Designing a Mixed Public and Private System for the Health Insurance Market

Reviews features of a reform proposal offering both public and private plans in a government-run purchasing pool, modeled on Medicare, in the commercial insurance market. Analyzes potential issues, including standardization of benefits and risk selection

A Competitive Bidding Approach to Medicare Reform

Medicare reform is a critical issue for the public agenda. The most promising option for addressing Medicare reform is competitive bidding -- using health plans' bids to determine the government's contribution to a basic set of benefits in every market area. This paper begins with a review of the history of competitive bidding in Medicare. It then moves to a definition of terms, which is crucial in any discussion of competitive pricing because the often-heated public debate around these issues frequently distorts positions and confuses issues by conflating different terms and making some arguments appear other than they are. Following this terminological exercise, the report includes a series of sections discussing competitive bidding in Medicare, with special focus on the challenges to introducing it

Setting Physicians\u27 Prices in FFS Medicare: An Economic Perspective

Recent policy discussions by the Medicare Payment Advisory Commission (MedPAC) regarding physician prices in the traditional fee-for-service (FFS) Medicare Program reflect movement toward a market pricing model. Earlier objectives such as sustainable levels of spending have given way to concerns over the relationship between fees and actual costs, access to care, and the importance of demand and supply in local markets. An important objective in other policy settings is economically efficient distribution of services. We explain the meaning of economic efficiency for Medicare physician prices and explore difficulties one might encounter in pursuing economic efficiency, as well as the cost of not pursuing it

The relativistic pulsar-white dwarf binary PSR J1738+0333 II. The most stringent test of scalar-tensor gravity

(abridged) We report the results of a 10-year timing campaign on PSR J1738+0333, a 5.85-ms pulsar in a low-eccentricity 8.5-hour orbit with a low-mass white dwarf companion (...) The measurements of proper motion and parallax allow for a precise subtraction of the kinematic contribution to the observed orbital decay; this results in a significant measurement of the intrinsic orbital decay: (-25.9 +/- 3.2) \times 10^{-15} s/s. This is consistent with the orbital decay from the emission of gravitational waves predicted by general relativity, (-27.7 +1.5/-1.9) \times 10^{-15} s/s (...). This agreement introduces a tight upper limit on dipolar gravitational wave emission, a prediction of most alternative theories of gravity for asymmetric binary systems such as this. We use this limit to derive the most stringent constraints ever on a wide class of gravity theories, where gravity involves a scalar field contribution. When considering general scalar-tensor theories of gravity, our new bounds are more stringent than the best current solar-system limits over most of the parameter space, and constrain the matter-scalar coupling constant {\alpha}_0^2 to be below the 10^{-5} level. For the special case of the Jordan-Fierz-Brans-Dicke, we obtain the one-sigma bound {\alpha}_0^2 < 2 \times 10^{-5}, which is within a factor two of the Cassini limit. We also use our limit on dipolar gravitational wave emission to constrain a wide class of theories of gravity which are based on a generalization of Bekenstein's Tensor-Vector-Scalar gravity (TeVeS), a relativistic formulation of Modified Newtonian Dynamics (MOND).Comment: Accepted for publication in MNRAS. 18 pages in emulate MNRAS format, 9 figures and 1 tabl

Long-term outcome after anterior cervical discectomy without fusion

To retrospectively study the long-term outcome of patients after anterior cervical discectomy without fusion (ACD) compared to results published on the long-term outcome after ACD with fusion (ACDF). We reviewed the charts of all patients receiving ACD surgery between 1985 and 2000 to analyze the direct post-operative results as well as complications of the surgery. Moreover, 102 patients, randomly selected, were interviewed with the neck disability index to study possible persisting complaints up to 18 years after ACD surgery. A total of 551 Patients were identified. Two months post-operative follow up at the outpatient clinic revealed that 90.1% of patients were satisfied with the result of ACD surgery. At the time of the survey, this percentage had dropped to 67.6%. In addition, 20.6% and 11.8% had obtained moderate to severe complaints, respectively, in daily-life activities. Complaints were mainly localized in the neck region and occasionally provoked radiating pain in the arm. On the short term, ACD leads to a satisfied outcome. Over the longer term, patients report increasing complaints. The increase in complaints at the time of the survey may be the result of ongoing degenerative effects. Compared to published data on ACDF, there is no superiority of any fusion technique compared to ACD alone

Chimpanzee accumulative stone throwing

The study of the archaeological remains of fossil hominins must rely on reconstructions to elucidate the behaviour that may have resulted in particular stone tools and their accumulation. Comparatively, stone tool use among living primates has illuminated behaviours that are also amenable to archaeological examination, permitting direct observations of the behaviour leading to artefacts and their assemblages to be incorporated. Here, we describe newly discovered stone tool-use behaviour and stone accumulation sites in wild chimpanzees reminiscent of human cairns. In addition to data from 17 mid- to long-term chimpanzee research sites, we sampled a further 34 Pan troglodytes communities. We found four populations in West Africa where chimpanzees habitually bang and throw rocks against trees, or toss them into tree cavities, resulting in conspicuous stone accumulations at these sites. This represents the first record of repeated observations of individual chimpanzees exhibiting stone tool use for a purpose other than extractive foraging at what appear to be targeted trees. The ritualized behavioural display and collection of artefacts at particular locations observed in chimpanzee accumulative stone throwing may have implications for the inferences that can be drawn from archaeological stone assemblages and the origins of ritual sites

Learning at the bottom of the pyramid : Science, measurement, and policy in low-income countries

In this volume, a diverse group of authors discuss and analyse the scientific tensions in understanding learning among poor and marginalized populations in Low- and Middle-income countries (LMICs). Four broad areas are considered: how to define the BoP; how to measure and assess learning outcomes across diverse populations within a country; variations in learning across the life-span; and the implications for international education policy. Each of the 12 chapters is complemented by two commentaries, thus there are a total of 36 contributions. In the social sciences, learning is defined most commonly as a change – such as in knowledge, skills, attitudes, and values – based on experiences of some kind.Thus, schooling is not the same thing as learning. While schooling is usually designed to foster curriculum-based learning in classrooms, research increasingly demonstrates that much of what we presume is learned in school is not, and that a great deal of learning takes place outside of schools. There is a large and diverse empirical research base in the area of human learning. However, much of the available research is limited by constraints of various kinds. Most prominent among these is the limited ability to generalize from findings in one population or context to others. In Chapter 1, Schmelkes considers common elements to human learning, in and out of school, including important cultural variations that are large and often poorly understood. She concludes that much more should be done to improve educational policy and address such contextual issues. A second key priority is to determine what populations are meant by the phrase BoP. How do populations differ in LMICs – both across and within countries? As pointed out by Montoya in Chapter 2, there are at least six prominent dimensions through which populations at the BoP may be described in low-income countries, and each is important for considering the ways that young people can escape from persistent poverty. Building on the first two chapters, Crouch (Chapter 3) lays out a conceptual model, buttressed by data from international assessments, that describes how to flatten the learning pyramid to ensure more equitable learning outcomes for all by focusing on the poorest learners. Overall, these three chapters provide a framework for considering the nature and extent of BoP studies of learning. There are many critiques of the educational assessment enterprise, the beginning of which is sometimes attributed to the French psychometrician Alfred Binet. In order to support the expansion of public schooling in France, Binet famously created assessments through which he could predict which children would have the most difficulty in school. In this section, we consider contemporary approaches to learning assessments, with a specific focus on the socio-cultural determinants of who succeeds and who does not at the BoP. Kanjee, in Chapter 4, takes a broad perspective by reviewing the purposes of international assessment studies, suggesting that assessments have only limited impact on supporting BoP learning achievement. He concludes that assessments can better address the learning needs of poor and marginalized learners by reporting results through formative evaluations that can impact children before learning gaps widen. In Chapter 5, Willms describes a conceptual model for improved learning over the life-course, empirically supported by research in Uruguay among preschool children, and in Canada with young indigenous children. One of his findings is that in order to succeed in school, children need to learn to read with confidence during the primary grades, and use language to think critically, solve problems, and create new knowledge. He concludes that national and international assessments can serve to establish standards, assess the extent of inequalities among various subpopulations, and provide a framework for basic or theoretical research, but that there should be greater focus on changing classroom practice. One way to understand the inner workings of assessments and use them to promote learning at the BoP is provided by Vagh and Sharma (Chapter 6) in their action research project in Allahabad, India. This project sought to develop and evaluate a local language literacy and numeracy programme for children from low socioeconomic backgrounds in government school primary grades, using measurement and assessment to drive programme change. It highlights some of the strengths and challenges of localized assessments. Moreover, it suggests that assessments can be used by teachers to support early reading. Finally, in Chapter 7, Maddox asks a seminal question: To what extent are learning assessments able to identify and include individual and cultural differences, without reproducing relations of disadvantage? These issues are described in terms of test fairness and procedures for anticipating and removing sources of test bias. In a series of ethnographic studies, Maddox advises the reader to pay close attention to how assessments are carried out in situ, and how questions are interpreted by the person tested. Serious problems can and will ensue without such care in local contexts. Another approach to BoP issues is through a life-span perspective. How do measurement tools on learning and learning outcomes vary for young children, students in school, as well as among youth and adults? Three chapters in this section consider such age-related differences. Dowd and Pisani, in Chapter 8, have been deeply involved in the field of assessments of young children before they reach school age. Their chapter reviews the application of the International Development and Early Learning Assessment (IDELA) instrument to explore young children’s skills at the BoP and identify learning gaps in early academic, physical, and social-emotional development. Based on the broad findings from more than 20 LMICs, and closer analysis of particular contexts, the authors make that case that there is much variation in early childhood learning within countries, particularly between urban and rural contexts. They argue that national policies in support of early childhood need to be guided by disaggregated data in order to ensure that children at the BoP receive adequate support. In Chapter 9, Care, Robertson, and Ferido describe how well-designed assessments for school-aged children can provide individualized information that can support school-based learning. These assessments build on the skill levels that children bring to the classroom. Through what they term a ‘learning progression model’, they present data on children in the Philippines who are best able to learn from specifically guided instruction tailored to their particular skill level. They conclude that learning assessments can and should be inclusive of diverse groups within any larger target population. Finally, Oketch (Chapter 10) focuses on youth and adult learning in subSaharan African, pointing out that rapidly changing demographics and economies in the region require significantly greater attention. Further, the population of low-skilled youth is growing dramatically, even though more African children are going to school than ever before. This chapter describes the importance of technical and vocational education and training (TVET) and non-formal education as two known methodologies for directly providing instruction and learning outside of the classroom in support of out-of-school youth and adults. The problem remains, according to Oketch, that there is a paucity of research in this domain, and in particular among populations at the BoP. In Chapters 1–10, authors and commentators present multiple views on scientific definitions, measurement tools, and life-span approaches for understanding learning at the BoP. This final section of the volume considers the kinds of educational policy implications that need to be considered by both national and international decision-makers. Benavot (Chapter 11) raises a key issue in supporting learning at the BoP, notably the need to move beyond easily accessible measures of learning – namely, school-based surveys of a narrow range of learning outcomes at the primary and lower secondary level – and engage with the broader and more comprehensive learning agenda proposed in the SDGs. He points out that many of the UN goals contain diverse elements of learning, and the specific targets for each goal may vary a great deal across diverse populations. Further, he notes that many of the key markers of disadvantage in education (such as socio-economic status, SES) are very difficult to change. He concludes that a serious focus on learning at the BoP will require greater clarity of definitions, and a more deliberate approach to building evidence on how best to improve relevant learning outcomes for the disadvantaged. In Chapter 12, Van Damme provides a global policy perspective supported by the findings of the Organisation for Economic Co-operation and Development (OECD) international learning assessments. He asserts that international educational policies can only be inclusive and sustainable if those at the bottom of the social and educational pyramid benefit from them. To support this perspective, Van Damme presents findings that demonstrate how higher levels of economic growth are driven by more years of education and greater learning achievement within countries. By disaggregating data from the Programme for International Student Assessment (PISA) 2015 assessment, he reminds us that students with very low proficiency tend to drive down national averages (similar to the findings by Crouch in Chapter 3). He concludes that countries need to focus on raising average learning outcomes to desired national standards while at the same time narrowing the distribution of national learning outcomes