of a Urology Department

OBJETIVO: En la consulta de urología existe un importante volumen de patología con limitada sofisticación que consume una parte importante de los recursos. El delegar algunas tareas de este tipo en el personal de enfermería podría suponer una ventaja competitiva en términos económicos sin que ello implique una merma de la calidad prestada a los pacientes y de su nivel de satisfacción. Ello supone un ejemplo del concepto de innovación inversa. En este trabajo pretendemos dar a conocer nuestra experiencia en la gestión por parte del personal de enfermería de aspectos de la consulta de urología tradicionalmente reservados al personal facultativo, así como en el diseño de los procesos relacionados. MÉTODOS: Se desarrollaron los procesos de uso más frecuente que competen al personal de enfermería de la unidad: 1) Atención a la patología urológica quirúrgica ambulatoria; 2) Ecografía urológica; 3) Consulta de enfermería urológica tradicional. RESULTADOS: Durante el año 2013 el personal de enfermería llevó a cabo 423 consultas de patología urológica quirúrgica ambulatoria, 931 ecografías urológicas y 1019 actuaciones diversas correspondientes a la labor tradicional de enfermería urológica. Se desarrollan los formularios de estabilización y los diagramas de flujo de los procesos mencionados. Se llevó a cabo una cuantificación del ahorro monetario obtenido comparando los costes generados en el caso de emplear personal de enfermería o facultativo. Dicho ahorro fue de 2,78 y 4,00 euros en los procesos de patología urológica quirúrgica ambulatoria y de ecografía urológica, respectivamente. El ahorro total obtenido en ambos procesos fue de 4.900 Euros durante el año 2013. CONCLUSIONES: Es posible la implicación del personal de enfermería urológica en determinadas labores asistenciales tradicionalmente reservadas al facultativo sin que ello represente un incremento de los defectos de calidad, obteniendo una ventaja en términos de coste económico y de flexibilidad en cuanto a la organización de la plantilla gracias a la ampliación del abanico de competencias

OBJECTIVES: In the urology clinics there is an important volume of limited-complexity pathology that consumes an important part of resources. Delegating some tasks of this type to Nurses may imply a competitive advantage in economic terms without decrease in the quality of the care given to patients and their level of satisfaction. This is an example of the concept of inverse innovation. In this work we try to make public our experience in the management by nursing staff of features of the urology consultation traditionally reserved to physicians, as well as the design of the related processes. METHODS: We developed the most frequent processes competence of the nursing staff in the unit: 1) Care of ambulatory urological surgery pathology; 2) Urologic ultrasound; 3) Traditional urologic nurse consultation. RESULTS: During 2013 the nursing staff performed 423 ambulatory urologic surgery pathology clinic visits, 931 urologic ultrasounds and 1019 varied actions corresponding to traditional urological nurse work.We developed stabilization formularies and flow diagrams of the aforementioned processes. We performed a quantification of the amount of money saved in comparison with the costs generated if a nurse or a physician was employed. Such saving was 2,78 and 4,00 Euros in the ambulatory urological surgery pathology and urologic ultrasound, respectively. Total savings in both processes was 4900 Euros. CONCLUSIONS: Implication of urological nursing staff in certain care tasks traditionally reserved to the physician is possible without increase in quality defects, obtaining an advantage in terms of economic cost and flexibility in staff organization thanks to the expansion of the competence array

State liberalism, female supervisors, and the gender wage gap.

Whereas some are concerned that the gender revolution has stalled, others note the rapid increase in women's representation in the ranks of management, and the reduction of wage inequality in larger and more active welfare states. Although these latter trends portend an attenuation of gender inequality, their effects on the gender pay gap in the U.S. are understudied due to data limitations, or to the assumption that in the U.S. pay is determined by market forces. In this study we extend research on the determinants of the gender wage gap by examining sex-of-supervisor effects on subordinates' pay, and to what degree the state's commitment to equality conditions this relationship. We pooled the 1997 and 2002 National Study of the Changing Workforce surveys to estimate hierarchical models of reporting to a female supervisor and wages, with theoretically important predictors at the individual level, and at the state of residence (an index composed of women's share of legislators, a measure of the liberal leanings of the state, and the size of the public sector relative to the labor force). We found that state effects on pay were mixed, with pay generally rising with state liberalism on the one hand. On the other hand, working for a female boss significantly reduced wages. We discussed the theoretical implications of our results, as well as the need for further study of the career effects on subordinates as women increasingly enter the ranks of management.

Billing and insurance-related administrative costs in United States' health care: synthesis of micro-costing evidence.

BACKGROUND: The United States' multiple-payer health care system requires substantial effort and costs for administration, with billing and insurance-related (BIR) activities comprising a large but incompletely characterized proportion. A number of studies have quantified BIR costs for specific health care sectors, using micro-costing techniques. However, variation in the types of payers, providers, and BIR activities across studies complicates estimation of system-wide costs. Using a consistent and comprehensive definition of BIR (including both public and private payers, all providers, and all types of BIR activities), we synthesized and updated available micro-costing evidence in order to estimate total and added BIR costs for the U.S. health care system in 2012. METHODS: We reviewed BIR micro-costing studies across healthcare sectors. For physician practices, hospitals, and insurers, we estimated the % BIR using existing research and publicly reported data, re-calculated to a standard and comprehensive definition of BIR where necessary. We found no data on % BIR in other health services or supplies settings, so extrapolated from known sectors. We calculated total BIR costs in each sector as the product of 2012 U.S. national health expenditures and the percentage of revenue used for BIR. We estimated "added" BIR costs by comparing total BIR costs in each sector to those observed in existing, simplified financing systems (Canada's single payer system for providers, and U.S. Medicare for insurers). Due to uncertainty in inputs, we performed sensitivity analyses. RESULTS: BIR costs in the U.S. health care system totaled approximately $471 ($330 - $597) billion in 2012. This includes $70 ($54 - $76) billion in physician practices, $74 ($58 - $94) billion in hospitals, an estimated $94 ($47 - $141) billion in settings providing other health services and supplies, $198 ($154 - $233) billion in private insurers, and $35 ($17 - $52) billion in public insurers. Compared to simplified financing, $375 ($254 - $507) billion, or 80%, represents the added BIR costs of the current multi-payer system. CONCLUSIONS: A simplified financing system in the U.S. could result in cost savings exceeding $350 billion annually, nearly 15% of health care spending.

A renationalised health service would drive down supply costs.

'Politicians alienate nurses at their peril' and '£32 for 100 wipes--what a waste of NHS money' (Editorial and News July 30) highlight poor procurement policies in the NHS.