Alternative Logics Coexistence: the Supplementary Health Field in Brazil

The paper examined the conditions that allow alternative logics a long standing coexistence, when no one logic predominates in the supplementary health field in Brazil. It contributes to the literature bringing the analysis of the coexistence over several decades of the following competitive logics - professional, public, market, regulatory, and social protection logic, in an institutional order level, while medical groups, insurance companies, and cooperatives established alternative health provision logics in the market level. The state’s incapacity or unwillingness to alienate the private sector is the main reason for the emergence of the various market medical providers with their distinct forms of service delivery.     

Making combination vaccines more accessible to low-income countries: The antigen bundle pricing problem

Combination vaccines have become the preferred choice for immunizing children in high- and middle-income countries. However, these new vaccines are prohibitively expensive for low-income countries, causing them to rely on older, less-expensive vaccines. This product divergence decreases economies of scale for the purchase of vaccines and eliminates the financial incentive for manufacturers to maintain production of less-expensive vaccines or even to develop new vaccines for diseases affecting developing countries. This paper treats combination vaccines as bundles of antigens that can be priced as a single item. Such bundles are used to formulate an optimization problem that determines the combination vaccine allocation between vaccine producers and different countries under a price discrimination agreement. The objective of the optimization problem is to satisfy countries' antigen demand at the lowest possible price, while providing a reasonable profit for the vaccine producers. The optimization problem results in a mixed-integer non-linear programming model that maximizes the sum of manufacturing profits and the customer surplus, and hence, it maximizes the total social surplus. Moreover, a constructive heuristic is proposed to determine an approximation to the best allocation of combination vaccines and their range of feasible prices. Computational results show that vaccine prices in all market segments become more affordable as the supply of the most complex combination vaccines becomes more available to low-income countries.     

Enterprising Education: Doing Away with the Public School System

We critically examine the accepted notion that primary education is a legitimate and necessary function of the state. The notion is based upon three tenets: 1) public education is a necessary condition for democracy, 2) the market will not provide equal access and quality of education to all, and 3) education represents an external economy. Each tenet is addressed and evaluated according to its merits. In doing so, we also contrast the fulfillment of the ends implicit in the tenets under state and market provisions. We conclude that the state provision of primary education cannot be justified by these goals, and that market provision is a preferable alternative. This revised version was published online in July 2006 with corrections to the Cover Date.     

Modeling the Effectiveness of Respiratory Protective Devices in Reducing Influenza Outbreak

Outbreaks of influenza represent an important health concern worldwide. In many cases, vaccines are only partially successful in reducing the infection rate, and respiratory protective devices (RPDs) are used as a complementary countermeasure. In devising a protection strategy against influenza for a given population, estimates of the level of protection afforded by different RPDs is valuable. In this article, a risk assessment model previously developed in general form was used to estimate the effectiveness of different types of protective equipment in reducing the rate of infection in an influenza outbreak. It was found that a 50% compliance in donning the device resulted in a significant (at least 50% prevalence and 20% cumulative incidence) reduction in risk for fitted and unfitted N95 respirators, high‐filtration surgical masks, and both low‐filtration and high‐filtration pediatric masks. An 80% compliance rate essentially eliminated the influenza outbreak. The results of the present study, as well as the application of the model to related influenza scenarios, are potentially useful to public health officials in decisions involving resource allocation or education strategies.     

Designing Referral Network Structures and Decision Rules to Streamline Provision of Urgent Health and Human Services*

This study uses fully factorial computer simulation to identify referral network attributes and referral decision rules that streamline the routing of people to urgent, limited services. As an example of a scenario, the model represents vaccine delivery in a city of 100,000 people during the first 30 days of a pandemic. By modeling patterns of communication among health care providers and daily routing of overflow clients to affiliated organizations, the simulations determine cumulative effects of referral network designs and decision rules on citywide delivery of available vaccines. Referral networks generally improve delivery rates when compared with random local search by clients. Increasing the health care organizations’ tendencies to form referral partnerships from zero to about four partners per organization sharply increases vaccine delivery under most conditions, but further increases in partnering yield little or no gain in system performance. When making referrals, probabilistic selection among partner organizations that have any capacity to deliver vaccines is more effective than selection of the highest‐capacity partner, except when tendencies to form partnerships are very low. Implications for designing health and human service referral networks and helping practitioners optimize their use of the networks are discussed. Suggestions for using simulations to model comparable systems are provided.     

Improving Health Risk Assessment as a Basis for Public Health Decisions in the 21st Century

One-fifth of the way through the 21st century, a commonality of factors with those of the last 50 years may offer the opportunity to address unfinished business and current challenges. The recommendations include: (1) Resisting the tendency to oversimplify scientific assessments by reliance on single disciplines in lieu of clear weight-of-evidence expressions, and on single quantitative point estimates of health protective values for policy decisions; (2) Improving the separation of science and judgment in risk assessment through the use of clear expressions of the range of judgments that bracket protective quantitative levels for public health protection; (3) Use of comparative risk to achieve the greatest gains in health and the environment; and (4) Where applicable, reversal of the risk assessment and risk management steps to facilitate timely and substantive improvements in public health and the environment. Lessons learned and improvements in the risk assessment process are applied to the unprecedented challenges of the 21st century such as, pandemics and climate change. The beneficial application of the risk assessment and risk management paradigm to ensure timely research with consistency and transparency of assessments is presented. Institutions with mandated stability and leadership roles at the national and international levels are essential to ensure timely interdisciplinary scientific assessment at the interface with public policy as a basis for organized policy decisions, to meet time sensitive goals, and to inform the public.     

Managed care in the pediatric subspecialty of neonatology. The challenges, impact, and consequences

As our health care system moves toward a more managed competition model, the delivery of pediatric and pediatric specialists' services, especially the intensive and procedural services of neonatology, will be impacted. Pediatricians and pediatric subspecialists cannot avoid being buffeted from the powerful market forces that are now driving revolutionary changes in our health care system; they, like nonpediatric physicians, are often concerned and bewildered about the new realities of the day.     

Federal budget helps drive health policy. A close-up look at the budget process and how it affects health care funding

Crafting the budget is an annual process that Congress and the administration use to define the national policy agenda. It is a massive undertaking to decide how more than two trillion dollars is spent by the federal government. Over 20 percent of the budget is used for health care. The budget is a political document that defines the priorities of the federal government and directly influences overall health policy. Its construction deserves to be followed and influenced by physicians to ensure the health of the public.     

POLITICIANS AT WORK: THE PRIVATE RETURNS AND SOCIAL COSTS OF POLITICAL CONNECTIONS

We quantify the private returns and social costs of political connections exploiting a unique longitudinal dataset that combines matched employer–employee data for a representative sample of Italian firms with administrative archives on the universe of individuals appointed in local governments over the period 1985–1997. According to our results, the revenue premium granted by political connections amounts to 5.7% on average, it is obtained through changes in domestic sales but not in exports, and it is not related to improvements in firm productivity. The connection premium is positive for upstream producers for the public administration only, and larger (up to 22%) in areas characterized by high public expenditure and high levels of corruption. These findings suggest that the gains in market power derive from public demand shifts towards politically connected firms. We estimate that such shifts reduce the provision of public goods by approximately 20%.     

The shape of public health policy: the Australian experience

Public health policy is shaped by many factors. A brief historical reflection is given on policy development in Australia to illustrate the various influences on health policy. Medical technology; ethical trade-offs; environmental, social, and political imperatives; popular movements; and changing patterns of disease; as well as market forces have helped to shape Australian contemporary public health policy. These multiple and often competing forces, however, can work against individual consumer choice in health care decisions. This article demonstrates through the eyes of history the factors that shape public health policy. As Australia has a short history compared to most industrialized democratic societies and can be viewed as a microcosm, it is used as the exemplar.     

制造商售后服务质量决策对灰色市场的影响研究

考虑一个分散式供应链下零售商窜货的灰色市场结构，其中制造商直接将产品销往高端市场，但通过中间零售商销往低端市场，两个市场相对独立。零售商未经制造商授权私自将产品窜货到高端市场而形成灰色市场。为了抑制灰色市场，制造商额外在低端市场提供增值售后服务。本文将建立两种模型：基本模型和服务决策模型，通过两种模型的对比分析，研究制造商售后服务质量决策对灰色市场规模和企业收益的影响。研究发现：对于制造商而言，售后服务质量决策是一种有效的灰色市场管理手段，不仅可以抑制灰色市场规模，同时还可以增加制造商的收益；对于零售商而言，售后服务质量决策有可能降低零售商的收益，也有可能增加零售商的收益，取决于消费者对高端产品和低端产品支付意愿的差异程度。     

Retrospective Cost-Effectiveness Analyses for Polio Vaccination in the United States

The history of polio vaccination in the United States spans 50 years and includes different phases of the disease, multiple vaccines, and a sustained significant commitment of resources. We estimated cost-effectiveness ratios and assessed the net benefits of polio vaccination applicable at various points in time from the societal perspective and we discounted these back to appropriate points in time. We reconstructed vaccine price data from available sources and used these to retrospectively estimate the total costs of the U.S. historical polio vaccination strategies (all costs reported in year 2002 dollars). We estimate that the United States invested approximately US dollars 35 billion (1955 net present value, discount rate of 3%) in polio vaccines between 1955 and 2005 and will invest approximately US dollars 1.4 billion (1955 net present value, or US dollars 6.3 billion in 2006 net present value) between 2006 and 2015 assuming a policy of continued use of inactivated poliovirus vaccine (IPV) for routine vaccination. The historical and future investments translate into over 1.7 billion vaccinations that prevent approximately 1.1 million cases of paralytic polio and over 160,000 deaths (1955 net present values of approximately 480,000 cases and 73,000 deaths). Due to treatment cost savings, the investment implies net benefits of approximately US dollars 180 billion (1955 net present value), even without incorporating the intangible costs of suffering and death and of averted fear. Retrospectively, the U.S. investment in polio vaccination represents a highly valuable, cost-saving public health program. Observed changes in the cost-effectiveness ratio estimates over time suggest the need for living economic models for interventions that appropriately change with time. This article also demonstrates that estimates of cost-effectiveness ratios at any single time point may fail to adequately consider the context of the investment made to date and the importance of population and other dynamics, and shows the importance of dynamic modeling.     

Safety Management and Public Spaces: Restoring Balance

Since 2000, the reputation of health and safety in the United Kingdom has been tarnished, so much so that it has become the subject of both a media circus and a government inquiry. This not only threatens the worthy goals of health and safety, but also impacts upon the associated tool of risk assessment itself such that "risk assessment" is increasingly seen by the public at large as a term inviting ridicule, even abuse. The main thrust of the government's examination of health and safety has been its concern that safety requirements were placing a disproportionate burden on business. However, there is another source of discontent, which is public chagrin over the impact of injury control measures upon life beyond the conventional workplace, in particular upon the public spaces that people frequent in their leisure time and on the activities they engage in there. This article provides a perspective on this second dimension of the crisis in confidence. It describes how many U.K. agencies with responsibilities for a wide portfolio of public amenities ranging from the provision of play spaces for the young to the management of publicly accessible countryside, the maintenance of urban and rural trees, the stewardship of sites of cultural heritage, and the pursuit of outdoor educational activities have responded to some conflicts posed to their services by the new safety culture. It concludes with a discussion of implications for the management of public space and for risk assessment itself.     

It's Complicated: The 2014–2015 U.S. Measles Outbreak and Parents’ Vaccination Beliefs,Confidence, and Intentions

While it seems intuitive that highly visible vaccine‐preventable disease outbreaks should impact perceptions of disease risk and facilitate vaccination, few empirical studies exist to confirm or dispel these beliefs. This study investigates the impact of the 2014–2015 Disneyland measles outbreak on parents’ vaccination attitudes and future vaccination intentions. The analysis relies on a pair of public opinion surveys of American parents with at least one child under the age of six (N = 1,000 across each survey). Controlling for basic demographics, we found higher levels of reported confidence in the safety and efficacy of childhood vaccinations in our follow‐up data collection. However, this confidence was also accompanied by elevated levels of concern toward childhood vaccines among American parents. We then examined how different subgroups in the population scored on these measures before and after the outbreak. We found that parents with high levels of interest in the topic of vaccines and a child who is not fully upto date with the recommended vaccination schedule reported more supportive attitudes toward vaccines. However, future intentions to follow the recommended vaccination schedule were not positively impacted by the outbreak. Possible explanations for these results and implications for vaccination outreach are discussed.     

Three Principles for Managing Risk in the Public Interest

We propose three principles and a general framework of reasoning for managing risk in the public interest. Principle 1. Risks shall be managed to maximize the total expected net benefit to society— The principle that the net benefit is to be maximized across society as a whole is argued to be a sufficient and rational guide to assessing the effectiveness of efforts directed at reducing risk and thus improving health and safety. The net benefit of an activity is the excess of the totality of benefits over the totality of detriments. Principle 2. The safety benefit to be promoted is life-expectancy— The goal is to ensure that risk mitigation efforts maximize the net benefit to society in the specific terms of length of life for all individuals. The effect of an activity on life expectancy is proposed as the proper basic measure of its net safety impact. Life expectancy is a universal measure valid for comparisons both within and among countries and can be adjusted to include health expectancy and other factors such as income levels that affect the quality of life. The impact on life expectancy allows a dispassionate accounting of the good and the bad inherent in any proposal or activity that is in the public interest but has some impact on life and health. Principle 3. Decisions for the public in regard to health and safety must be open and apply across the complete range of hazards to life and health— Systematic efforts to evaluate all the important consequences, both direct and indirect, are required to improve the basis for risk management in society. Balancing of the detriments and the benefits of any given initiative is the key aspect of the undertaking. Safety may well be an important objective in society, but it is not the only one. Thus, allocation of society's resources devoted to safety must be openly and continually appraised in light of other competing social needs because there is a limit on the resources that can be expended to save lives. Maximization of healthful life for all is judged the proper basis for managing risk in the public interest, and that this is achieved when the net of the contribution to the total saving of life exceeds the loss of life.     

Would Allowing Privately Funded Health Care Reduce Public Waiting Time? Theory and Empirical Evidence from Canadian Joint Replacement Surgery Data

This study develops a theoretical model and then, using Canadian joint replacement surgery data, empirically tests the relationship between government policies that promote privately funded health care and patients’ waiting time in the public health care system. Two policies are tested: one policy allows opt‐out physicians to extra‐bill private patients, and the other provides public subsidies to private patients. We find that both policies are associated with shorter public waiting time, and that the subsidy policy appears to be more effective in waiting time reduction than the extra‐billing policy. Our findings are consistent with a dominant demand‐side effect in that these policies would provide patients an option, and some incentive, to opt out of the public health system, shifting the demand from the public health system to the private care market.     

Public Perceptions of Health Risks from Polluted Coastal Bathing Waters: A Mixed Methodological Analysis Using Cultural Theory

This article explores public perceptions of, and attitudes toward, possible health risks from polluted coastal bathing waters in the United Kingdom. Cultural theory is applied in the present analysis, using a mixed methodology of quantitative analysis from interviews and qualitative interpretation of focus group discussions to provide insights into how different cultural solidarities view a number of issues. These include risks to health; attitudes toward regulation; public consultation and information provision; and trust, blame, and accountability applied to different stakeholders in the bathing-water-quality debate. The results show that individuals' standpoints can be represented on a number of dimensions, consistent with cultural theory, including perceptions of power and authority, beliefs in the efficacy of collective action, and acceptance or rejection of incremental change as opposed to radical solutions. The discussion focuses both on methodological and substantive issues related to the use of cultural theory as a research tool, and on policy recommendations arising from this research.     

Equilibria in Health Exchanges: Adverse Selection versus Reclassification Risk

This paper studies regulated health insurance markets known as exchanges, motivated by the increasingly important role they play in both public and private insurance provision. We develop a framework that combines data on health outcomes and insurance plan choices for a population of insured individuals with a model of a competitive insurance exchange to predict outcomes under different exchange designs. We apply this framework to examine the effects of regulations that govern insurers' ability to use health status information in pricing. We investigate the welfare implications of these regulations with an emphasis on two potential sources of inefficiency: (i) adverse selection and (ii) premium reclassification risk. We find substantial adverse selection leading to full unraveling of our simulated exchange, even when age can be priced. While the welfare cost of adverse selection is substantial when health status cannot be priced, that of reclassification risk is five times larger when insurers can price based on some health status information. We investigate several extensions including (i) contract design regulation, (ii) self‐insurance through saving and borrowing, and (iii) insurer risk adjustment transfers.     

流动性供给与日内价格效率——基于中国股票市场的实证研究

本文基于中国A股市场高频交易数据从流动性供给的角度探究提高价格效率的途径，并结合信息交易和市场状态分析流动性供给与日内价格效率的关系。用短期收益的可预测程度来衡量价格效率，用逆势交易比例来衡量流动性供给水平，基于日内分时数据建立面板回归模型对流动性供给与价格效率之间的关系进行实证分析。结果表明，提高流动性供给能够促进日内价格效率的改善，同时较高的机构交易比例和较低的价格波动对流动性供给与价格效率之间的关系有正向促进作用。研究结论对于提高价格效率，稳定和完善市场具有启示作用。     

St Christopher's and the future

The founding vision of St Christopher's Hospice was based on a recognition that permeating mainstream health care services would be essential and an emphasis on an adaptable philosophy rather than a building. Today, demographic and disease related changes mean that need and demand for end-of-life care will inevitably outstrip professional and financial resource. Hospices must engage with the development of cost-effective models of service delivery and rational planning. Only partnership working with the National Health Service, care homes, and others will ensure that appropriate care is available to everyone wherever the bed in which they die, regardless of diagnosis. Only collaboration and active engagement will ensure that future strategy in end-of-life care retains the original insight that its focus rightly includes not only patients but also the social context that will be affected by their death. Cost and patient choice dictate an emphasis on care at home. Health-promoting, public education and family-focused strategies will be essential. At a pivotal moment for the delivery of health care generally, hospices can play a vital part by marrying the role of "insistent conscience" of the health care service with continued cost-effective clinical innovation.