Physicians' Multitasking and Incentives: Empirical Evidence from a Natural Experiment

We analyse how physicians respond to contractual changes and incentives within a multitasking environment. In 1999 the Quebec government (Canada) introduced an optional mixed compensation system, combining a fixed per diem with a discounted (relative to the traditional fee-for-service system) fee for services provided. We combine panel survey and administrative data on Quebec physicians to evaluate the impact of this change in incentives on their practice choices. We highlight the differentiated impact of incentives on various dimensions of physician behaviour by considering a wide range of labour supply variables: time spent on seeing patients, time devoted to teaching, administrative tasks or research, as well as the volume of clinical services and average time per clinical service. Our results show that, on average, the reform induced physicians who changed from FFS to MC to reduce their volume of (billable) services by 6.15% and to reduce their hours of work spent on seeing patients by 2.57%. Their average time spent per service increased by 3.58%, suggesting a potential quality-quantity substitution. Also the reform induced these physicians to increase their time spent on teaching and administrative duties (tasks not remunerated under the fee-for-service system) by 7.9%.Physician payment mechanisms, multitasking, mixed-payment systems, incentive contracts, labour supply, self-selection, panel estimation

Exploiting technological synergies for future launch vehicles

Two launch vehicle concepts based on technologies available today or in a short term future in Western Europe are presented. The design of both launchers has the goal of exploiting synergies with current European programs to limit development and operational costs. Technologies of particular interest here are the high performance solid rocket motors with carbon-epoxy filament wound monolithic motor cases and the future high performance cryogenic expander cycle engine Vinci. The first concept dubbed ANGELA (A New GEneration LAuncher) is a study financed with funds of the German Ministry of Economics and managed by the DLR Space Administration. The project, which started in the summer of 2012 aims at designing a low cost versatile launcher able to place payloads between 2 and 5 tons into GTO. Three architectures have been considered during the first phase of the study. This phase was concluded in March 2013 with the preliminary stagings, which will be the starting point of more detailed analyses. The first architecture is made out of an H110 (stage with 110 tons of LOx/LH2) equipped with two Vulcain 2 engines with shortened nozzles and an H29 propelled by a Vinci engine. In addition the variation of the number of P36 solid rocket boosters allow to reach the entire range of payload performance. The second architecture differs from the first one only by the use of a new staged-combustion engine instead of two Vulcain 2 engines. The new engine, which should deliver 1800 kN in vacuum, allows a reduction of the size of the stages to H90-H24, enhanced with P34 boosters. The third and last architecture is a so called Multi PPH. The first stage is a bundle of 2 or 3 P120 solid rocket motors. The second stage is made out of one single P120, strictly similar to those used for the first stage. Finally the upper stage is an H23 equipped with a Vinci engine, the same as the two other architectures. The second launcher concept described in this paper is the small TSTO launch vehicle. It consists of a large solid rocket motor first stage P175 and a cryogenic upper stage propelled by the Vinci engine, H26. The preliminary design performed at DLR-SART considers two target performances. The light version of the small TSTO shall perform Galileo satellite replacement single launch missions to MTO corresponding to a payload performance of about 1400 kg in GTO. A heavy version of the launch vehicle shall be able to launch payloads up to 3000 kg in GTO. The performance increase for the heavy version is made possible by the addition of two pairs of P23 boosters, the second pair being ignited with a delay

High-Thrust in-Space Liquid Propulsion Stage: Storable Propellants

In the frame of a project funded by ESA, a consortium led by Avio in cooperation with Snecma, Cira, and DLR is performing the preliminary design of a High-Thrust in-Space Liquid Propulsion Stage for two different types of manned missions beyond Earth orbit. For these missions, one or two 100 ton stages are to be used to propel a manned vehicle. Three different propellant combinations; LOx/LH2, LOx/CH4 and MON-3/MMH are being compared. The preliminary design of the storable variant (MON-3/MMH) has been performed by DLR. The Aestus II engine with a large nozzle expansion ratio has been chosen as baseline. A first iteration has demonstrated, that it indeed provides the best performance for the storable propellant combination, when considering all engines available today or which may be available in a short- to medium term. The RD-861 K engine has been proposed as alternative to reduce the development duration of the high-thrust stage. Structure analyses and optimisations have converged towards a common bulkhead architecture with a Whipple shield, similar to the one used on the ATV, to protect the main propellant tanks against perforations caused by meteoroids and space debris. The propulsion system has been built around six Aestus II engines equipped with TVC and placed on a circular engine thrust frame. The RCS, the thermal system, and the power system have also been included in the preliminary design, and they have been sized for the most demanding mission. The performance of the high-thrust stage, resulting from the preliminary design, has been assessed for both missions taken into consideration

Physicians' Multitasking and Incentives: Empirical Evidence from a Natural Experiment

We analyse how physicians respond to contractual changes and incentives within a multitasking environment. In 1999 the Quebec government (Canada) introduced an optional mixed compensation system, combining a xed per diem with a partial (relative to the traditional fee-for-service system) fee for services provided. We combine panel survey and administrative data on Quebec physicians to evaluate the impact of this change in incentives on their practice choices. We highlight the dierentiated impact of incentives on various dimensions of physician behaviour by considering a wide range of labour supply variables: time spent on seeing patients, time devoted to teaching, administrative tasks or research, as well as the volume of clinical services and average time per clinical service. Our results show that, on average, the reform induced physicians who changed from FFS to MC to reduce their volume of (billable) services by 6.15% and to reduce their hours of work spent on seeing patients by 2.57%. Their average time spent per service increased by 3.58%, suggesting a potential quality-quantity substitution. Also the reform induced these physicians to increase their time spent on teaching and administrative duties (tasks not remunerated under the fee-for-service system) by 7.9%.physician payment mechanisms; multitasking; mixed-payment systems; incentive contracts; labour supply; self-selection; panel estimation

Physicians’ Multitasking and Incentives: Empirical Evidence from a Natural Experiment

We analyse how physicians respond to contractual changes and incentives within a multitasking environment. In 1999 the Quebec government (Canada) introduced an optional mixed compensation (MC) system, combining a fixed per diem with a partial (relative to the traditional fee-for-service system) fee for services provided. We combine panel survey and administrative data on Quebec physicians to evaluate the impact of this change in incentives on their practice choices. We highlight the differentiated impact of incentives on various dimensions of physician behaviour by considering a wide range of labour supply variables: time spent on seeing patients, time devoted to teaching, administrative tasks or research, as well as the volume of clinical services and average time per clinical service. Our results show that, on average, the reform induced physicians who changed from FFS to MC to reduce their volume of (billable) services by 6.15% and to reduce their hours of work spent on seeing patients by 2.57%. Their average time spent per service increased by 3.81%, suggesting a potential quality-quantity substitution. Also the reform induced these physicians to increase their time spent on teaching and administrative duties (tasks not remunerated under the fee-for-service system) by 7.9%. En 1999, le ministère de la Santé et des Services Sociaux du Québec introduisait un mode de rémunération mixte optionnel pour rémunérer l’activité hospitalière des médecins spécialistes. Ce mode combine une rémunération forfaitaire pour chaque jour de travail (per diem ou demi per diem) et une rémunération partielle à l’acte s’exprimant en un pourcentage du tarif habituellement applicable pour un service donné. Cette étude jumelle en panel des données de sondage du Collège des Médecins du Québec et des données administratives de la Régie de l’assurance maladie du Québec pour évaluer l’impact de ce mode de rémunération sur les choix de pratique des spécialistes. Nous mettons l’accent sur l’effet de la rémunération mixte sur plusieurs dimensions du comportement professionnel du médecin : heures consacrées aux patients, heures consacrées à l’enseignement, aux activités médicales administratives et à la recherche, volume de services médicaux et temps moyen par service médical. Nos résultats montrent que l’introduction de la rémunération mixte a incité les médecins qui sont passés de la rémunération à l’acte à la rémunération mixte à réduire leur nombre de services médicaux (facturables) de 6,15 % et à réduire leurs heures de travail consacrées aux patients de 2,57 %. En revanche, le temps moyen par service médical s’est accru de 3,81 %, ce qui peut suggérer une substitution entre la quantité et la qualité des services. La réforme a aussi incité ces médecins à accroître le temps consacré à l’enseignement et aux activités médicales administratives (activités non rémunérées par la rémunération à l’acte) de 7,9 %. En outre, le temps consacré par ces médecins à la recherche (activité non rémunérée par l’un ou l’autre des modes de rémunération) a diminué de 14,7 %. Enfin, le revenu des médecins qui sont passés à la rémunération mixte s’est accru de 8,05 %, indiquant qu’il était financièrement rentable pour ceux-ci de choisir ce mode de rémunération.physician payment mechanisms, multitasking, mixed-payment systems, incentive contracts, labour supply, self-selection, panel estimation., mécanismes de rémunération des médecins, fonctionnement multitâche, rémunération mixte, contrats incitatifs, offre de travail, auto-sélection, estimation en panel

Monthly oral ibandronate is well tolerated and efficacious in postmenopausal women: Results from the monthly oral pilot study

Context: Ibandronate, a potent, nitrogen-containing bisphosphonate developed for intermittent administration in postmenopausal osteoporosis, aims to overcome current adherence issues with daily and weekly oral bisphosphonates through once-monthly oral dosing. Objective: The purpose of this study was to investigate the safety, pharmacodynamics, and pharmacokinetics of once-monthly oral ibandronate. Design: A randomized, 3-month, double-blind, placebo-controlled, phase I study (Monthly Oral Pilot Study) was conducted. Setting: The study was conducted at five clinical trial centers in the United Kingdom and Belgium. Patients or Other Participants: Subjects were postmenopausal women (age, 55 - 80 yr; >= 3 yr post menopause; n = 144). Intervention(s): Once-monthly oral ibandronate 50, 100, or 150 mg or placebo was used. After the first cycle, the 50-mg arm was split, with participants continuing on either 50 or 100 mg. Main Outcome Measure(s): Primary outcome measures were safety, serum and urinary C-telopeptide (CTX), and serum ibandronate AUC(0-infinity). Results: Once- monthly oral ibandronate was well tolerated, with a similar overall and upper gastrointestinal safety profile to placebo. Once- monthly ibandronate was also highly effective in decreasing bone turnover; substantial reductions from baseline in serum CTX (-56.7% and -40.7% in the 150- and 100- mg arms, respectively; P < 0.001 vs. placebo) and urinary CTX (-54.1% and -34.6%, respectively; P < 0.001 vs. placebo) were observed at d 91 (30 d after the final dose). Analysis of the area under the effect curve (d1 - 91) for change from baseline (percent x days) in serum CTX and urinary CTX indicated a dose- response relationship. The AUC(0-infinity) for ibandronate increased with dose but not in a dose- proportional manner. Conclusions: These findings indicate a potential role for once-monthly oral ibandronate in the treatment of postmenopausal osteoporosis

CALLISTO, a demonstrator for reusable launchers

Japan and Europe are now getting ready for the maiden flight of their new workhorse launch vehicles: H-3, Vega-C and Ariane 6. But continued improvements, especially in term of costs, are necessary to continue to offer an affordable access to space. To prepare this next step, three countries and their space organizations: CNES for France, DLR for Germany and JAXA for Japan have developed the CALLISTO system as a joint project. This include the CALLISTO vehicle which is a flight demonstrator for future reusable launcher stages. The challenge is to develop, all along the project, the skills of the partners. This know-how includes products and vehicle design, ground segment set up, and post-flight operations for vehicle recovery then reuse. The first tests will be conducted in 2024 from the CSG, Europe's Spaceport for commercial launches, and this paper presents an overview of the status of the CALLISTO project. General development status is described. Next step of the development will be the Critical Design Review

Soil to Sail - Asteroid Landers on Near-Term Sailcraft as an Evolution of the GOSSAMER Small Spacecraft Solar Sail Concept for In-Situ Characterization

Any effort which intends to physically interact with specific asteroids requires understanding at least of the composition and multi-scale structure of the surface layers, sometimes also of the interior. Therefore, it is necessary first to characterize each target object sufficiently by a precursor mission to design the mission which then interacts with the object. In small solar system body (SSSB) science missions, this trend towards landing and sample-return missions is most apparent. It also has led to much interest in MASCOT-like landing modules and instrument carriers. They integrate at the instrument level to their mothership and by their size are compatible even with small interplanetary missions. The DLR-ESTEC GOSSAMER Roadmap NEA Science Working Groups‘ studies identified Multiple NEA Rendezvous (MNR) as one of the space science missions only feasible with solar sail propulsion. The parallel Solar Polar Orbiter (SPO) study showed the ability to access any inclination and a wide range of heliocentric distances. It used a separable payload module conducting the SPO mission after delivery by sail to the proper orbit. The Displaced L1 (DL1), spaceweather early warning mission study, outlined a very lightweight sailcraft operating close to Earth, where all objects of interest to planetary defence must pass. These and many other studies outline the unique capability of solar sails to provide access to all SSSB, at least within the orbit of Jupiter. Since the original MNR study, significant progress has been made to explore the performance envelope of near-term solar sails for multiple NEA rendezvous. However, although it is comparatively easy for solar sails to reach and rendezvous with objects in any inclination and in the complete range of semi-major axis and eccentricity relevant to NEOs and PHOs, it remains notoriously difficult for sailcraft to interact physically with a SSSB target object as e.g. the HAYABUSA missions do. The German Aerospace Center, DLR, recently brought the GOSSAMER solar sail deployment technology to qualification status in the GOSSAMER-1 project and continues the development of closely related technologies for very large deployable membrane-based photovoltaic arrays in the GOSOLAR project, on which we report separately. We expand the philosophy of the GOSSAMER solar sail concept of efficient multiple sub-spacecraft integration to also include landers for one-way in-situ investigations and sample-return missions. These are equally useful for planetary defence scenarios, SSSB science and NEO utilization. We outline the technological concept used to complete such missions and the synergetic integration and operation of sail and lander. We similarly extend the philosophy of MASCOT and use its characteristic features as well as the concept of Constraints-Driven Engineering for a wider range of operations. For example, the MASCOT Mobility hopping mechanism has already been adapted to the specific needs of MASCOT2. Utilizing sensors as well as predictions, those actuators could in a further development be used to implement anti-bouncing control schemes, by counteracting with the lander‘s rotation. Furthermore by introducing sudden jerk into the lander by utilization of the mobility, layers of loose regolith can be swirled up for sampling

Aerothermal characterization of the CALLISTO vehicle during descent

Aerothermal loads are a design driving factor during launcher development as the thermal loads directly in- fluence TPS design and trajectory. Recent developments in reusable launch vehicles (RLV) (e.g. SpaceX, Blue Origin) have added the dimension of refurbishment to the challenges the thermal design must con- sider. For disposable launchers the heat flux due to base heating during ascent needs to be considered for aft thermal protections system (TPS) and structural design. With the current European long term strategy[1] moving towards a reusable first stage - aerothermal loads may significantly change. The CAL- LISTO vehicle is a flight demonstrator for future reusable launcher stages and their technologies. The program involves three countries and their space organizations: CNES for France, DLR for Germany and JAXA for Japan. The first tests will be conducted in 2024 from CSG, Europe’s Spaceport. The challenge is to develop, all along the project, the skills of the partners. This know-how includes products and vehicle design, ground segment set up, and post-flight operations for vehicle recovery then reuse [2–5]. For the CALLISTO vehicle the highest heat fluxes are mainly due to heating from hot exhaust gases and heated air in proximity of the aft bay and on the exposed structures like legs and fins. The development of the plume extension is different for the considered re-entry, when compared to Falcon 9, or the studies presented in [6–8]. As shown by Dumont et al.[9] the plume remains relatively concentrated at the aft end of the vehi- cle due to high atmospheric pressure and only very low fractions of actual exhaust gas species enclosing the vehicle. In the current study we conducted computational fluid dynamics (CFD) studies in order to determine the aerothermal loads on the vehicle during descent through the landing approach corridor for both phase B and phase C aeroshapes. The database development for vehicle phase B and phase C are described in detail and analyzed for some of the most prominent interfaces. The final phase C database presented allows interpolation of interface heatfluxes for the entire flight domain (M, ρ) at varying angle of attack (between 180 deg and 160 deg). Further the sensitivity of the plume-vehicle interaction to angle of attack, chemistry, thrust vector deflection and engine throttling are investigated for a critical Mach number indicating further area of improvement for future databases

Aerothermal analysis of plume interaction with deployed landing legs of the CALLISTO vehicle

The current European long term strategy aims at moving towards reusable launch vehicles (RLV) for the first stages of launchers. In accordance with this strategy the German Aerospace Center (DLR) has entered into a collaboration with the Japan Aerospace Exploration Agency (JAXA) and the French Space Agency (CNES) for the development of RLV relevant technologies. A part of this collaboration is a vertical take off and vertical landing (VTVL) reusable subscale launcher first stage demonstrator - the Cooperative Action Leading to Launcher Innovation in Stage Toss back Operations (CALLISTO). The mission of the CALLISTO vehicle is to return to the launch pad using retro propulsion and an Approach and Landing System (ALS) with extendable landing legs. This development leads to additional aerothermal design questions compared to traditional launchers. In the case of CALLISTO the highest heat fluxes are caused by heating from hot exhaust gases of the aft bay section. This especially affects the unfolded ALS during the final phase of the landing approach. The arising heat fluxes, therefore, influence the structural design and the thermal protection system (TPS) of the ALS. In this study we conduct computational fluid dynamics (CFD) investigations using Reynolds averaged Navier Stokes (RANS) methods of the aerothermal loads on the ALS during the landing phase. We use the Spalart-Allmaras turbulence model and frozen chemistry for the simulations. We analyse the flow field as well as the surface distributions. We investigate the necessity of simulations including the plume for these analyses. We use analyses of the flow fields as well as the surface distributions to investigate the influence of angle of attack, angle of roll, atmospheric conditions, flight speed and thrust level