Global Maize Trade and Food Security: Implications from a Social Network Model

In this study, we developed a social network model of the global trade of maize: one of the most important food, feed, and industrial crops worldwide, and critical to food security. We used this model to analyze patterns of maize trade among nations, and to determine where vulnerabilities in food security might arise if maize availability was decreased due to factors such as diversion to nonfood uses, climatic factors, or plant diseases. Using data on imports and exports from the U.N. Commodity Trade Statistics Database for each year from 2000 to 2009 inclusive, we summarized statistics on volumes of maize trade between pairs of nations for 217 nations. There is evidence of market segregation among clusters of nations; with three prominent clusters representing Europe, Brazil and Argentina, and the United States. The United States is by far the largest exporter of maize worldwide, whereas Japan and the Republic of Korea are the largest maize importers. In particular, the star‐shaped cluster of the network that represents U.S. maize trade to other nations indicates the potential for food security risks because of the lack of trade these other nations conduct with other maize exporters. If a scenario arose in which U.S. maize could not be exported in as large quantities, maize supplies in many nations could be jeopardized. We discuss this in the context of recent maize ethanol production and its attendant impacts on food prices elsewhere worldwide.     

An overview of managed care in state Medicaid programs

The National Governor's Association predicts that Medicaid will account for 28 percent of total state spending in 1995, double the 1991 level. During 1992, total Medicaid enrollment reached 31.6 million beneficiaries, up 4.7 million (17.5 percent) from 1991. The total expenditure of $118.2 billion in 1992 was up 25 percent from the 1991 level of 94.5 billion. A recent General Accounting Office (GAO) report, revealed that, in 1990, 43 percent of 99 million emergency department visits were for minor ailments. From 1985 to 1990, Medicaid emergency department visits increased 34 percent, compared to 19 percent growth in all emergency department visits. A Department of Health and Human Services Inspector General Report on Medicaid recipient emergency department usage recommended that states develop a comprehensive initiative to reduce nonemergency usage of the emergency department, including increased implementation of managed care options. During 1992, 42 states used some type of Medicaid cost containment measure, with managed care being the most frequent choice.     

Fraud and abuse: the payer's perspective

As the health care sector consumes an ever-increasing portion of our nation's gross national product (GNP)), forecast to represent 15 percent of the GNP by the year 2000, increasingly intensive efforts are being used to control the growth rate of these costs. Medicare fraud alone is estimated to represent $2 billion yearly. Abusive billing of private health insurers represents a far larger amount. This article discusses the concept of fraudulent and abusive physician billing practices.     

A new perspective on quality

The U.S. health care sector consumes nearly 13 percent of our nation's gross national product, $800 billion annually. Our nation allocates the highest amount per capita to health care in the world. Yet many measures of health care outcomes from these expenditures are inferior to other developed nations. The American health care system costs too much, excludes too many, fails too often, contains much excessive and inappropriate care, and knows too little about the effectiveness of the things it does. The purpose of this article is to discuss current payers' perspectives on the potential for quality improvement in the U.S. health care system.     

Branch banking in the year 2000

The topic of branch banking in the United States in the year 2000 is obviously one that has been in the minds of California bankers for some time because California is the largest state in the United States to permit virtually unlimited statewide branch banking. It is a topic that must also be in the minds of a large number of European and Asian bankers as well because several non-U.S. banking systems have already established large branch networks in the United States. It is a difficult topic because no one knows precisely what will be the status of branch banking in the year 1990, let alone the year 2000. This article makes some predictions.     

Nursing home care: ensuring quality.

There are more than 17,000 nursing homes in the United States providing care for 1.7 million disabled and elderly individuals. Medicare and Medicaid paid $28 billion in 1997 for nursing home services, more than one half of all nursing home expenditures. Improvements in the quality of care in these facilities and ensuring value for public expenditures has been a long sought after goal. Recent actions by the federal government are designed to strengthen state and federal authority and processes to accomplish this goal. Physician leadership in this area is essential to its success.     

Five-Hundred Life-Saving Interventions and Their Cost-Effectiveness

We gathered information on the cost-effectiveness of life-saving interventions in the United States from publicly available economic analyses. "Life-saving interventions" were defined as any behavioral and/or technological strategy that reduces the probability of premature death among a specified target population. We defined cost-effectiveness as the net resource costs of an intervention per year of life saved. To improve the comparability of cost-effectiveness ratios arrived at with diverse methods, we established fixed definitional goals and revised published estimates, when necessary and feasible, to meet these goals. The 587 interventions identified ranged from those that save more resources than they cost, to those costing more than 10 billion dollars per year of life saved. Overall, the median intervention costs $42,000 per life-year saved. The median medical intervention costs $19,000/life-year; injury reduction $48,000/life-year; and toxin control $2,800,000/life-year. Cost/life-year ratios and bibliographic references for more than 500 life-saving interventions are provided.     

Reinhardt on reform. Interview by Donna Vavala

Almost since the federal government took its giant step into health care delivery and financing in 1965 with Medicare and Medicaid, the emphasis in Washington has been on reducing the costs of health care. Almost all federal health law subsequent to those two programs has been aimed at cost control, even when the titles of the bills promised a more noble purpose. The most notable exception is the law establishing end-stage renal disease coverage, but it has become a prime exacerbator of rising costs. Not even the designers of the federal programs envisioned how quickly health care costs would rise and how substantial the increases would be. The federal tab in 1993 was $280.6 billion. In 1960, it was $3 billion and in 1970 it was $17.8 billion. And overall health care costs have followed a similar curve, growing from 5.3 percent of the U.S. GDP in 1960 and 7.4 percent in 1970 to 13.8 percent in 1993. The end is not in sight. Economists are predicting growth to 18 percent of GDP by the next century. Uwe E. Reinhardt, PhD, James Madison Professor of Political Economics in the Woodrow Wilson School at Princeton University, does not believe that the "bite" will become that large, but he does expect increases to continue into the near future. In the interview recorded in this article, Professor Reinhardt assesses both the current and his predicted financial scenario for the health care field.     

Veteran's health care: time for a change?

The Department of Veterans Affairs' mission is "to care for him who are shall have borne the battle for his widow and orphan." The Veterans Health Administration comprises 172 hospitals that are the hub of the health care delivery system. It is the largest provider of graduate medical education, and one of the major research organizations in the United States. The medical care budget exceeds $17 billion annually. Most of the persons cared for are not legally entitled to this health care based on service connected disability. The utilization of acute care hospital beds appears excessive when compared to that obtainable with managed care for Medicare or commercial insurance beneficiaries--the cost per member per month is three times higher. There may also be exploitation of the Veterans Administration hospitals by university medical schools. The Veterans Health Administration is a very expensive way to deliver care to entitled service connected veterans. Therefore, it is suggested that privatization be considered as an alternative vehicle for delivering health care.     

Primary care: the driver in health care reform

The changes occurring in the health care industry have resulted in a cost-quality competition that has not been present in the past. Because of this competition, managed care is a growing way of financing and providing health care to the people of the United States. Managed care depends heavily on competent primary care physicians. Because primary care physicians are in short supply, the status and financial rewards of primary care practice are increasing. The primary care physician will be the dominant force in medical practice in the immediate future. He or she is capable in a managed setting of resolving the perceived problems of the health care industry in responding to the drivers of health care reform. Costs are reduced while quality is maintained. Access to health care is improved, and fragmentation of health care is significantly lessened.     

Risks of Hazardous Waste Sites versus Asteroid and Comet Impacts: Accounting for the Discrepancies in U.S. Resource Allocation

Approximately $6 billion is spent annually in the United States on the cleanup of sites regulated under the Comprehensive Environmental Response, Compensation and Liability Act (CERCLA, or Superfund). The current health risks posed by such sites are thought to be quite small; the expenditures are justified primarily as protecting hypothetical future residents of these sites. Approximately 0.05% of this amount, or $3 million, is spent annually by the U.S. government on the detection of asteroids or comets that could strike the earth. Such damaging impacts do occur from time to time--most recently in 1908 in an unpopulated region of Siberia--but no person is confirmed ever to have died as a result. Anticipated impacts over the course of 1 million years would yield deaths that, when annualized, total approximately 4,000 per year. The risk reduction goal for CERCLA is 15 orders of magnitude greater than that for asteroid/comet detection. A modest increase in resources devoted to asteroid detection would greatly increase the chances of early detection of a threatening object, allowing an effective defense to be attempted. This article argues that the much lower risk-to-resources ratio for CERCLA cleanups than for asteroid and comet detection can be explained by four primary factors: (1) the regard for future generations, since CERCLA benefits mainly the unborn; (2) concrete fears, since toxics are much more feared than asteroids or comets; (3) the source of the threat, since toxic contamination is caused by human beings, unlike impacts from space objects; and (4) the greater political constituencies for hazardous waste cleanup than for space object detection.     

Development of hospice and palliative care in the United States

More than 30 years have passed since palliative care was introduced in the United States, and what began as a small rebellion has evolved into a fairly large health care industry. Although the palliative care movement has considerably improved the care given to those at the end of life, many challenges remain for palliative care providers in the United States. This article discusses the history of hospice and palliative care in the United States, the Medicare Hospice Benefit, the growth of hospice and palliative care, and challenges such as the need for regulatory change, workforce issues, improving access to care, and improving the quality of palliative care.     

Cash Is King—How OBM Helped a North American Telecommunications Organization Obtain $76 Million in Receivables

Imagine a freshly formed team of people who are new to their jobs, assigned by top leadership to meet very ambitious targets in the mission-critical department that collects aged (past-due) payments from the company's largest accounts … (cue Mission Impossible theme). At a large telecommunications company in North America, the Senior Leadership Team led an effort to increase collections of aged receivables on its top accounts by $50 million from the previous year. Using OBM techniques, they surpassed the $50 million goal, reaching $76 million. The team also lowered the Days Sales Outstanding (DSO) by 8.5 days.     

Reducing the Risk of Injury from Table Saw Use: The Potential Benefits and Costs of Automatic Protection

The use of table saws in the United States is associated with approximately 28,000 emergency department (ED) visits and 2,000 cases of finger amputation per year. This article provides a quantitative estimate of the economic benefits of automatic protection systems that could be designed into new table saw products. Benefits are defined as reduced health‐care costs, enhanced production at work, and diminished pain and suffering. The present value of the benefits of automatic protection over the life of the table saw are interpreted as the switch‐point cost value, the maximum investment in automatic protection that can be justified by benefit‐cost comparison. Using two alternative methods for monetizing pain and suffering, the study finds switch‐point cost values of $753 and $561 per saw. These point estimates are sensitive to the values of inputs, especially the average cost of injury. The various switch‐point cost values are substantially higher than rough estimates of the incremental cost of automatic protection systems. Uncertainties and future research needs are discussed.     

Human Health Risk Assessment of Penicillin/Aminopenicillin Resistance in Enterococci Due to Penicillin Use in Food Animals

Penicillin and ampicillin drugs are approved for use in food animals in the United States to treat, control, and prevent diseases, and penicillin is approved for use to improve growth rates in pigs and poultry. This article considers the possibility that such uses might increase the incidence of ampicillin-resistant Enterococcus faecium (AREF) of animal origin in human infections, leading to increased hospitalization and mortality due to reduced response to ampicillin or penicillin. We assess the risks from continued use of penicillin-based drugs in food animals in the United States, using several assumptions to overcome current scientific uncertainties and data gaps. Multiplying the total at-risk population of intensive care unit (ICU) patients by a series of estimated factors suggests that not more than 0.04 excess mortalities per year (under conservative assumptions) to 0.14 excess mortalities per year (under very conservative assumptions) might be prevented in the whole U.S. population if current use of penicillin drugs in food animals were discontinued and if this successfully reduced the prevalence of AREF infections among ICU patients. These calculations suggest that current penicillin usage in food animals in the United States presents very low (possibly zero) human health risks.     

Spirituality and the care of patients at the end-of-life: an essential component of care

Spirituality is an essential component of the care of patients with serious illness and those that are dying. Dame Cicely Saunders developed the hospice movement based on the biopsychosocialspiritual model of care, in which all four dimensions are important in the care of patients. Of all the models of care, hospice and palliative care recognize the importance of spiritual issues in the care of patients and their families. The National Consensus Project Guidelines for Quality Palliative Care, in the United States, provides specific recommendations about all domains of care including the spiritual domain, which is recognized as a critical component of care (The National Consensus Project for Quality Palliative Care www.nationalconsensusproject.org). Studies indicate that the majority of patients would like their spiritual issues addressed, yet find that their spiritual needs are not being met by the current system of care. Interestingly, spirituality is the one dimension that seems to get slightly less emphasis than the biopsychosocial dimensions of care. Some reasons may include the difficulty with definitions of spirituality for clinical and research purposes, the time constraints and financial burdens in the current healthcare system in the United States, and the lack of uniform training for all healthcare professionals. Yet, there are theoretical and ethical frameworks that support spiritual care as well as some educational models in spirituality and health that have been successful in medical education in the United States. Spirituality can be seen as the essential part of the humanity of all people. It is at its root, relational and thus forms the basis of the altruistic care healthcare professionals are committed to. Spirituality has to do with respecting the inherent value and dignity of all persons, regardless of their health status. It is the part of humans that seeks healing, particularly in the midst of suffering. Spiritual care models are based on an intrinsic aspect that calls for compassionate presence to patients as well as an extrinsic component where healthcare professionals address spiritual issues with patients and their loved ones. Currently in the healthcare system, evidence-base models are the criteria for practice recommendations. Yet, spirituality may not be amenable entirely to strict evidence-base criteria. As hospice and palliative care continues to develop as a field, healthcare professionals are challenged to think of ways to advocate for and include the spiritual dimension of care.     

Study tour examines health care systems in Germany, Holland--Part I: A comparison of three health care systems

In October 1992, the American College of Physician Executives sponsored a study tour to Berlin, Germany, and Amsterdam, Holland. Meetings were held with government officials, third-party payers, and providers, and onsite visits were made at hospitals, clinics, and academic centers. The purpose was to study the health care delivery system in those countries and to share some insights with the countries' hosts on the U.S. system. Beginning in this issue of the journal, 5 of the 10 study tour participants describe their impressions of the tour and of the health care systems in the countries that were visited. This first report compares the health care delivery systems of the United States, Germany, and Holland. In subsequent reports, the German and Dutch health care systems will be described in greater detail and the ability of the United States to adopt European health care systems will be assessed.     

Training and organizational commitment among nurses following industry and organizational change in New Zealand and the United States

This survey study examines the relationship between employee attitudes related to training and organizational commitment among a sample of nurses in New Zealand and the United States. The magnitude of recent restructuring to New Zealand's public health system allows for an examination of employee attitudes towards training and organizational commitment in comparison to nurses from similar sized hospitals in the United States. Results show that perceived access to training, supervisory support for training, motivation to learn from training and perceived benefits of training were positively related to the affective and normative components of organizational commitment. Several significant differences were found on both training and organizational commitment variables between New Zealand and the United States. The findings are discussed in terms of their theoretical and practical application to human resource development (HRD) outcomes and the management of HRD in health care settings.     

The ethicist

The 1990s seem drawn for major changes in the U.S. health care delivery system. After a quarter century of piecemeal changes to compensate for the cost dislocations caused by passage of the federal Medicare and Medicaid programs, legislators, moved by a high level of demand from buyers, third-party payers, and consumers, are at last positioned for some structural revamping. Nothing is certain, however, as evidenced by the shifting deadline for introduction of the current Administration's approach to solutions. In this article, the author uses a fictionalized scenario to imagine the status of our health care system in the year 2000. As in 1990, much will remain to be done, even if much will have been accomplished.     

Risk to Groundlings of Death Due to Airplane Accidents: A Risk Communication Tool

During the period 1975-85 in the United States the 70 year lifetime risk of dying from being hit by an airplane when the individual is on the ground was 4.2 per million people. In contrast to many other risks used for comparison purposes, risk to those on the ground from an airplane crash is not a function of our own skills; is not optional; provides no benefit to anyone involved; and is not an act of nature. As a risk comparison tool it also has the useful characteristics of being something about which we can agree that regulatory action, such as control of airplane use and traffic, is warranted; but that no significant change in personal behavior, such as living in the basement to protect against dying from a plane hitting the home, is commensurate with the extent of risk.