Promoting Collaborative Care: Relative Performance-based Payment Models for Hospitals and Post-acute Care Providers

Diagnosis-Related Group (DRG) and bundled payment models are widely used in healthcare reimbursement by entities like the Centers for Medicare & Medicaid Services (CMS) and insurance companies. However, these models were primarily designed for conditions managed by a single healthcare provider in a centralized manner, often overlooking the complexities of cases requiring post-acute care (PAC) following an initial hospital stay. This can result in inadequate incentives for effective care coordination between hospitals and PAC providers, especially when treatment decisions are decentralized. Motivated by the Comprehensive Care for Joint Replacement (CJR) payment model recently introduced by CMS, which holds hospitals accountable for the quality and cost of the entire CJR episode, including the cost of PAC, we propose simple payment models that incentivize hospitals and PAC providers to collaboratively enhance the cost efficiency and quality of care for such conditions. Our approach extends traditional payment models by introducing performance targets for all providers, encompassing the entire care episode. Using a game-theoretical model, we demonstrate that the proposed payment model elicits socially optimal actions from all providers, under various assumptions. Importantly, our models do not require detailed knowledge of the hospital-PAC network structure but rely solely on observed cost and quality outcomes within the entire system. Furthermore, while the CJR payment model represents a positive step forward, our analysis reveals potential areas for improvement. Specifically, we suggest that holding both hospitals and PAC providers financially accountable, instead of solely focusing on hospitals, would yield further enhancements in the care delivery model

Optimal policies for inventory systems with finite capacity and partially observed Markov-modulated demand and supply processes

We analyze a single-item periodic-review inventory system with random yield and finite capacity operating in a random environment. The primary objective is to extend the model of Gallego and Hu (2004) to the more general case when the environment is only partially observable. Although our analysis is specific to inventory systems, it can also be applied to production systems by replacing the fixed capacity supplier with a fixed capacity producer. Using sufficient statistics, we consider single-period, multiple-period and infinite-period problems to show that a state-dependent modified inflated base-stock policy is optimal. Moreover, we show that the multiple-period cost converges to the infinite-period cost as the length of the planning horizon increases.Random yield Fixed capacity Random environment Modified inflated base-stock policy Dynamic programming Sufficient statistics POMDP

Inventory management with random supply and imperfect information: A hidden Markov model

In most of the papers on inventory models operating in a random environment, the state of the environment in each period is assumed to be fully observed with perfect information. However, this assumption is not realistic in most real-life situations and we provide a remedy in this paper by assuming that the environment is only partially observed with imperfect information. We accomplish this by analyzing two formulations of single-item models with periodic-review and random supply in a random environment. In the first one, supply is random due to random capacity of production and random availability of transportation. We show that state-dependent base-stock policy is optimal if the capacity and all costs are observed, while demand and availability are unobserved. In the second model, we consider a model with random availability only with fixed-ordering cost. We show that state-dependent (s,S) policy is optimal if the availability process is observable.Random supply Random environment Imperfect information Base-stock policy Dynamic programming Sufficient statistics POMDP

Comparison of phacoemulsification parameters effect on macular thickness changes after uneventful phacoemulsification in diabetic and non-diabetic patients

AIM: To evaluate the effect of phacoemulsification(phaco)parameters in micropulse phaco-tecnology with chamber stabilization environment(CASE)and increased control and efficiency(ICE)mode on central foveal thickness(CFT)changes after uneventful cataract surgery in normal and diabetic patients without retinopathy.<p>METHODS: In this prospective study a total of 120 patients consist of 60 patients with type 2 diabetes mellitus as a diabetic group(DG)without retinopathy and 60 normal subjects as a control group(CG)who underwent uneventful phaco were evaluated. Intraoperative phacoemulsification parameters including phaco time(PT), and effective phaco time(EPT)were recorded. The CFT measurements were performed preoperatively, at 1 and 3mo postoperatively. The CFT differences were calculated in each exam.<p>RESULTS:The mean PT in DG was 1.40±0.43min and it was 1.44±0.32min in CG, the difference was not significant(<i>P</i>=0.85). The mean EPT was 20.12±8.82s and 19.24±9.02s in DG and CG respectively which was statistically insignificant(<i>P</i>=0.964). The mean preoperative CFT was 218.4±12.0 μm in DG and 222.1±16.6 μm in CG which was not statistically different(<i>P</i>=0.168). The mean increment of CFT in DG was 30.3±37.2 μm at 1mo postoperatively, while it was 13.1±12.5 μm in CG. Even the CFT increments were significant in both groups at 1mo postoperatively, it was statistically higher in DG than that of CG(<i>P</i>=0.001). The average CFT increment at 3mo postoperatively comparing to preoperative level was 12.5±12.4 μm and 4.6±9.7 μm in DG and CG respectively. The increment of CFT was significantly higher in DG than that of CG(<i>P</i>=0.00). But the comparison of the mean CFTs changes from postoperative 1mo and 3mo in both DG and CG, significant decrements were observed in each group(<i>P</i>=0.00 and <i>P</i>=0.03 respectively).<p>CONCLUSION: The significant increment of CFT following uneventful phaco. With the similar phaco parameters were observed in both normal and diabetic subjects. The CFT changes were higher in DG than that of CG but fortunately these were mostly subclinical and optic coherence tomography(OCT)based changes and regressed or disappeared after 3mo postoperatively therefore not require immediate treatment in both group

Prevalence of asthma and allergies in children from the Greek-Cypriot and Turkish-Cypriot communities in Cyprus: a bi-communal cross-sectional study

Background: The Greek-Cypriot (G/C) and Turkish-Cypriot (T/C) communities have lived apart since 1974, with the former presumably adopting a more westernized way of life. We estimated the prevalence of asthma and allergies among children in the two communities and investigated differences in socio-demographic and lifestyle risk factors. Methods: The ISAAC questionnaire was completed by 10156 children aged 7–8 and 13–14 years. Relative differences in asthma and allergic symptoms between the two communities were expressed as odds ratios (OR), estimated in multivariable logistic regression models before and after adjusting for participants’ risk characteristics. Results: In contrast to our original speculation, consistently lower prevalence rates were observed for respiratory outcomes (but not eczema) among G/C compared to T/C children in both age-groups. For instance, the prevalence of current wheeze among 7–8 year-olds was 8.7% vs 11.4% (OR = 0.74, 95%, CI: 0.61, 0.90) and of current rhinoconjuctivitis 2.6% vs 4.9% (OR = 0.52, 95% CI: 0.37, 0.71). Surprisingly, the proportion reporting family history of allergy was almost double in the G/C community. With the exception of early life nursery attendance, several protective factors were more prevalent amongst T/C, such as bedroom sharing, less urbanized environment and exposure to farm animals. In contrast, exposure to tobacco smoke was more frequent in the T/C community. Controlling for risk factors did not account for the observed lower prevalence of current wheeze (in the younger age-group) and rhinoconjuctivitis (in both age-groups) among G/C children while differences in the prevalence of eczema between the two communities were no longer statistically significant. Conclusions: A mixed picture of potential risk factors was observed in the two communities of Cyprus, not consistently favoring one over the other community since, for example, bedroom sharing and rural living but also exposure to tobacco smoke were more common among T/C children. Investigated risk factors do not fully account for the lower prevalence of asthma and allergies among G/C children, especially against a background of higher family history of allergy in this community