Expanded newborn screening for genetic and metabolic disorders: modeling costs and outcomes

Newborn screening for genetic and metabolic disorders is a state-based public health program in the United States, for the elimination and/or reduction of associated mortality, morbidity, and disabilities. As new technologies for newborn screening and new interventions for treatment are realized, it will be increasingly important for health leaders and policymakers to have data to inform their decisions regarding expanding newborn testing. The entire costs of a screening program, including not only instrumentation but also labor and time costs; initial, repeat, and confirmatory testing; screening sensitivity and specificity; and short and long-term followup, should be considered in decisions regarding expansion of screening programs. The decision model cited in this study can serve as a tool in exploring alternatives for critical decisions regarding the addition of new disorders to existing newborn screening panels. The evaluation of genetic disorders in this study can be used as a prototype of an approach to evaluating screening for any newborn genetic/metabolic disorder.     

Optimal component substitution within system evolution planning considering multiple-vendor,functionally equivalent commercial products

The use of commercial-off-the-shelf components (COTS) in systems with long-term life cycles eventually affects system functionality. Such systems must undergo component substitutions to avoid component obsolescence and maintain the system operationally effective. While performing such substitutions, sustainment costs must be kept within projected budgets, and system and component evolution must seamlessly provide continued availability. However, planning system evolution while minimising costs becomes a competing resource allocation problem (even more so when multiple manufacturers offer functionally equivalent COTS that can satisfy the system requirements). This research presents a mathematical model for calculating system life cycle costs while considering different substitution alternatives, and proposes an optimisation approach and a network model to obtain an optimal substitution sequence based on a minimisation criteria of life cycle costs. It was observed that upgrading the system with available technologies often results in better affordability than keeping the same technologies for the entire system life cycle.     

Regulating an externality-generating public utility: A multi-dimensional screening approach

In this paper, I present a monopoly screening model in which a firm holds private information on fixed abatement costs. Because of the nature of the optimal contracts, bunching is never optimal even with ‘n’ distinct types. A characterization of full and limited information solutions is offered and it is shown that the design standards alone determine the value of an information rent. The variable charge is completely free of any marginal information costs. This allows the variable charge to track marginal damages and thereby ensures that marginal social costs are covered. A fixed charge implements the optimal solution.     

Projecting total costs and health consequences of increasing mt-sDNA utilization for colorectal cancer screening from the payer and integrated delivery network perspectives

Abstract

Aims: To evaluate total costs and health consequences of a colorectal cancer (CRC) screening program with colonoscopy, fecal immunochemical tests (FIT), and expanded use of multitarget stool DNA (mt-sDNA) from the perspectives of Integrated Delivery Networks (IDNs) and payers in the United States.

Materials and methods: We developed a budget impact and cost-consequence model that simulates CRC screening for eligible 50- to 75-year-old adults. A status quo scenario and an increased mt-sDNA scenario were modeled. The status quo includes the current screening mix of colonoscopy (83%), FIT (11%), and mt-sDNA (6%) modalities. The increased mt-sDNA scenario increases mt-sDNA utilization to 28% over 10 years. Costs for both the IDN and the payer perspectives incorporated diagnostic and surveillance colonoscopies, adverse events (AEs), and CRC treatment. The IDN perspective included screening program costs, composed of direct nonmedical (e.g. patient navigation) and indirect (e.g. administration) costs. It was assumed that IDNs do not incur the costs for stool-based screening tests or bowel preparation for colonoscopies.

Results: In a population of one million covered lives, the 10-year incremental cost savings incurred by increasing mt-sDNA utilization was $16.2 M for the IDN and $3.3 M for the payer. The incremental savings per-person-per-month were $0.14 and $0.03 for the IDN and payer, respectively. For both perspectives, increased diagnostic colonoscopy costs were offset by reductions in screening colonoscopies, surveillance colonoscopies, and AEs. Extending screening eligibility to 45- to 75-year-olds slightly decreased the overall cost savings.

Limitations: The natural history of CRC was not simulated; however, many of the utilized parameters were extracted from highly vetted natural history models or published literature. Direct nonmedical and indirect costs for CRC screening programs are applied on a per-person-per modality basis, whereas in reality some of these costs may be fixed.

Conclusions: Increased mt-sDNA utilization leads to fewer colonoscopies, less AEs, and lower overall costs for both IDNs and payers, reducing overall screening program costs and increasing the number of cancers detected while maintaining screening adherence rates over 10 years.     

基于消费者视角的电动汽车全寿命周期成本模型及分析

本文以全寿命周期成本理论为基础,从消费者角度对电动汽车全寿命周期内的成本进行了全面分析,建立了电动汽车的全寿命周期成本模型,为电动汽车的保有成本估算提供了方法依据。同时,将电动汽车与燃油汽车就成本进行了比较分析。结论表明,电动汽车的全寿命周期成本远低于燃油汽车,在同等条件下理性消费者会更倾向于选择电动汽车。     

Regulation of non-marketed outputs and substitutable inputs

We study the regulation of a monopolistic firm that provides a non-marketed output based on multiple substitutable inputs. The regulator is able to observe the effectiveness of the provision, but faces information asymmetries with respect to the efficiency of the firm’s activities. Specifically, we consider a setting where one input and the output are observable, while another input and related costs are not. Multi-dimensional information asymmetries are introduced by discrete distributions for the functional form of the marginal rate of substitution between the inputs as well as for the input costs. For this novel setting, we investigate the theoretically optimal Bayesian regulation mechanism. We find that the first-best solution cannot be obtained in case of shadow costs of public funding. The second-best solution implies separation of the most efficient type with first-best input levels, and upwards distorted (potentially bunched) observable input levels for all other types. Moreover, we compare these results to a simpler non-Bayesian approach, i.e., a single pooling contract, and hence, bridge the gap between the academic discussion and regulatory practice. In a numerical simulation, we identify certain conditions in which a single contract non-Bayesian regulation can indeed get close to the second-best solution of the Bayesian menu of contracts regulation.     

Identifying cost-effective screening algorithms for active hepatitis C virus infections in a high prevalence setting

Objective: To evaluate the cost-effectiveness of different screening patterns for active chronic hepatitis C virus (HCV) infections utilizing the hepatitis C core antigen test compared to standard care in the context of a general screening program in a high-prevalence country.

Methods: This study developed a decision analytic model to estimate the cost-effectiveness of four screening algorithms for the detection of active HCV infections among asymptomatic individuals with an unknown HCV status in a context of high (>5%) HCV prevalence. Three algorithms started with a serological test for antibodies (AB) followed by a nucleic acid test for HCV-RNA (RNA), the HCVAg (AG) assay, or both. An additional single marker screening strategy with AG was added to the analysis. By the example of the Republic of Georgia, strategies were compared in terms of total costs for screening and diagnosis of an active infection from a health system perspective.

Results: Replacing RNA with AG for confirmation of positive AB identified fewer active infections (–110 per 100,000 screened subjects) at significantly reduced total costs (–$2.74 per screened) and costs per diagnosed infection (–$44). Adding a subsequent RNA confirmatory test on AG negative results captured at least the same rate compared to the standard (AB followed by RNA) at still reduced costs (–$1.16 per subject screened, –$22 per case detected). Utilizing AG as the frontline test revealed the highest detection rate (97.9%) at the highest costs (+$3.80 per subject, +$323 per case detected vs standard).

Conclusion: A combined pattern of HCV AB screening followed by sequential confirmation with AG and RNA on AG negatives would provide equal or better diagnostic performance at lower cost over a broad range of scenarios. Potential long-term consequences of screening strategies to patients and society have to be considered, since the latency period for HCV to develop into severe liver disease is long.     

Leaving your tailings behind: Environmental bonds,bankruptcy and waste cleanup

This paper studies the impacts of an environmental bond, which fully covers waste cleanup costs, on a mining firm's optimal actions over the full life cycle of a mine, when bankruptcy may shift cleanup costs to the government. A firm's stochastic optimal control problem is described by an HJB equation with the resource price modelled as an Ito process. A theoretical result shows that under certain assumptions, an environmental bond can ensure that the option to declare bankruptcy has no impact on the firm's optimal actions. A numerical solution is implemented for a hypothetical copper mine using two different models of bankruptcy risk. Numerical results show that when bankruptcy is an option and no bond is required, the firm produces too much waste relative to a benchmark case, resulting in an efficiency loss and a cleanup liability imposed on government. In the presence of bankruptcy risk, a bond ensures that the firm acts optimally and no efficiency loss is imposed on society.     

Asymmetric information and contract design for payments for environmental services

In contractual relationships involving payments for environmental services, conservation buyers know less than landowners know about the costs of contractual compliance. Landowners in such circumstances use their private information as a source of market power to extract informational rents from conservation agents. Reducing informational rents is an important task for buyers of environmental services who wish to maximize the services obtained from their limited budgets. Reducing informational rents also mitigates concerns about the “additionality” of PES contracts because low-cost landowners are least likely to provide different levels of services in the absence of a contract. Paying low-cost landowners less thus makes resources available for contracts with higher opportunity cost landowners, who are more likely to provide substantially different levels of services in the absence of a contract. To reduce informational rents to landowners, conservation agents can take three approaches: (1) acquire information on observable landowner attributes that are correlated with compliance costs; (2) offer landowners a menu of screening contracts; and (3) allocate contracts through procurement auctions. Each approach differs in terms of its institutional, informational and technical complexity, as well as in its ability to reduce informational rents without distorting the level of environmental services provided. No single approach dominates in all environments. Current theory and empirical work provides practitioners with insights into the relative merits of each approach. However, more theoretical work and experimentation in the laboratory and the field are necessary before definitive conclusions about the superiority of one or more of these approaches can be drawn.     

Expansion and welfare in microfinance: A screening model

The expansion of microfinance has triggered concerns of rising indebtedness, and higher default and interest rates. Using a screening model, we show that even if interest and default rates increase due to expansion, borrower welfare may improve. This is because: (i) all borrowers previously denied credit can obtain loans, and (ii) screening costs for pre-existing borrowers go down. Hence, policies that seek to regulate interest and screening levels can be counterproductive.     

住房需求动态模型的演进

在家庭生命周期内,最优住房消费并不是一成不变的。为了最大化整个生命周期的效用,家庭通常需要权衡迁居的交易成本和不迁居的效用损失。本文介绍研究住房需求的动态模型,给出家庭住房消费决策的理论解释。     

Pricing of Transport Networks,Redistribution, and Optimal Taxation

The author studies optimal pricing of roads and public transport in the presence of nonlinear income taxation. Individuals are heterogeneous in unobservable earning ability. Optimal transport tariffs depend on time costs of travel and work schedule adjustments (days and hours worked per day) as a response to commuting costs. The author finds that discounts for low‐income individuals are optimal only if the time cost of a trip is small enough. Lower travel time costs facilitate screening; therefore, redistribution provides an additional motive for congestion pricing. Finally, the study investigates the desirability of means‐testing of transport tariffs.     

Exchange rate dynamics in economies with portfolio rigidities

This paper studies the international transmission of productivity and monetary shocks in a general equilibrium two-country monetary model with portfolio rigidities and distribution costs in trade. The model features two types of transport costs (iceberg costs and distribution costs in terms of nontradables) and incomplete markets. The specification employed here is able to generate the domestic liquidity effect, increase in the foreign–domestic interest rate differential, and the nominal depreciation after a monetary injection. Quantitatively, the model with distribution costs as in Burstein, Neves and Rebelo (2003) performs better matching some business cycle moments, but fails to generate the high volatility of exchange rates observed in the data.     

Theory and Application of Linear Supply Function Equilibrium in Electricity Markets

We consider a supply function equilibrium (SFE) model of interaction in an electricity market. We assume a linear demand function and consider a competitive fringe and several strategic players having capacity limits and affine marginal costs. The choice of SFE over Cournot equilibrium and other models and the choice of affine marginal costs is reviewed in the context of the existing literature. We assume that bid rules allow affine or piecewise affine non-decreasing supply functions by firms and extend results of Green and Rudkevitch concerning the linear SFE solution. An incentive compatibility result is proved. We also find that a piecewise affine SFE can be found easily for the case where there are non-negativity limits on generation. Upper capacity limits, however, pose problems and we propose an ad hoc approach. We apply the analysis to the England and Wales electricity market, considering the 1996 and 1999 divestitures. The piecewise affine SFE solutions generally provide better matches to the empirical data than previous analysis.     

Using the stochastic health state function to forecast healthcare demand and healthcare financing: Evidence from Singapore

Typically, healthcare financing for an ageing population requires projections on healthcare demand and cost. However, projecting healthcare demand based on projected elderly does not consider changes in population health state over time. This paper proposes a new approach to forecast health variables using a stochastic health state function and the well‐established Lee–Carter stochastic mortality model. With the estimated health state at each age over time, we project the hospitalization rate, healthcare demand, and financing cost for Singapore using historical life tables and hospital admission data. Our findings show that while hospital insurance claims increase owing to an aging population, improving health state could save costs from hospital insurance claims. This has policy implications: more attention should be given to preventive healthcare such as health screening to improve the overall health state of the population.     

Social security trust fund flows and the welfare costs of rent seeking

The current study provides estimates from a Parks regression (using panel data) that suggest that the welfare costs due to rent seeking efforts by interest groups to obtain Social Security trust fund flows ranged from approximately $132 million (per twoyear federal election cycle from 1985–1994) to a theoretical expectation of $66 billion, all in real terms. These welfare costs are in addition to any other social costs that may be present, including the reduced levels of national saving that Social Security may induce.     

The business cycle of capitalism

In every business expansion the wage share declines because productivity rises faster than hourly wages. As a result, towards the end of expansion the limited wages and salaries cause an insufficient growth of consumer demand, which makes it difficult to realize profits. At the same time costs - including wage costs, material costs and interest costs - are rising, so it is difficult to produce at a profit. Therefore, at the peak of the cycle rising costs and insufficient demand squeeze profits as in a nutcracker, causing a fall in the expected rate of profit, which leads to a business contraction. In every business contraction the opposite trends tend to produce eventual recovery and a new expansion.     

Did Open Access Integrate Natural Gas Markets? An Arbitrage Cost Approach

Several studies, using analyses that measure the correlation between prices in various markets, have argued that deregulation of natural gas pipeline contracts has reduced the transaction costs between natural gas markets. Correlations approaches, however, have potentially serious problems. Given these problems, this article estimates transactions costs directly. Deregulation is found to have lowered transactions costs to and from the Louisiana, Oklahoma, and Texas regions, but increased transactions costs from the Rocky Mountain area. Deregulation of pipeline contracts, by lowering the cost of using the market and therefore increasing demand for pipeline capacity, may therefore have differential impacts upon transactions costs between markets. This study implies that the transactions cost approach may be able to overcome several difficulties inherent in the correlations approach.     

Competitive screening and information transmission

We consider a model in which schools and colleges compete for high-ability students, which are independently identified through a costly screening procedure. This independence creates a channel through which students' preferences affect the strategic interaction between schools: students with competing offers accept the most-preferred one, increasing the screening costs of unpopular schools. When preferences between schools are more heterogeneous, schools screen more, increasing the proportion of students with multiple offers, but paradoxically reducing the extent to which their preferences determine their outcomes. By observing the students' schools of origin, colleges can free-ride of the fierce competition that occurs during screening.