Balancing influence between actors in healthcare decision making

<p>Abstract</p> <p>Background</p> <p>Healthcare costs in most developed countries are not clearly linked to better patient and public health outcomes, but are rather associated with service delivery orientation. In the U.S. this has resulted in large variation in healthcare availability and use, increased cost, reduced employer participation in health insurance programs, and reduced overall population health outcomes. Recent U.S. healthcare reform legislation addresses only some of these issues. Other countries face similar healthcare issues.</p> <p>Discussion</p> <p>A major goal of healthcare is to enhance patient health outcomes. This objective is not realized in many countries because incentives and structures are currently not aligned for maximizing population health. The misalignment occurs because of the competing interests between "actors" in healthcare. In a simplified model these are individuals motivated to enhance their own health; enterprises (including a mix of nonprofit, for profit and government providers, payers, and suppliers, etc.) motivated by profit, political, organizational and other forces; and government which often acts in the conflicting roles of a healthcare payer and provider in addition to its role as the representative and protector of the people. An imbalance exists between the actors, due to the resources and information control of the enterprise and government actors relative to the individual and the public. Failure to use effective preventive interventions is perhaps the best example of the misalignment of incentives. We consider the current Pareto efficient balance between the actors in relation to the Pareto frontier, and show that a significant change in the healthcare market requires major changes in the utilities of the enterprise and government actors.</p> <p>Summary</p> <p>A variety of actions are necessary for maximizing population health within the constraints of available resources and the current balance between the actors. These actions include improved transparency of all aspects of medical decision making, greater involvement of patients in shared medical decision making, greater oversight of guideline development and coverage decisions, limitations on direct to consumer advertising, and the need for an enhanced role of the government as the public advocate.</p

The timing of gold mineralization across the eastern Yilgarn craton using U–Pb geochronology of hydrothermal phosphate minerals

The highly mineralized Eastern Goldfields of the eastern Yilgarn craton is an amalgamation of dominantly Neoarchaean granitoid-greenstone terranes and domains that record a history of early rifting, followed by westward directed collision with initial arc formation, collision and clastic basin formation, and final accretion to the western Yilgarn proto-craton between 2.66 and 2.60 billion years ago. The gold deposits that define this region as a world-class gold province are the product of orogenic processes that operated during accretion late in the tectonic history, after initial compressional deformation (D1–D2) and the majority of granitoid magmatism. Minor gold was also deposited throughout the entire tectonic history in magmatic-hydrothermal-related systems. However, such mineralization (mostly < 0.3 g/t gold) is nowhere economic unless it overprints, or is overprinted by, much higher-grade orogenic gold lodes.Robust SHRIMP U–Pb geochronology of gold-related hydrothermal xenotime and monazite supports structural studies that gold mineralization occurred during late transpressional events (D3–D4), shortly before cratonization. However, westward migration of collision and accretion produced a complementary diachroneity in the timing of gold mineralization of 5 to 20 m.y. between c. 2.65 Ma in the east (including Laverton District, Kurnalpi Terrane) to c. 2.63 Ma in the west (including Kalgoorlie Terrane) across the eastern part of the craton. The robust geochronology refutes previous suggestions that significant gold mineralization events extended from DE to D4 in the evolution of the orogen and that the Kalgoorlie gold deposits formed over a period of 45 m.y. The crustal continuum model is applicable within terranes where orogenic gold depositional events were penecontemporaneous, but must be modified to account for diachroneity of orogenic events and gold mineralization across the Eastern Goldfields

Neoarchean orogenic, magmatic and hydrothermal events in the Kalgoorlie-Kambalda area, Western Australia: constraints on gold mineralization in the Boulder Lefroy-Golden Mile fault system

The Boulder Lefroy-Golden Mile (BLF-GMF) fault system is the most intensely mineralized structure (>2150 t Au to 2015) in the Archean Yilgarn Craton, Western Australia. The fault system links the Kalgoorlie and Kambalda mining districts in the Eastern Goldfields Province, a continental-margin orogen subdivided into the western Kalgoorlie ensialic rift and the eastern Kurnalpi volcanic arc. After rifting, the 2.73–2.66 Ga greenstone-greywacke succession in the Kalgoorlie-Kambalda area underwent five phases of orogenic deformation, predominantly during ENE-WSW shortening: D1 upright folding at ca. 2680 Ma, D2 sinistral strike-slip faulting at 2678–2663 Ma, D3 folding of late conglomerate-turbidite successions at 2665–2655 Ma, D4 dextral strike-slip faulting at 2655–2640 Ma and D5 east-northeast-striking normal faulting. Regional prehnite-pumpellyite to greenschist facies burial metamorphism took place during D1 and D3 crustal thickening, and amphibolite facies aureoles formed around granite batholiths during and after D3 at 400 ± 100 MPa pressure. The D2 BLF offsets D1 folds by 12 km SW-side south and contains a porphyry dyke (2676 ± 7 Ma) boudinaged by transtensional oblique-slip along a line pitching 21° southeast. The BLF is linked by transverse D2 thrusts to other sinistral faults recording strike-slip until 2663 ± 7 Ma. Late D2 strike-slip movement alternated with early D3 shortening. D3 thrusts accommodated strain in fault blocks of rigid mafic-ultramafic volcanic rocks consolidated during D1, while the sedimentary rocks in D3 synclines were foliated at high strain.Biotite-sericite alteration and gold-pyrite mineralization in the BLF-GMF system took place at 11 ± 4 km burial depth in faults active during D2 and D3. The Golden Mile (1708 t Au) and other deposits are associated with stocks and dykes of high-Mg monzodiorite-tonalite porphyry, part of a late-orogenic (2665–2645 Ma) mantle-derived suite of adakitic affinity. Hornblende and apatite compositions indicate that these intrusions are characterized by high water contents (5–6 wt% H2O in melt), by high oxidation states (dNNO +1.0 to +2.4 log units) and by igneous anhydrite. Some stocks contain pervasive anhydrite-pyrite mineralization of low gold grade (0.4 g/t). Biotite-sericite-pyrite ore bodies such as those at Kanowna Belle (140 t Au) also replace faulted metamorphic rocks above batholith domes cored by plutons of the monzodiorite suite. The D4 strike-slip faults are barren at Kambalda but control gold quartz-vein ore at Kalgoorlie (2651 ± 9 Ma), and Au-Ag breccia ore at Black Flag (<2648 ± 6 Ma)