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

Asynchronous variation in the Quaternary East Asian winter monsoon associated with the tropical Pacific ENSO‐like system

Quaternary East Asian winter monsoon (EAWM) evolution has long been attributed to high-latitude Northern Hemisphere climate change. However, it cannot explain the distinct relationships of the EAWM in the northern and southern East Asian marginal sea in paleoclimatic records. Here we present an EAWM record of the northern East China Sea over the past 300 ka and a transient climate simulation with the Kiel Climate Model through the Holocene. Both proxy record and simulation suggest anticorrelated long-term EAWM evolution between the northern East China Sea and the South China Sea. We suggest that this spatial discrepancy of EAWM can be interpreted as El Niño–Southern Oscillation (ENSO)-like controlling, which generates cyclonic/anticyclonic wind anomalies in the northern/southern East Asian marginal sea. This research explains much of the controversy in nonorbital scale variability of Quaternary EAWM records in the East Asian marginal sea and supports a potent role of tropical forcing in East Asian winter climate change

Retreat, Adapt, Defend - Urban Design Response to Sea Level Rise in 5 Coastal Georgia Communities

Information on this record corrected per JIRA ticket LDC-1043, 11/16/2021This studio is part of a Georgia Conservancy Blueprints initiative assessing impacts of climate change and sea level rise for Coastal Georgia. The studio was organized into five teams to address issues five cities: Savannah, Tybee Island, Brunswick, Darien and St. Marys. Student teams visited each city, meeting with local officials and leaders of non-profit organization who were involved in adapting to climate change.The Georgia Conservanc

Distinct control mechanism of fine-grained sediments from Yellow River and Kyushu supply in the northern Okinawa Trough since the last glacial

© 2017. American Geophysical Union. All Rights Reserved. High-resolution multiproxy records, including clay minerals and Sr-Nd-Pb isotopes of the clay-sized silicate fraction of sediments from IODP Site U1429 in the northern Okinawa Trough, provide reliable evidence for distinct control mechanism on fine-grained sediments input from the Yellow River and the southern Japanese Islands to the northern Okinawa Trough since 34 ka BP. Provenance analysis indicates that the sediments were mainly derived from the Yellow River and the island of Kyushu. Since the last glacial, clay-sized sediments transported from the Yellow River to the study site were strongly influenced by sea-level fluctuation. During low sea-level stage (∼34–14 ka BP), the paleo-Yellow River mouth was positioned closer to the northern Okinawa Trough, favoring large fluvial discharge or even direct input of detrital sediments, which resulted about four times more flux of clay-sized sediments supply to the study area as during the relatively high sea-level stage (∼14–0 ka BP). The input of Kyushu-derived clay-sized sediments to the study site was mainly controlled by the Kuroshio Current and Tsushima Warm Current intensity, with increased input in phase with weakened Kuroshio Current/Tsushima Warm Current. Our study suggests that the Kuroshio Current was very likely flowed into the Okinawa Trough and thus influenced the fine-grained sediment transport in the area throughout the last glacial and deglacial. During ∼34–11 ka BP, the Kyushu clay-sized sediment input was mainly controlled by the Kuroshio Current. Since ∼11 ka BP, the occurrence of Tsushima Warm Current became important in influencing the Kyushu fine-grained sediment input to the northern Okinawa Trough

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