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.     

Disruptive Innovation in the Nordic Countries＇ Healthcare Systems

The Nordic healtheare model is recognized to be one of the most innovative in the world. Here billions of USD are annually invested in developing new treatments, drugs, robots etc. to diagnose and cure diseases. Nevertheless, this study establishes that there is a fundamental shortcoming in the system that supports healthcare innovation： It is strongly biased towards micro-level innovation projects focusing on new products, alternative processes, and new financial solutions. The problem with this approach to support new projects is that the results are created as inventions within the system thus lacking holistic perspectives. This has consequently contributed with increasing costs that are out of proportion with existing budgets. Therefore this study seeks to analyze the current understanding of the Nordic healthcare system from a business model perspective. Here other aspects of the healthcare system are explored to determine if they could be redesigned to promote new types of innovation projects. The purpose of undertaking this task is to challenge the established patterns of the current healthcare innovation support practices. Here the vertical innovation process （VIP） framework, which is a systematic radical innovation model that seeks macro-level outcomes based on standalone inventions （see more below）, is applied to analyze the current state-of-the-art in Nordic healthcare innovation projects. The results determine that very little attention is given to rethink and redesign the healthcare system at a macro-level, and it is discussed that stand-alone inventions ought to be rethought into the entire healthcare system to create a larger impact. Finally, it is argued that existing performance measures are inappropriate to foster projects that innovate the existing system： New measuring points should be developed to promote macro-level projects and to avoid the current rapid increase of costs in the Nordic healthcare system.     

Within-group heterogeneity and group dynamics: analyzing exit of microcredit groups in Angola

The effect of within-group heterogeneity on the survival of social groups is theoretically ambiguous. A greater diversity of ideas, experience, and networks can have a positive effect on members’ benefits from group membership, but diversity also creates a potential for conflict. This paper analyzes the relation between heterogeneity and exit of microcredit groups, using data from Angola. The results suggest that the form of group heterogeneity matters. Fragmentation in terms of social identities, or more specifically religious-linguistic fractionalization, is associated with a greater probability of group exit. Within-group economic inequality, however, is associated with a decrease in the probability of exit, but at a diminishing rate.     

Alternatives to local content requirements in resource-rich countries

This paper discusses whether and to what extent resource-rich developing countries should introduce local content policies, i.e. requirements to include local inputs in petroleum extraction activities of multinational corporations. We argue that local content needs to be seen as a public expenditure question, since local content requirements increase multinational costs, and hence reduce the taxes which can be extracted from these companies. This implies that there are opportunity costs in imposing local content requirements, since the forgone taxes can be used in others ways which could potentially do more to improve development prospects. Moreover, past experiences of resource-rich developing countries suggest that local content policies can exacerbate key problems of patronage and rent-seeking which resource rents generate, increasing the chance that the resource wealth will prevent rather than help development. These arguments suggest that an optimal local content policy in the context of flawed institutions is a more limited one than those typically pursued by developing countries with recently discovered petroleum reserves. Using qualitative data from Tanzania, a country with recent discoveries of substantial natural gas deposits, we analyze why local content tends to become such a central issue in debates and policy processes, despite its potentially problematic aspects.     

Global emissions effects of CDM projects with relative baselines

CDM is an offset mechanism designed to reduce the overall cost of implementing a given global target for greenhouse gas (GHG) emissions in Annex B countries of the Kyoto Protocol. A problem with CDM is that it provides incentives to increase, if possible, the baseline emissions for CDM projects, to optimize the value of CDM credits. Under a “relative baselines” crediting rule, the CDM may also unduly increase energy consumption even during the CDM implementation phase. Less than full offset of emissions is then likely, and the CDM will lead to increased global GHG emissions. We show that this is a potentially serious problem, due to asymmetric information between project hosts and the regulator, the CDM Executive Board, and to the basic rules for crediting CDM quotas. In certain cases, the use of “relative baselines” to credit CDM quotas could fully eliminate any emissions reductions achieved by CDM projects. Remedies to overcome the problems are discussed. They may involve setting the baseline independently of initial energy intensity and final output for the project; or involve information revelation mechanisms that minimize policy losses and net rent capture by project sponsors.     

How Effective are WTO Disciplines on Domestic Support and Market Access for Agriculture?

A new round of trade negotiations through the World Trade Organization (WTO) was launched in 2001. One of the major aims of the Doha Development Round is to reduce agricultural protection and impose greater discipline on domestic agricultural subsidies, particularly those that are the most trade distorting. In this article, we examine whether the proposed WTO modalities for agriculture will actually achieve this aim in Norway, which ranks among the top providers of government assistance for agriculture. Norway has a complex system of farm subsidies buttressed by substantial import protection. The extent to which its agricultural support policies will have to change in response to new WTO disciplines provides an important indication of how successful these are likely to be. We find that Norway will probably be able to sustain its current agricultural activity and production levels while staying within the new WTO rules. Following recent practice in some other WTO members, Norway will be able to reduce its notified support without making real changes in some of its programmes. However, there will have to be a shift from market price support, which is paid for by consumers through higher food prices, to budgetary support paid by taxpayers. This could generate increased domestic pressure for policy reform.