Accountable Care Organizations and Transaction Cost Economics

Using a Transaction Cost Economics (TCE) approach, this paper explores which organizational forms Accountable Care Organizations (ACOs) may take. A critical question about form is the amount of vertical integration that an ACO may have, a topic central to TCE. We posit that contextual factors outside and inside an ACO will produce variable transaction costs (the non-production costs of care) such that the decision to integrate vertically will derive from a comparison of these external versus internal costs, assuming reasonably rational management abilities. External costs include those arising from environmental uncertainty and complexity, small numbers bargaining, asset specificity, frequency of exchanges, and information impactedness. Internal costs include those arising from human resource activities including hiring and staffing, training, evaluating (i.e., disciplining, appraising, or promoting), and otherwise administering programs. At the extreme, these different costs may produce either total vertical integration or little to no vertical integration with most ACOs falling in between. This essay demonstrates how TCE can be applied to the ACO organization form issue, explains TCE, considers ACO activity from the TCE perspective, and reflects on research directions that may inform TCE and facilitate ACO development

Clustered and Distinct: A Taxonomy of Local Multihospital Systems

Despite their prevalence and power in markets throughout the United States, local multihospital systems (LMSs)—also referred to as hospital-based “clusters”—remain an understudied organizational form, with studies instead primarily focusing either upon individual hospitals or viewing hospital systems collectively without distinguishing the local “sub-systems” that comprise larger regional or national hospital chains. To better understand these organizational forms, we develop a taxonomy specifically devoted to LMSs, applying taxonomic analysis methods to a sample of LMSs in six U.S. states while accounting for LMSs’ geographic arrangements and non-hospital-based service locations. Our analysis identifies five distinct LMS categories, with forms clearly distinguished according to their varying degrees of differentiation and integration. The study’s results accentuate the importance of accounting for hospital systems’ activities and arrangements in local markets—including their non-hospital-based sites—and highlight differences in systems’ achievement of integration and coordination across services and locations, providing considerations in light of U.S. health system reform as well as international patterns of regional system formation

Whooping crane use of riverine stopover sites

Migratory birds like endangered whooping cranes (Grus americana) require suitable nocturnal roost sites during twice annual migrations. Whooping cranes primarily roost in shallow surface water wetlands, ponds, and rivers. All these features have been greatly impacted by human activities, which present threats to the continued recovery of the species. A portion of one such river, the central Platte River, has been identified as critical habitat for the survival of the endangered whooping crane. Management intervention is now underway to rehabilitate habitat form and function on the central Platte River to increase use and thereby contribute to the survival of whooping cranes. The goal of our analyses was to develop habitat selection models that could be used to direct riverine habitat management activities (i.e., channel widening, tree removal, flow augmentation, etc.) along the central Platte River and throughout the species’ range. As such, we focused our analyses on two robust sets of whooping crane observations and habitat metrics the Platte River Recovery Implementation Program (Program or PRRIP) and other such organizations could influence. This included channel characteristics such as total channel width, the width of channel unobstructed by dense vegetation, and distance of forest from the edge of the channel and flow-related metrics like wetted width and unit discharge (flow volume per linear meter of wetted channel width) that could be influenced by flow augmentation or reductions during migration. We used 17 years of systematic monitoring data in a discrete-choice framework to evaluate the influence these various metrics have on the relative probability of whooping crane use and found the width of channel unobstructed by dense vegetation and distance to the nearest forest were the best predictors of whooping crane use. Secondly, we used telemetry data obtained from a sample of 38 birds of all ages over the course of seven years, 2010–2016, to evaluate whooping crane use of riverine habitat within the North-central Great Plains, USA. For this second analysis, we focused on the two metrics found to be important predictors of whooping crane use along the central Platte River, unobstructed channel width and distance to nearest forest or wooded area. Our findings indicate resource managers, such as the Program, have the potential to influence whooping crane use of the central Platte River through removal of in-channel vegetation to increase the unobstructed width of narrow channels and through removal of trees along the bank line to increase unforested corridor widths. Results of both analyses also indicated that increases in relative probability of use by whooping cranes did not appreciably increase with unobstructed views 200 m wide and unforested corridor widths that were 330 m. Therefore, managing riverine sites for channels widths \u3e200 m and removing trees beyond 165 m from the channel’s edge would increase costs associated with implementing management actions such as channel and bank-line disking, removing trees, augmenting flow, etc. without necessarily realizing an additional appreciable increase in use by migrating whooping cranes

Shared and distinct transcriptional programs underlie the hybrid nature of iNKT cells

Invariant natural killer T cells (iNKT cells) are innate-like T lymphocytes that act as critical regulators of the immune response. To better characterize this population, we profiled gene expression in iNKT cells during ontogeny and in peripheral subsets as part of the Immunological Genome Project. High-resolution comparative transcriptional analyses defined developmental and subset-specific programs of gene expression by iNKT cells. In addition, we found that iNKT cells shared an extensive transcriptional program with NK cells, similar in magnitude to that shared with major histocompatibility complex (MHC)-restricted T cells. Notably, the program shared by NK cells and iNKT cells also operated constitutively in γδ T cells and in adaptive T cells after activation. Together our findings highlight a core effector program regulated distinctly in innate and adaptive lymphocytes

The Science Performance of JWST as Characterized in Commissioning

This paper characterizes the actual science performance of the James Webb Space Telescope (JWST), as determined from the six month commissioning period. We summarize the performance of the spacecraft, telescope, science instruments, and ground system, with an emphasis on differences from pre-launch expectations. Commissioning has made clear that JWST is fully capable of achieving the discoveries for which it was built. Moreover, almost across the board, the science performance of JWST is better than expected; in most cases, JWST will go deeper faster than expected. The telescope and instrument suite have demonstrated the sensitivity, stability, image quality, and spectral range that are necessary to transform our understanding of the cosmos through observations spanning from near-earth asteroids to the most distant galaxies.Comment: 5th version as accepted to PASP; 31 pages, 18 figures; https://iopscience.iop.org/article/10.1088/1538-3873/acb29

Selectivity and Mechanism of Hydrogen Atom Transfer by an Isolable Imidoiron(III) Complex

This article discusses a mechanistic study of hydrogen atom transfer by an isolable iron (III) imido complex, LᴹᵉFeNAd (Lᴹᵉ = bulky β-diketiminate ligand, 2,4-bis(2,6-diisopropylphenylimido)pentyl; Ad = 1-adamantyl)

Onward and Upward: The Importance of Organization Theory in Health Administration Education

Is organization theory of significant relevance or value for students of health administration? And if so, is organization theory taken for granted in health administration education today? Looking upon my own experiences as a health administration student, practitioner, and educator, I believe now that, as a graduate student pursuing my master’s degree in healthcare administration over 10 years ago, I took the subject of organization theory for granted. It was only later in my doctoral studies as I reflected upon my experiences in healthcare administration that I began to gain a genuine appreciation for organization theory. For that, I owe many thanks to a handful of exemplary professors and colleagues who stoked a fiery interest in the subject. In particular, Dr. Stephen Mick’s influence was considerable, and as this special issue of the Journal of Health Administration Education recognizes his legacy throughout the field, I offer this commentary to briefly share his influence in my career, to note his many contributions to healthcare organization theory, and to appeal for a continued emphasis of the importance of organization theory in health administration education

Organizational and Environmental Factors Associated with Local Multihospital Systems: Precipitants for Coordination?

Background: Local multihospital systems (LMSs) commonly struggle to effectively coordinate across system members. Although a recent taxonomy of LMSs found the majority of systems to display lower levels of differentiation, integration, and coordination, some categories of LMS forms exhibited higher levels of integration and coordination. Purpose: This study examines organizational and environmental factors associated with LMS forms displaying higher levels of integration and coordination. Methodology/approach: Applying a multitheoretical framework and drawing from sources including the American Hospital Association Annual Survey, Intellimed databases, and primary data collected from LMS communications, descriptive and multinomial logistic regression analyses were conducted to examine the association between LMS forms and varied organizational and environmental characteristics among LMSs in Florida, Maryland, Nevada, Texas, Virginia, and Washington. Results: The results of analysis of variance, Games-Howell, and Fisher\u27s exact tests identified significant relationships between each of the five LMS categories and varying market, competitive, organizational, and operational factors. A multinomial logistic regression analysis also distinguished the three most common LMS forms according to organizational and environmental factors. Conclusion: Recognizing the varied degrees of integration and coordination across LMSs today, the results point to several factors that may explain such variation, including market size and resources, local competitors and their forms, organizational size and ownership, patient complexity, and regulatory restrictions. Practice implications: With the continued promotion and development of innovative health care reform models and with the progressing expansion of care into outpatient sites and diverse settings, LMSs will continue to face greater pressure to integrate and coordinate services throughout the continuum of care across system components and service locations. Navigating the challenges of effective coordination requires administrators and policymakers to be cognizant of the organizational and environmental factors that may hinder or fuel coordination efforts across system components in local markets