Hospital Reimbursement in the Presence of Cherry Picking and Upcoding

Hospitals throughout the developed world are reimbursed on the basis of diagnosis-related groups (DRGs). Under this scheme, patients are divided into clinically meaningful groups, and hospitals receive a fixed fee per patient episode tied to the patient DRG. The fee is based on the average cost of providing care to patients who belong to the same DRG across all hospitals. This scheme, sometimes referred to as ‘yardstick competition’, provides incentives for cost reduction, as no hospital wants to operate at a higher cost than average, and can be implemented using accounting data alone. Nevertheless, if costs within a DRG are heterogeneous, this scheme may give rise to cherry-picking incentives, where providers ‘drop’ patients who are more expensive to treat than average. To address this problem, regulators have tried to reduce within DRG cost heterogeneity by expanding the number of DRG classes. In this paper, we show that even if cost heterogeneity is eliminated, such expansion will fail to completely eliminate patient cherry picking. In equilibrium, the market will bifurcate into two groups, one of which will continue to cherry-pick patients and underinvest in cost reduction, while the other group treats all patients. Furthermore, we show that DRG expansion is particularly problematic if hospitals are also able to ‘upcode’ patients, i.e., intentionally assign patients to a more resource-intensive DRG than needed to increase income. Upcoding increases within DRG cost heterogeneity and amplifies cherry-picking incentives. We examine potential solutions involving yardstick competition based on input statistics

Orbital Controls on North Pacific Dust Flux During the Late Quaternary

Abstract Airborne mineral dust is sensitive to climatic changes, but its response to orbital forcing is still not fully understood. Here, we present a reconstruction of dust input to the Subarctic Pacific Ocean covering the past 190 kyr. The dust composition record is indicative of source moisture conditions, which were dominated by precessional variations. In contrast, the dust flux record is dominated by obliquity variations and displays an out‐of‐phase relationship with a dust record from the mid‐latitude North Pacific Ocean. Climate model simulations suggest precession likely drove changes in the aridity and extent of dust source regions. Additionally, the obliquity variations in dust flux can be explained by meridional shifts in the North Pacific westerly jet, driven by changes in the meridional atmospheric temperature gradient. Overall, our findings suggest that North Pacific dust input was primarily modulated by orbital‐controlled source aridity and the strength and position of the westerly winds

Orbital Controls on North Pacific Dust Flux During the Late Quaternary

Airborne mineral dust is sensitive to climatic changes, but its response to orbital forcing is still not fully understood. Here, we present a reconstruction of dust input to the Subarctic Pacific Ocean covering the past 190 kyr. The dust composition record is indicative of source moisture conditions, which were dominated by precessional variations. In contrast, the dust flux record is dominated by obliquity variations and displays an out‐of‐phase relationship with a dust record from the mid‐latitude North Pacific Ocean. Climate model simulations suggest precession likely drove changes in the aridity and extent of dust source regions. Additionally, the obliquity variations in dust flux can be explained by meridional shifts in the North Pacific westerly jet, driven by changes in the meridional atmospheric temperature gradient. Overall, our findings suggest that North Pacific dust input was primarily modulated by orbital‐controlled source aridity and the strength and position of the westerly winds

A consistent approach for probabilistic residential flood loss modeling in Europe

In view of globally increasing flood losses, a significantly improved and more efficient flood risk management and adaptation policy are needed. One prerequisite is reliable risk assessments on the continental scale. Flood loss modeling and risk assessments for Europe are until now based on regional approaches using deterministic depth‐damage functions. Uncertainties associated with the risk estimation are hardly known. To reduce these shortcomings, we present a novel, consistent approach for probabilistic flood loss modeling for Europe, based on the upscaling of the Bayesian Network Flood Loss Estimation MOdel for the private sector, BN‐FLEMOps. The model is applied on the mesoscale in the whole of Europe and can be adapted to regional situations. BN‐FLEMOps is validated in three case studies in Italy, Austria, and Germany. The officially reported loss figures of the past flood events are within the 95% quantile range of the probabilistic loss estimation, for all three case studies. In the Italian, Austrian, and German case studies, the median loss estimate shows an overestimation by 28% (2.1 million euro) and 305% (5.8 million euro) and an underestimation by 43% (104 million euro), respectively. In two of the three case studies, the performance of the model improved, when updated with empirical damage data from the area of interest. This approach represents a step forward in European wide flood risk modeling, since it delivers consistent flood loss estimates and inherently provides uncertainty information. Further validation and tests with respect to adapting the model to different European regions are recommended

An 11-bp Insertion in Zea mays fatb Reduces the Palmitic Acid Content of Fatty Acids in Maize Grain

The ratio of saturated to unsaturated fatty acids in maize kernels strongly impacts human and livestock health, but is a complex trait that is difficult to select based on phenotype. Map-based cloning of quantitative trait loci (QTL) is a powerful but time-consuming method for the dissection of complex traits. Here, we combine linkage and association analyses to fine map QTL-Pal9, a QTL influencing levels of palmitic acid, an important class of saturated fatty acid. QTL-Pal9 was mapped to a 90-kb region, in which we identified a candidate gene, Zea mays fatb (Zmfatb), which encodes acyl-ACP thioesterase. An 11-bp insertion in the last exon of Zmfatb decreases palmitic acid content and concentration, leading to an optimization of the ratio of saturated to unsaturated fatty acids while having no effect on total oil content. We used three-dimensional structure analysis to explain the functional mechanism of the ZmFATB protein and confirmed the proposed model in vitro and in vivo. We measured the genetic effect of the functional site in 15 different genetic backgrounds and found a maximum change of 4.57 mg/g palmitic acid content, which accounts for ∼20–60% of the variation in the ratio of saturated to unsaturated fatty acids. A PCR-based marker for QTL-Pal9 was developed for marker-assisted selection of nutritionally healthier maize lines. The method presented here provides a new, efficient way to clone QTL, and the cloned palmitic acid QTL sheds lights on the genetic mechanism of oil biosynthesis and targeted maize molecular breeding

Upstream Supply Chain Visibility and Complexity Effect on Focal Company’s Sustainable Performance: Indian Manufacturers’ Perspective

Understanding supply chain sustainability performance is increasingly important for supply chain researchers and managers. Literature has considered supply chain sustainability and the antecedents of performance from a triple bottom line (economic, social, and environmental) perspective. However, the role of supply chain visibility and product complexity contingency in achieving sustainable supply chain performance has not been explored in depth. To address this gap, this study utilizes a contingent resource-based view theory perspective to understand the role of product complexity in shaping the relationship between upstream supply chain visibility (resources and capabilities) and the social, environmental, and economic performance dimensions. We develop and test a theoretical model using survey data gathered from 312 Indian manufacturing organizations. Our findings indicate that supply chain visibility (SCV) has significant influence on social and environmental performance under the moderation effect of product complexity. Hence, the study makes significant contribution to the extant literature by examining the impact of SCV under moderating effect of product complexity on social performance and environmental performance

Orwellian Language and the Politics of Tribal Termination (1953-1960)

From 1953 to 1960, the federal government terminated sovereign recognition for 109 American Indian nations. Termination was a haphazard policy of assimilation that had disastrous consequences for Indian land and culture. Nonetheless, termination cloaked latent motivations for Indian land within individual rights rhetoric that was at odds with Indian sovereignty. Termination highlights the rhetorical features of social control under capitalism portrayed in George Orwell’s Nineteen Eighty-Four (1949), in which opposing principles are fused and inverted. This essay critiques termination’s Orwellian language to show how ideographs of social liberation are refashioned by the state to subvert Indian sovereignty and popular dissent

Fludarabine, cytarabine, granulocyte colony-stimulating factor, and idarubicin with gemtuzumab ozogamicin improves event-free survival in younger patients with newly diagnosed aml and overall survival in patients with npm1 and flt3 mutations

Purpose To determine the optimal induction chemotherapy regimen for younger adults with newly diagnosed AML without known adverse risk cytogenetics. Patients and Methods One thousand thirty-three patients were randomly assigned to intensified (fludarabine, cytarabine, granulocyte colony-stimulating factor, and idarubicin [FLAG-Ida]) or standard (daunorubicin and Ara-C [DA]) induction chemotherapy, with one or two doses of gemtuzumab ozogamicin (GO). The primary end point was overall survival (OS). Results There was no difference in remission rate after two courses between FLAG-Ida + GO and DA + GO (complete remission [CR] + CR with incomplete hematologic recovery 93% v 91%) or in day 60 mortality (4.3% v 4.6%). There was no difference in OS (66% v 63%; P = .41); however, the risk of relapse was lower with FLAG-Ida + GO (24% v 41%; P < .001) and 3-year event-free survival was higher (57% v 45%; P < .001). In patients with an NPM1 mutation (30%), 3-year OS was significantly higher with FLAG-Ida + GO (82% v 64%; P = .005). NPM1 measurable residual disease (MRD) clearance was also greater, with 88% versus 77% becoming MRD-negative in peripheral blood after cycle 2 (P = .02). Three-year OS was also higher in patients with a FLT3 mutation (64% v 54%; P = .047). Fewer transplants were performed in patients receiving FLAG-Ida + GO (238 v 278; P = .02). There was no difference in outcome according to the number of GO doses, although NPM1 MRD clearance was higher with two doses in the DA arm. Patients with core binding factor AML treated with DA and one dose of GO had a 3-year OS of 96% with no survival benefit from FLAG-Ida + GO. Conclusion Overall, FLAG-Ida + GO significantly reduced relapse without improving OS. However, exploratory analyses show that patients with NPM1 and FLT3 mutations had substantial improvements in OS. By contrast, in patients with core binding factor AML, outcomes were excellent with DA + GO with no FLAG-Ida benefit