"Tricks and tips for home mechanical ventilation" Home mechanical ventilation: set-up and monitoring protocols.

In this part of the review series "Tricks and tips for home mechanical ventilation", we will discuss the evidence with regard to the place and manner of home mechanical ventilation initiation and follow-up. Outsourcing more and more of this chronic care to the home situation is a big challenge for the future: especially for the home situation, monitoring has to be non-invasive, reliable and easy to use, data security needs to be ensured, signals need to be integrated and preferably automatically processed and algorithms need to be developed based on clinically relevant outcomes.

Buying Time: Comptroller Delays Medical Billing Tax Until October 2021.

Comptroller delays medical billing tax until October 2021, giving TMA a chance to work out a legislative fix.

The Development of New Diagnostic Tests for Neurologic Disorders in the Commercial Laboratory Environment.

Development of new diagnostic tests in a commercial laboratory for neurologic disorders is challenging. Development occurs in a highly regulated environment. Relevant research infrastructure may not be readily available in-house and may require outsourcing with additional management and costs. Clinically characterized specimens for validation of biomarkers for esoteric diseases may be difficult to acquire, and market size may be difficult to predict. More common diseases with heterogeneous subsets may require better clinical definition. Absence of guidelines may delay health provider acceptance of novel testing. Regulatory agency approval and categorization of tests affects validation requirements and impacts market acceptance and reimbursement.

Evolving Outsourcing Landscape in Pharma R&D: Different Collaborative Models and Factors To Consider When Choosing a Contract Research Organization.

Outsourcing has become an integral part of how research and early development (R&D) is executed in biotech companies and large pharmaceutical organizations. Drug discovery organizations can choose from several operational models when partnering with a service provider, ranging from short-term, fee-for-service (FFS)-based arrangements to more strategic full-time-equivalent (FTE)-based collaborations and even risk-sharing relationships. Clients should consider a number of criteria when deciding which contract research organization (CRO) is best positioned to help meet their goals. Besides cost, other factors such as intellectual property protection, problem solving skills, value-creation ability, communication, data integrity, safety and personnel policies, ease of communication, geography, duration of engagement, scalability of capacity, and contractual details deserve proper consideration. In the end, the success of a drug discovery partnership will depend in large part on the people who execute the science.

Hospital purchasing alliances: Ten years after.

BACKGROUND: Most hospitals outsource supply procurement to purchasing alliances, or group purchasing organizations (GPOs). Despite their early 20th century origin, we lack both national and trend data on alliance utilization, services, and performance. The topic is important as alliances help hospitals control costs, enjoy tailwinds from affiliated regional/local alliances, and face headwinds from hospital self-contracting and criticism of certain business practices. PURPOSE: We compare the utilization, services, and performance of alliances in 2004 and 2014. APPROACH: We analyze alliances using two comparable surveys of hospitals. We use significance tests to assess changes in alliance utilization, services, and performance (e.g., cost savings). We also assess the use of regional/local alliances affiliated with national GPOs. RESULTS: Purchasing through national alliances has somewhat diminished. Over 10 years, hospitals have diversified GPO memberships to include regional/local alliances (many affiliated with their national GPO) and engaged in self-contracting. At the same time, hospitals have increased purchases of many categories of supplies/services through national GPOs and endorsed their value-added functions and increasingly important role. Hospitals report greater satisfaction with several GPO functions; performance on most dimensions has not changed. CONCLUSIONS: National alliances still play important roles that hospitals find valuable. PRACTICE IMPLICATIONS: Purchasing alliances continue to play an important role in helping hospitals with both cost savings and new services. Their growing complexity, along with growing use of self-contracting, poses managerial challenges for hospital purchasing staff that may require greater hospital investment.

Outsourcing Microbiology Services in Medical Centers: Is It Worth It?

BACKGROUND: Outsourcing of microbiology laboratory services is a growing trend in US medical centers. Data on the actual impact of outsourcing on patient care, safety, and medical education, including costs, are limited. The objective of this study was to examine the published literature on the potential benefits and harms when medical centers outsource common microbiology services. METHODS: We conducted a 16-step literature search of PubMed and Embase. Articles were selected for full-text review if their content matched our key questions: (1) What are the potential benefits of outsourcing core microbiology laboratory testing? (2) What are the potential harms to patient care and medical education when medical centers outsource essential microbiology services? RESULTS: The initial search yielded 6111 unique published articles; 36 were selected for full-text review, which resulted in the identification of 8 articles that addressed our key questions (2 editorials, 3 editorials with observational data, 1 survey, 1 case series, and 1 study of blood culture transport). These articles described a variety of issues, including longer turnaround times for blood cultures that resulted in delays in diagnosis and treatment, errors that resulted in patient morbidity, limited cost savings, and communication barriers. CONCLUSIONS: In this study, with the exception of the blood culture transport study, we found no published prospective studies that quantified the effects of outsourcing microbiology services on patient care, patient safety, or medical education. However, these largely anecdotal reports suggest that outsourcing microbiology services may have a detrimental impact on medical education, especially infectious disease training programs.

Schrödinger's pipeline and the outsourcing of pharmaceutical innovation.

In the wake of the Global Financial Crisis (2007-2008) cheaper, softer money flooded the worldwide markets. Faced with historically low capital costs, the pharmaceutical industry chose to pay down debt through share buybacks rather than invest in research and development (R&D). Instead, the industry explored new R&D models for open innovation, such as open-sourcing, crowd-sourcing, public-private partnerships, innovation centres, Science Parks, and the wholesale outsourcing of pharmaceutical R&D. However, economic Greater Fool Theory suggests that outsourcing R&D was never likely to increase innovation. Ten years on, the period of cheaper and softer money is coming to an end. So how are things looking? And what happens next?

One lab, two firms, many possibilities: On R&D outsourcing in the biopharmaceutical industry.

We draw from documented characteristics of the biopharmaceutical industry to construct a model where two firms can choose to outsource R&D to an external unit, and/or engage in internal R&D, before competing in a final market. We investigate the distribution of profits among market participants, and the incentives to coordinate outsourcing activities or to integrate R&D and production. Consistent with the empirical evidence, we find that the sign and magnitude of an aggregate measure of direct (inter-firm) and indirect (through the external unit) technological externalities drives the distribution of industry profits, with higher returns to the external unit when involved in development (clinical trials) than in early-stage research (drug discovery). In the latter case, the delinkage of investment incentives from industry value, together with the ability of firms to transfer risks to the external unit, imply a vulnerability of early-stage investors' returns to negative shocks, and the likely abandonment of projects with economic and medical value. We also find that competition in the equity market makes a buyout by one of the two firms more profitable to a research biotech than to a clinical services unit, and can stimulate early-stage investments. However, this long-term incentive can be minimal, notably if the superior efficiency of outsourced operations originates from economies of scope that can hardly be exploited when a firm takes control of the external unit exclusively for itself. R&D outsourcing thus does not always qualify as a relevant pathway to address the declining productivity in innovation that has characterized the industry over several decades.

The impact of contracts on outsourcing computed tomography examinations from a Swedish public university hospital to a private radiology unit.

INTRODUCTION: After years of outsourcing without detailed contracts from one of Sweden's largest university hospitals to external radiology units, the hospital started to use a specific contract for outsourcing computed tomography (CT) examinations. The purpose of this study was to compare the cost-effectiveness of two outsourcing approaches, where examinations were performed either with a detailed, specific contract (with-contract) or without (no-contract), between a hospital radiology department and private external units. METHODS: This retrospective study included a group of electively outsourced CT-examinations (n = 132) and a control group of in-house CT-examinations (n = 132), selected from the three different types of CT-examinations referred from the Departments of Oncology and Hematology. These examinations were randomly selected from four different groups over two time periods of one year each, one being outsourcing without a contract (no-contract, during 2013), one time period with a specific contract (with-contract, during 2014) and two control groups of examinations performed in-house within both these time periods. We compared outsourced examinations (both no-contract and with-contract groups) and in-house examinations. The comparison of these groups include five parameters; management-time, patient waiting-time, the quality of the examinations, - image interpretations and costs. RESULTS: During 2013, management-time for CT-examinations was longer in the outsourced group (no-contract) than in the in-house group, with a statistical significance (P = 0.002). Fewer examinations performed in-house and in the with-contract group needed re-interpretation than in the no-contract group. CT-examinations in the with-contract group were associated with shorter overall management-time, patient waiting time and lower costs compared to the no-contract group. CONCLUSION: Using a contract with detailed specifications for outsourcing CT-examinations may be an effective way of reducing patient waiting time. Outsourcing based on a well-founded contract can be cost-effective, compared with outsourcing without a detailed plan for the services required.

Dependence and power in healthcare equipment supply chains.

Most healthcare organizations (HCOs) engage Group Purchasing Organizations (GPOs) as an outsourcing strategy to secure their supplies and materials. When an HCO outsources the procurement function to a GPO, this GPO will directly interact with the HCO's supplier on the HCO's behalf. This study investigates how an HCO's dependence on a GPO affects supply chain relationships and power in the healthcare medical equipment supply chain. Hypotheses are tested through factor analysis and structural equation modeling, using primary survey data from HCO procurement managers. An HCO's dependence on a GPO is found to be positively associated with a GPO's reliance on mediated power, but, surprisingly, negatively associated with a GPO's mediated power. Furthermore, analysis indicates that an HCO's dependence on a GPO is positively associated with an HCO's dependence on a GPO-contracted Original Equipment Manufacturer (OEM). HCO reliance on GPOs may lead to a buyer's dependence trap, where HCOs are increasingly dependent on GPOs and OEMs. Implications for HCO procurement managers and recommended steps for mitigation are offered. Power-dependence relationships in the medical equipment supply chain are not consistent with relationships in other, more traditional, supply chains. While dependence in a supply chain relationship typically leads to an increase in reliance on mediated power, GPO-dependent HCOs instead perceive a decrease in GPO mediated power. Furthermore, HCOs that rely on procurement service from GPOs are increasingly dependent on the OEMs.

Assessing the Financial Benefits of Faster Development Times: The Case of Single-source Versus Multi-vendor Outsourced Biopharmaceutical Manufacturing.

PURPOSE: The extent to which new drug developers can benefit financially from shorter development times has implications for development efficiency and innovation incentives. We provided a real-world example of such gains by using recent estimates of drug development costs and returns. METHODS: Time and fee data were obtained on 5 single-source manufacturing projects. Time and fees were modeled for these projects as if the drug substance and drug product processes had been contracted separately from 2 vendors. The multi-vendor model was taken as the base case, and financial impacts from single-source contracting were determined relative to the base case. FINDINGS: The mean and median after-tax financial benefits of shorter development times from single-source contracting were $44.7 million and $34.9 million, respectively (2016 dollars). The after-tax increases in sponsor fees from single-source contracting were small in comparison (mean and median of $0.65 million and $0.25 million). IMPLICATIONS: For the data we examined, single-source contracting yielded substantial financial benefits over multi-source contracting, even after accounting for somewhat higher sponsor fees.

Contracting out to improve the use of clinical health services and health outcomes in low- and middle-income countries.

BACKGROUND: Contracting out of governmental health services is a financing strategy that governs the way in which public sector funds are used to have services delivered by non-governmental health service providers (NGPs). It represents a contract between the government and an NGP, detailing the mechanisms and conditions by which the latter should provide health care on behalf of the government. Contracting out is intended to improve the delivery and use of healthcare services. This Review updates a Cochrane Review first published in 2009. OBJECTIVES: To assess effects of contracting out governmental clinical health services to non-governmental service provider/s, on (i) utilisation of clinical health services; (ii) improvement in population health outcomes; (iii) improvement in equity of utilisation of these services; (iv) costs and cost-effectiveness of delivering the services; and (v) improvement in health systems performance. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, NHS Economic Evaluation Database, EconLit, ProQuest, and Global Health on 07 April 2017, along with two trials registers - ClinicalTrials.gov and the International Clinical Trials Registry Platform - on 17 November 2017. SELECTION CRITERIA: Individually randomised and cluster-randomised trials, controlled before-after studies, interrupted time series, and repeated measures studies, comparing government-delivered clinical health services versus those contracted out to NGPs, or comparing different models of non-governmental-delivered clinical health services. DATA COLLECTION AND ANALYSIS: Two authors independently screened all records, extracted data from the included studies and assessed the risk of bias. We calculated the net effect for all outcomes. A positive value favours the intervention whilst a negative value favours the control. Effect estimates are presented with 95% confidence intervals. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of the evidence and we prepared a Summary of Findings table. MAIN RESULTS: We included two studies, a cluster-randomised trial conducted in Cambodia, and a controlled before-after study conducted in Guatemala. Both studies reported that contracting out over 12 months probably makes little or no difference in (i) immunisation uptake of children 12 to 24 months old (moderate-certainty evidence), (ii) the number of women who had more than two antenatal care visits (moderate-certainty evidence), and (iii) female use of contraceptives (moderate-certainty evidence).The Cambodia trial reported that contracting out may make little or no difference in the mortality over 12 months of children younger than one year of age (net effect = -4.3%, intervention effect P = 0.36, clustered standard error (SE) = 3.0%; low-certainty evidence), nor to the incidence of childhood diarrhoea (net effect = -16.2%, intervention effect P = 0.07, clustered SE = 19.0%; low-certainty evidence). The Cambodia study found that contracting out probably reduces individual out-of-pocket spending over 12 months on curative care (net effect = $ -19.25 (2003 USD), intervention effect P = 0.01, clustered SE = $ 5.12; moderate-certainty evidence). The included studies did not report equity in the use of clinical health services and in adverse effects. AUTHORS' CONCLUSIONS: This update confirms the findings of the original review. Contracting out probably reduces individual out-of-pocket spending on curative care (moderate-certainty evidence), but probably makes little or no difference in other health utilisation or service delivery outcomes (moderate- to low-certainty evidence). Therefore, contracting out programmes may be no better or worse than government-provided services, although additional rigorously designed studies may change this result. The literature provides many examples of contracting out programmes, which implies that this is a feasible response when governments fail to provide good clinical health care. Future contracting out programmes should be framed within a rigorous study design to allow valid and reliable measures of their effects. Such studies should include qualitative research that assesses the views of programme implementers and beneficiaries, and records implementation mechanisms. This approach may reveal enablers for, and barriers to, successful implementation of such programmes.

Outsourcing within the Nordic context: Care services for older people in Finland.

The early 1990s economic setback brought significant reforms favoring the outsourcing of care in Finnish municipalities. Here, outsourcing refers to the practice of municipalities employing private organizations through different means (e.g., open tendering) to deliver public care services. In this context, this study examines the growth in the outsourcing of service housing and home-help services in 311 municipalities from 2001 to 2015 and investigates the municipal factors associated with outsourcing using four dimensions: care needs, population size, economic situation, and political ideology of the municipality. The findings reveal a steep increase in the outsourcing of home-help and service housing. Care needs of older people are the most influential factor for outsourcing, particularly for service housing. Overall, the findings show a growing trend in private care provision in Finnish municipalities.

Managing Risk Aversion for Low-Carbon Supply Chains with Emission Abatement Outsourcing.

Reducing carbon emissions, including emission abatement outsourcing at the supply-chain level, is becoming a significant but challenging problem in practice. Confronting this challenge, we therefore break down the practice to focus on a low-carbon supply chain consisting of one supplier, one manufacturer and one third-party emission-reducing contractor. The contractor offers a carbon reduction service to the manufacturer. In view of the increasing proportion of Greenhouse Gases (GHG) emissions and absence of carbon reduction policies in developing countries, we adopt the prospect of consumers' low-carbon preferences to capture the demand sensitivity on carbon emission. By exploiting the Mean-Variance (MV) model, we develop a supply chain game model considering risk aversion. Comparing the supply chain performances of the cases under risk neutrality and risk aversion, we investigate the impact of the risk aversion of the supplier and the manufacturer on the low-carbon supply chain performances, respectively. We show that the risk aversion of chain members will not influence the relationship underlain by the profit-sharing contract between the manufacturer and contractor, whereas they may extend the supplier's concerning range. Although the manufacturer's risk aversion has a positive impact on the wholesale price, interestingly, the supplier's impact on the wholesale price is negative. Furthermore, we propose a contract to coordinate the risk-averse low-carbon supply chain by tuning the aversion levels of the supplier and the manufacturer, respectively. Through numerical study, we draw on managerial insights for industrial practitioners to adopt a low carbon strategy potentially by managing the risk attitudes along the supply chain channel.

Purchased Behavioral Health Care Received by Military Health System Beneficiaries in Civilian Medical Facilities, 2000-2014.

Introduction: Behavioral health conditions are a significant concern for the U.S. military and the Military Health System (MHS) because of decreased military readiness and increased health care utilization. Although MHS beneficiaries receive direct care in military treatment facilities, a disproportionate majority of behavioral health treatment is purchased care received in civilian facilities. Yet, limited evidence exists about purchased behavioral health care received by MHS beneficiaries. This longitudinal study (1) estimated the prevalence of purchased behavioral health care and (2) identified patient and visit characteristics predicting receipt of purchased behavioral health care in acute care facilities from 2000 to 2014. Materials and Methods: Medical claims with Major Diagnostic Code 19 (mental disorders/diseases) or 20 (alcohol/drug disorders) as primary diagnoses and TRICARE as the primary/secondary payer were analyzed for MHS beneficiaries (n = 17,943) receiving behavioral health care in civilian acute care facilities from January 1, 2000, to December 31, 2014. The primary dependent variable, receipt of purchased behavioral health care, was modeled for select mental health and substance use disorders from 2000 to 2014 using generalized estimating equations. Patient characteristics included time, age, sex, and race/ethnicity. Visit types included inpatient hospitalization and emergency department (ED). Time was measured in days and visits were assumed to be correlated over time. Behavioral health care was described by both frequency of patients and visit type. The University of South Carolina Institutional Review Board approved this study. Results: From 2000 to 2014, purchased care visits increased significantly for post-traumatic stress disorder, adjustment, anxiety, mood, bipolar, tobacco use, opioid/combination opioid dependence, nondependent cocaine abuse, psychosocial problems, and suicidal ideation among MHS beneficiaries. The majority of care was received for mental health disorders (78.8%) and care was most often received in EDs (56%). Most commonly treated diagnoses included mood, tobacco use, and alcohol use disorders. ED visits were associated with being treated for anxiety (excluding post-traumatic stress disorder; Adjusted odds ratio [AOR]: 9.14 [95% confidence interval (CI): 8.26, 10.12]), alcohol use disorders (AOR = 1.67 [95% CI: 1.53, 1.83]), tobacco use (AOR = 1.16 [95% CI: 1.06, 1.26]), nondependent cocaine abuse (AOR = 5.47 [95% CI: 3.28, 9.12]), nondependent mixed/unspecified drug abuse (AOR = 7.30 [95% CI: 5.11, 10.44]), and psychosis (AOR = 1.38 [95% CI: 1.20, 1.58]). Compared with adults age 60 yr and older, adolescents (ages 12-17 yr), and adults under age 60 yr were more likely to be treated for suicidal ideation, adjustment, mood, bipolar, post-traumatic stress disorder, nondependent cocaine, and mixed/unspecified drug abuse. Adults under age 60 yr also had increased odds of being treated for tobacco use disorders, alcohol use disorders, and opioid/combination opioid dependence compared with adults age 60 yr and older. Conclusions: Over the past 15 yr, purchased behavioral health care received by MHS beneficiaries in acute care facilities increased significantly. MHS beneficiaries received the majority of purchased behavioral health care for mental health disorders and were treated most often in the ED. Receiving behavioral health care in civilian EDs raises questions about access to outpatient behavioral health care and patient-centered care coordination between civilian and military facilities. Given the influx of new Veterans Health Administration users from the MHS, findings have implications for military, veteran, and civilian facilities providing behavioral health care to military and veteran populations.

Critical analysis of valuation and strategical orientation of merger and acquisition deals in the pharmaceutical industry.

INTRODUCTION: The pharmaceutical industry is undergoing major shifts due to changing macro and micro factors. As the industry is highly capital intensive and patents are expiring, the outlook is on generating inorganic growth, mainly through M&A. Using the income valuation approach, one analyses two completed deals in 2016 above 1bn USD. Thereafter one outlines the main motives behind M&A deals and concluded by discussing whether M&A harms medical innovations. AREAS COVERED: The paper is based on empirical study questioning existing literature in order to critically analyse valuation and the strategical orientation of pharmaceutical companies. EXPERT COMMENTARY: Pharmaceutical companies understand the changing market conditions and favour their expertise. The restructuring of the industry moves to small niche companies (I.e. Biopharma or biotech companies) researching key innovations and big companies purchasing them to develop them, create clinical trials and distribute them as this is a costly manner Conclusion: One can expect more M&A deals during the next years focusing on value rather than volume. Pharmaceutical players resilient to the market changes may survive if they change their business model from a traditional vertical one to outsourcing and diversification including external players.