San Diego: Major Providers Pursue Countywide Networks and New Patient Care Models

San Diego has long been a geographically well-defined health care market with high managed care penetration and a consolidated provider sector. In recent years, hospital systems have faced increasing cost pressures as commercial health plans have responded to employer demands for more affordable premiums. Safety-net providers expanded capacity to deal with the large Medi-Cal expansion that began in 2014, but continue to grapple with how to provide adequate care for a new enrollee population that is far sicker, with more complex medical and social service needs, than the providers' previous patient base.Key developments include:While the hospital market remained largely stable in recent years, most of the smaller hospitals have been losing volume and struggling financially.Major systems are pursuing population health strategies and increasingly using provider-sponsored health plans to take full risk for more patients.The challenges of independent practice are leading many primary care physicians to choose employment at system-affiliated groups.In the two years since Medicaid eligibility was first expanded under the ACA, San Diego's Medi-Cal managed care enrollment almost doubled to 700,000. Many Medi-Cal enrollees without a regular primary care provider sought care at hospital emergency departments, and access gaps for many kinds of specialty care and behavioral health care were even more severe.San Diego County's commitment to providing health care for low-income residents continues to be limited, although the county Health and Human Services Agency has become more active in fostering collaborations between health and other social services

Niche differentiation in nitrogen metabolism among methanotrophs within an operational taxonomic unit

Background: The currently accepted thesis on nitrogenous fertilizer additions on methane oxidation activity assumes niche partitioning among methanotrophic species, with activity responses to changes in nitrogen content being dependent on the in situ methanotrophic community structure Unfortunately, widely applied tools for microbial community assessment only have a limited phylogenetic resolution mostly restricted to genus level diversity, and not to species level as often mistakenly assumed. As a consequence, intragenus or intraspecies metabolic versatility in nitrogen metabolism was never evaluated nor considered among methanotrophic bacteria as a source of differential responses of methane oxidation to nitrogen amendments. Results: We demonstrated that fourteen genotypically different Methylomonas strains, thus distinct below the level at which most techniques assign operational taxonomic units (OTU), show a versatile physiology in their nitrogen metabolism. Differential responses, even among strains with identical 16S rRNA or pmoA gene sequences, were observed for production of nitrite and nitrous oxide from nitrate or ammonium, nitrogen fixation and tolerance to high levels of ammonium, nitrate, and hydroxylamine. Overall, reduction of nitrate to nitrite, nitrogen fixation, higher tolerance to ammonium than nitrate and tolerance and assimilation of nitrite were general features. Conclusions: Differential responses among closely related methanotrophic strains to overcome inhibition and toxicity from high nitrogen loads and assimilation of various nitrogen sources yield competitive fitness advantages to individual methane-oxidizing bacteria. Our observations proved that community structure at the deepest phylogenetic resolution potentially influences in situ functioning

Healthcare Price Transparency: Policy Approaches and Estimated Impacts on Spending

Healthcare price transparency discussions typically focus on increasing patients' access to information about their out-of-pocket costs, but that focus is too narrow and should include other audiences -- physicians, employers, health plans and policymakers -- each with distinct needs and uses for healthcare price information. Greater price transparency can reduce U.S. healthcare spending.For example, an estimated $100 billion could be saved over the next 10 years if three select interventions were undertaken. However, most of the projected savings come from making price information available to employers and physicians, according to an analysis by researchers at the former Center for Studying Health System Change (HSC). Based on the current availability and modest impact of plan-based transparency tools, requiring all private plans to provide personalized out-of-pocket price data to enrollees would reduce total health spending by an estimated$18 billion over the next decade. While $18 billion is a substantial dollar amount, it is less than a tenth of a percent of the$40 trillionin total projected health spending over the same period. In contrast, using state all-payer claims databases to gather and report hospital-specific prices might reduce spending by an estimated $61 billion over 10 years.The effects of price transparency depend critically on the intended audience, the decision-making context and how prices are presented. And the impact of price transparency can be greatly amplified if target audiences are able and motivated to act on the information. Simply providing prices is insufficient to control spending without other shifts in healthcare financing, including changes in benefit design to make patients more sensitive to price differences among providers and alternative treatments. Other reforms that can amplify the impact of price transparency include shifting from fee-for-service payments that reward providers for volume to payment methods that put providers at risk for spending for episodes of care or defined patient populations. While price transparency alone seems unlikely to transform the healthcare system, it can play a needed role in enabling effective reforms in value-based benefit design and provider payment

Genetic Normalization of Differentiating Aneuploid Human Embryos

Early embryogenesis involves a series of dynamic processes, many of which are currently not well described or understood. Aneuploidy and aneuploid mosaicism, a mixture of aneuploid and euploid cells within one embryo, in early embryonic development are principal causes of developmental failure.^1,2^ Here we show that human embryos demonstrate a significant rate of genetic correction of aneuploidy, or "genetic normalization" when cultured from the cleavage stage on day 3 (Cleavage) to the blastocyst stage on day 5 (Blastocyst) using routine in vitro fertilization (IVF) laboratory conditions. One hundred and twenty-six human Cleavage stage embryos were evaluated for clinically indicated preimplantation genetic screening (PGS). Sixty-four of these embryos were found to be aneuploid following Cleavage stage embryo biopsy and single nucleotide polymorphism (SNP) 23 chromosome molecular karyotype (microarray). Of these, 25 survived to the Blastocyst stage of development and repeat microarray evaluation was performed. The inner cell mass (ICM), containing cells destined to form the fetus, and the trophectoderm (TE), containing cells destined to form the placenta were evaluated. Sixteen of 25 embryos (64%) [95% CI: 44-80%] possessed diploid karyotypes in both the ICM and TE cell populations. An additional three Blastocyst stage embryos showed genetic correction of the TE but not the ICM and one Blastocyst stage embryo showed the reverse. Mosaicism (exceeding 5%), was not detected in any of the ICM and TE samples analyzed. Recognizing that genetic normalization may occur in developing human embryos has important implications for stem cell biology, preimplantation and developmental genetics, embryology, and reproductive medicine. 

1)Hassold, T. et al. A cytogenetic study of 1000 spontaneous abortions. Ann Hum Genet. 44, 151-78 (1980).
2)Menasha, J., Levy, B., Hirschhorn, K., & Kardon, N.B. Incidence and spectrum of chromosome abnormalities in spontaneous abortions: new insights from a 12-year study. Genet Med. 7, 251-63 (2005)

Short shots and industrial case studies: Understanding fluid flow and solidification in high pressure die casting

AbstractThe geometric complexity and high fluid speeds involved in high pressure die casting (HPDC) combine to give strongly three dimensional fluid flow with significant free surface fragmentation and splashing. A simulation method that has proved particularly suited to modelling HPDC is Smoothed Particle Hydrodynamics (SPH). Materials are approximated by particles that are free to move around rather than by fixed grids, enabling more accurate prediction of fluid flows involving complex free surface motion. Three practical industrial case studies of SPH simulated HPDC flows are presented; aluminium casting of a differential cover (automotive), an electronic housing and zinc casting of a door lock plate. These show significant detail in the fragmented fluid free surfaces and allow us to understand the predisposition to create defects such as porosity in the castings. The validation of flow predictions coupled with heat transfer and solidification is an important area for such modelling. One powerful approach is to use short shots, where insufficient metal is used in the casting or the casting shot is halted part way through, to leave the die cavity only partially filled. The frozen partial castings capture significant detail about the order of fill and the flow structures occurring during different stages of filling. Validation can occur by matching experimental and simulated short shots. Here we explore the effect of die temperature, metal super-heat and volume fill on the short shots for the casting of a simple coaster. The bulk features of the final solid castings are found to be in good agreement with the predictions, but the fine details appear to depend on surface behaviour of the solidifying metals. This potentially has significant implications for modelling HPDC

Microwave Frequency Polarizers

This article describes the fabrication and analysis of microwave frequency polarizing grids. The grids are designed to measure polarization from the cosmic microwave background. It is effective in the range of 500 to 1500 micron wavelength. It is cryogenic compatible and highly robust to high load impacts. Each grid is fabricated using an array of different assembly processes which vary in the types of tension mechanisms to the shape and size of the grids. We provide a comprehensive study on the analysis of the grids' wire heights, diameters, and spacing