Consumer Financial Liabilities in the Health Care Setting: Three Comparative Case Studies

A recent Kaiser Family Foundation study found that consumer out-of-pocket health care expense increased 77% from 2004 to 2014 while wages only increased 32% over the same time period.1 This supports the prediction that the consumer cost of health care will only continue to increase over time. The larger question is who will be responsible for paying those rising costs, consumers, employers, payers or the government? An important question providers are asking is “Will I be able to collect payments that should be the consumer’s responsibility? Recently the cost shift has been directed at the consumer through increased co-insurance and deductibles.1 In 2012, consumer out-of-pocket (OOP) expenses were estimated at $320.2 billion dollars or just over 10% of total health care expenditures.2 It is unknown if this number will continue to grow or decline with the dynamic changes in health care. Historically collecting out-of-pocket consumer expenses (co-payments, co-insurance and deductibles) was not a top priority for providers, although payers required them to make a “good faith” effort. For providers the primary focus was on collecting third-party (payer) payments which represented the primary source of expected reimbursement. Providers, however, are recognizing that the financial landscape has shifted as their margins shrink and consumers become responsible for a significant portion of their expected reimbursement. This dissertation will review and compare three case studies with very similar interventions to test a proposed model for improving front-end collections (FEC) of out-of-pocket expenses. It will provide empirical results that can be disseminated throughout the field. It will also attempt to identify other factors that impact the success of front-end collection efforts. Many hospitals, health systems and physician practices have already started to prioritize front-end collections to enhance customer service and improve financial viability because of the market changes. Through the implementation of five primary performance improvement interventions, these case studies will provide insight into the following questions: • Did these interventions have a positive impact on front-end collections? • How much of an impact on front-end collections did all the interventions have collectively? • Did one intervention have more of an impact than another on front-end collections? • What factors were associated with successful interventions? The five interventions are focused on improving front-end collections (out-of-pocket consumer expenses) while educating consumers on their financial responsibility for health care. Results from all three case studies demonstrate that front-end collections were enhanced as a percent of net patient revenue as evaluated by reviewing the 12-month average for the baseline period compared to the intervention period. All three case studies experienced an increase in FEC when comparing the baseline to intervention periods. Net collections from baseline to intervention periods increased for all three case study organizations. Gloria Medical Center realized an increase of 43%, Fitzgerald Community Hospital realized the largest increase at 196% and Byrne Hospital achieved a 129% increase. All three organizations studied have experienced a growing consumer population covered by high-deductible health plans; these types of plans are rapidly becoming more of the norm for health insurance products selected by consumers. The major component of high-deductible health plans is as the name implies, higher deductibles which equates to additional out-of-pocket expenses for consumers and greater financial responsibility for their care

Crystal Structure of Azotobachter vinelandii Nitrogenase Iron Protein at 2.2 Å Resolution

Biological nitrogen fixation by the two-component metalloenzyme nitrogenase provides an elegant solution to the problem of reducing abundant, but relatively inert, dinitrogen to the biologically usable ammonia needed by all organisms. This oxygen sensitive enzyme, consisting of the separately purifiable nitrogenase iron protein and molybdenum iron protein, couples nucleotide hydrolysis to electron transfer to catalyze the ATP-dependent reaction. Iron protein acts as the sole known biological reductant to molybdenum iron protein, which contains the actual site of substrate reduction. MgATP binding to iron protein induces dramatic conformational changes in the protein's structure required for docking with molybdenum iron protein. Complex formation and dissociation are essential for nucleotide hydrolysis, electron transfer, and substrate reduction. We have determined the crystal structure of Azotobacter vinelandii nitrogenase iron protein at 2.2 Å resolution in the absence of nucleotide. Crystals grew in space group P212121, and represent a new crystal form compared with that of the structure previously determined at 2.9 Å resolution. X-ray diffraction data were collected from a single crystal using cryocrystallographic techniques. The structure was solved by molecular replacement, followed by solvent flattening and noncrystallographic averaging. The current model contains 575 of 578 possible amino acid residues and 372 solvent molecules, and has been refined to R-value of 22.3 % (R-free = 29.0 %) for all data to 2.2 Å, with good stereochemistry. The overall topology of nitrogenase iron protein consists of an Fe4S4 cluster symmetrically ligated by two identical subunits of doubly wound α/β structure similar to those of other nucleotide binding proteins. A detailed description is provided of those structural features important for iron protein function, including nucleotide binding regions, the Fe4S4 cluster environment, intersubunit interactions, and the molybdenum iron protein binding surface. Comparisons are made between the current model and that of C. pasteurianum iron protein, as well as those of two A. vinelandii nitrogenase complexes. Analysis of the various iron protein structures provides a framework for considering the wealth of relevant nitrogenase spectroscopic, biochemical, and genetic information.</p

Incidence, correlates, and origins of dioecy in the Island Flora of New Caledonia

Premise of research. Because it is an inherently risky sexual system, dioecy is globally rare. Attempts to explain unusually high incidences of dioecy on certain islands have generated a considerable literature on the relationships among dioecy, its ecological correlates, establishment after transoceanic dispersal, and postdispersal speciation. Nevertheless, few studies of dioecy on islands have included considerations of the origins and maintenance of dioecy on islands along with determinations of its incidence. Methodology. We used the literature, herbarium specimens, and fieldwork to determine the incidence of dioecy in the native angiosperm flora of New Caledonia. We inferred the number and characteristics of colonists needed to account for the extant dioecious flora. We made traditional species-based numerical assessments of associations between dioecy on New Caledonia and woodiness, plain flowers, fleshy fruit, habitat, and endemism, and we constructed a phylogenetic tree for New Caledonia's native angiosperms to investigate correlated evolution of dioecy and those associated traits. Pivotal results. This study is the first comprehensive survey of sexual systems for the flora of New Caledonia. One-fifth of New Caledonia's native angiosperms are dioecious. Dioecy is numerically overrepresented among species that are woody, have plain flowers, have fleshy fruit, occur in rainforest, or are endemic. However, we found strong evidence for correlated evolution only for dioecy and woodiness, plain flowers, and fleshy fruit. Dioecious groups with more of the widely accepted morphological correlates of dioecy tend to be more speciose. Approximately 90% of the colonists that gave rise to the extant dioecious flora were themselves dioecious. Approximately 60% of the colonists have two or more dioecious descendants, and those descendants comprise more than 90% of the extant dioecious species. Conclusions. Successful dispersal and establishment of already dioecious colonists and autochthonous speciation of dioecious lineages are primarily responsible for the high incidence of dioecy on New Caledonia. There were relatively few postdispersal transitions to dioecy. The associations of dioecy with woodiness, plain flowers, and fleshy fruit result from correlated evolution that occurred prior to dispersal to New Caledonia, while the associations of dioecy with rainforest habitat and endemism appear to result from autochthonous speciation of dioecious lineages. With similar to similar to 4% of the world's dioecious species occurring only there, New Caledonia should be a rich source of new information on the evolutionary ecology of dioecy. Realization of this potential will require both further study and concerted efforts to preserve the native flora

On the Effectiveness of Image Manipulation Detection in the Age of Social Media

Image manipulation detection algorithms designed to identify local anomalies often rely on the manipulated regions being ``sufficiently'' different from the rest of the non-tampered regions in the image. However, such anomalies might not be easily identifiable in high-quality manipulations, and their use is often based on the assumption that certain image phenomena are associated with the use of specific editing tools. This makes the task of manipulation detection hard in and of itself, with state-of-the-art detectors only being able to detect a limited number of manipulation types. More importantly, in cases where the anomaly assumption does not hold, the detection of false positives in otherwise non-manipulated images becomes a serious problem. To understand the current state of manipulation detection, we present an in-depth analysis of deep learning-based and learning-free methods, assessing their performance on different benchmark datasets containing tampered and non-tampered samples. We provide a comprehensive study of their suitability for detecting different manipulations as well as their robustness when presented with non-tampered data. Furthermore, we propose a novel deep learning-based pre-processing technique that accentuates the anomalies present in manipulated regions to make them more identifiable by a variety of manipulation detection methods. To this end, we introduce an anomaly enhancement loss that, when used with a residual architecture, improves the performance of different detection algorithms with a minimal introduction of false positives on the non-manipulated data. Lastly, we introduce an open-source manipulation detection toolkit comprising a number of standard detection algorithms

Model for eukaryotic tail-anchored protein binding based on the structure of Get3

The Get3 ATPase directs the delivery of tail-anchored (TA) proteins to the endoplasmic reticulum (ER). TA-proteins are characterized by having a single transmembrane helix (TM) at their extreme C terminus and include many essential proteins, such as SNAREs, apoptosis factors, and protein translocation components. These proteins cannot follow the SRP-dependent co-translational pathway that typifies most integral membrane proteins; instead, post-translationally, these proteins are recognized and bound by Get3 then delivered to the ER in the ATP dependent Get pathway. To elucidate a molecular mechanism for TA protein binding by Get3 we have determined three crystal structures in apo and ADP forms from Saccharomyces cerevisae (ScGet3-apo) and Aspergillus fumigatus (AfGet3-apo and AfGet3-ADP). Using structural information, we generated mutants to confirm important interfaces and essential residues. These results point to a model of how Get3 couples ATP hydrolysis to the binding and release of TA-proteins