Enrollee Mix, Treatment Intensity, and Cost in Competing Indemnity and HMO Plans

We examine why managed care plans are less expensive than traditional indemnity insurance plans. Our database consists of the insurance experiences of over 200,000 state and local employees in Massachusetts and their families, who are insured in a single pool. Within this group, average HMO costs are 40 percent below those of the indemnity plan. We evaluate cost differences for 8 conditions representing over 10 percent of total health expenditures. They are: heart attacks, cancers (breast, cervical, colon, prostate), diabetes (type I and II), and live births. For each condition, we identify the portions of the cost differential arising from differences in treatment intensity, enrollee mix, and prices paid for the same treatment. Surprisingly, treatment intensity differs hardly at all between the HMOs and the indemnity plan. That is, relative to their fee-for-service competitor, HMOs do not curb the use of expensive treatments. Across the 8 conditions, roughly half of the HMO cost savings is due to the lower incidence of the diseases in the HMOs. Virtually all of the remaining savings come because HMOs pay lower prices for the same treatment.

Is the relationship among outcome variables shown in randomized trials?

BACKGROUND: Randomized controlled trials (RCTs) often have more than one primary outcome and frequently have secondary and harm outcomes. Comparison of outcomes between study arms is the primary focus of RCTs, but there are times when the relation between outcomes is important, such as determining whether an intermediate outcome and a clinical outcome have a strong association. We sought to determine how often reports of RCTs depict the relations among outcomes at the individual patient level and, for those studies that use composite outcomes, how often the relations between component elements are depicted. METHODS: We selected 20 general, specialty and subspecialty medical journals with high impact factors that publish original clinical research. We identified every RCT in the 2011 and 2012 issues and randomly selected 10 articles per journal. For each article we recorded the number of outcomes, the number of composite outcomes and how often the relations between outcomes or elements of composite outcomes were portrayed. RESULTS: All but 16 of the 200 RCTs had more than one outcome. Thus, outcomes could have been related in 92% of studies, but such relations were only reported in 2 (1%). A total of 33 (17%) investigations measured a composite outcome, 32 of which showed data for each component. None, however, showed cross-tabulation of the components. CONCLUSIONS: Readers are rarely shown the relation between outcomes. Mandatory posting of datasets or requirements for detailed appendices would allow readers to see these cross-tabulations, helping future investigators know which outcomes are redundant, which provide unique information and which are most responsive to changes in the independent variables. While not every relationship between outcomes requires depiction, at present such information is seldom portrayed

Scoping review on interventions to improve adherence to reporting guidelines in health research

Objectives The goal of this study is to identify, analyse and classify interventions to improve adherence to reporting guidelines in order to obtain a wide picture of how the problem of enhancing the completeness of reporting of biomedical literature has been tackled so far. Design Scoping review. Search strategy We searched the MEDLINE, EMBASE and Cochrane Library databases and conducted a grey literature search for (1) studies evaluating interventions to improve adherence to reporting guidelines in health research and (2) other types of references describing interventions that have been performed or suggested but never evaluated. The characteristics and effect of the evaluated interventions were analysed. Moreover, we explored the rationale of the interventions identified and determined the existing gaps in research on the evaluation of interventions to improve adherence to reporting guidelines. Results 109 references containing 31 interventions (11 evaluated) were included. These were grouped into five categories: (1) training on the use of reporting guidelines, (2) improving understanding, (3) encouraging adherence, (4) checking adherence and providing feedback, and (5) involvement of experts. Additionally, we identified lack of evaluated interventions (1) on training on the use of reporting guidelines and improving their understanding, (2) at early stages of research and (3) after the final acceptance of the manuscript. Conclusions This scoping review identified a wide range of strategies to improve adherence to reporting guidelines that can be taken by different stakeholders. Additional research is needed to assess the effectiveness of many of these interventionsPeer ReviewedPostprint (author's final draft

Power, Culture, Economy (CAEPR 30)

Research over the past decade in health, employment, life expectancy, child mortality, and household income has confirmed that Indigenous Australians are still Australia’s most disadvantaged group. Those residing in communities in regional and remote Australia are further disadvantaged because of the limited formal economic opportunities there. In these areas mining developments may be the major—and sometimes the only—contributors to regional economic development. However Indigenous communities have gained only relatively limited long-term economic development benefits from mining activity on land that they own or over which they have property rights of varying significance. Furthermore, while Indigenous people may place high value on realising particular non-economic benefits from mining agreements, there may be only limited capacity to deliver such benefits. This collection of papers focuses on three large, ongoing mining operations in Queensland, Western Australia and the Northern Territory under two statutory regimes—the Aboriginal Land Rights (Northern Territory) Act 1976 and the Native Title Act 1993. The authors outline the institutional basis to greater industry involvement while describing and analysing the best practice principles that can be utilised both by companies and Indigenous community organisations. The research addresses questions such as: What factors underlie successful investment in community relations and associated agreement governance and benefit packages for Indigenous communities? How are economic and non-economic flows monitored? What are the values and aspirations which Indigenous people may bring to bear in their engagement with mining developments? What more should companies and government do to develop the capacity and sustainability of local Indigenous organisations? What mining company strategies build community capacity to deal with impacts of mining? Are these adequate? How to prepare for sustainable futures for Indigenous Australians after mine closure? This research was conducted under an Australian Research Council Linkage Project, with Rio Tinto and the Committee for Economic Development of Australia as Industry Partners

Reforming the Northern Territory Land Rights Act's financial framework into a more logical and more workable model

None available.The financial framework of the Aboriginal Land Rights (Northern Territory) Act 1976 (ALRA) has never been based on sound economic principles or even logical accounting, let alone clear and transparent policy messages or even obvious directives to Indigenous interests in the Northern Territory. With the benefit of hindsight it is clear that Justice Woodward tried hard to accommodate pre-land rights vested interests in his Royal Commission recommendations that were largely incorporated into the legislation enacted in 1976 and which became law on Australia Day, 1977. Nevertheless, it is also apparent that Woodward did not intend that the financial framework remain unaltered, by and large, for 25 years after conclusion of his Commission in 1974 (Woodward 1974). The recent recommendations of the Review of the ALRA by John Reeves propose radical reforms to the financial framework of the legislation. Rather than restructuring or reformulating the prescribed statutory allocations of the current financial framework, Reeves recommended that it be replaced by discretionary allocations determined by a new statutory authority—the Northern Territory Aboriginal Council (NTAC). The Review’s recommendations have been criticised widely for many reasons. Much of this criticism has been focused on the radical reform of institutions, the methodological approach of the Review, and a lack of understanding of key concepts and constructs within the legislative framework (for example, the concept of traditional ownership). Most notable amongst the criticisms is that directed at the Reeves notion that the Land Rights Act should be the primary framework to facilitate Indigenous socioeconomic advancement in the Northern Territory (see, for example, Altman, Morphy and Rowse 1999). Our discussion here is not a detailed critique of the Reeves Review; rather that Review is placed in the sequential history of a series of reviews over the last two decades. The major focus of this Working Paper is to re-examine the logic and historical policy legacies associated with the financial streams of monies paid under the Land Rights Act. This is an issue that is neither rarely explored nor evidently understood by past and current reviewers. We intend to proceed firstly by re-assessing the history, issues of principle and logic in the construction of the ALRA’s financial framework and the inherent long-term problems and inconsistencies in that framework. In addressing these problems and inconsistencies, we raise three very straightforward but crucial questions informed to a great extent by earlier research undertaken on the ALRA’s financial framework by reviewers, academics, government agencies and consultants. Should royalties be paid to people in areas affected, and if so, how much should be paid, to whom and for what purposes? How much should land councils receive, for what statutory functions and from where (royalties or consolidated revenue or both)? Should royalties be paid to Northern Territory Aboriginal people as grants, and why? In conclusion, and for discussion purposes, we will raise some options for change to the ALRA’s financial framework and ask how a more logical and more workable model can be negotiated and devised given competing interests and pressures for reform