Association between provider specialty and healthcare costs and glycemic control for patients with diabetes

Aims: To analyze the association between provider, healthcare costs, and glycemic control for patients with diabetes mellitus (DM).

Materials and methods: This cross-sectional study identified adults with type 1 or 2?DM (T1D, T2D) in the Optum database. The main independent variable was provider (endocrinologist or primary care). Regression analysis compared total medical and pharmacy costs, adjusting for health status and other patient differences, by provider.

Results: For all patients, HbA1C improvement was greater, and medical costs significantly lower with an endocrinologist rather than a primary care provider. The largest HbA1C improvement (4%) occurred for insulin-dependent patients seen by endocrinologists. Significant medical savings with endocrinologist management occurred within the Medicare Advantage population in every sub-group of patients, with 14% lower costs ($4,767) for patients with T1D, 11% lower costs ($3,160) for patients with macro- and microvascular complications, and 10% lower costs ($2,237) for insulin-dependent patients. Within the commercial insurance population, medical costs were reduced by ≥9% in every sub-group of patients, with a 20% reduction ($8,450) for patients with micro- and macrovascular complications. Overall total costs (medical and pharmacy) were 8% ($1,541) higher for patients receiving endocrinologist rather than primary care, although endocrinologist care resulted in a 9% reduction (–$3,710) in costs for Medicare Advantage patients with T1D. Total medical costs (excluding pharmacy costs) may be a more accurate indicator of costs associated with patients in various stages of DM.

Limitations: There was insufficient data to develop risk-adjustment payments for pharmacy costs based on disease severity. The cross-sectional design identifies associations and not cause–effect relationships.

Conclusion: DM management by an endocrinologist was associated with greater HbA1C improvement and significantly lower medical costs. Total costs were higher with an endocrinologist, but for patients with T1D lower costs were seen, ranging from 2–9% regardless of insurance type.     

ESTIMATING THE EFFECTS OF BROWNFIELDS AND BROWNFIELD REMEDIATION ON PROPERTY VALUES IN A NEW SOUTH CITY

Using data from Charlotte, NC, a New South city without a legacy of heavily contaminated properties, we find the distance from unremediated brownfields—typically former industrial properties believed to have modest contamination—to have no effect on residential sales values, but proposed cleanup and actual remediation have positive, substantial, and significant effects especially within 0.5 miles of the brownfield. Our results are consistent whether we examine all property values within a given distance, such as 0.5 miles, or examine discrete distances, such as 0.3–0.5 miles. An estimate of the benefits is on the order of $4 million. (JEL Q51, Q24, Q28, R52)     

Families at leisure outdoors: well-being through adventure

ABSTRACT

This study investigates families who choose to co-participate in outdoor adventure holidays, and explores how they benefit from these shared experiences. In so doing, it seeks to determine the role of adventure tourism in developing and enhancing family well-being (FWB). Hyper-modern family life for many is powered by technological hardware, each room in the house replete with on-line pleasures, distractions and identities. In response to this dystopia, some families opt to take adventure holidays together. However, scholarship concerning collective experiences of adventurous leisure, in this case as families, is limited. Using a qualitative whole family approach, 15 (adventure tourist) families were interviewed, totalling 62 interviewees (29 adults and 33 children under 18 years old), in their home environments. Four key themes related to FWB emerged. First, families extended their active lifestyles to adventure holidays and repeatedly mentioned the health and fitness benefits gained from these experiences. Second, adventure holidays facilitated unmediated time together for families. Third, parents harboured ideals of positive personal development for their children in these adventure settings. Fourth, making memories during adventure holidays, and recollecting these post-trip, were integral to family bonding. Further research should consider non-traditional families, and various socio-economic and cultural groups in this context.     

Real option pricing with mean-reverting investment and project value

In this work, we are concerned with valuing the option to invest in a project when the project value and the investment cost are both mean-reverting. Previous works on stochastic project and investment cost concentrate on geometric Brownian motions (GBMs) for driving the factors. However, when the project involved is linked to commodities, mean-reverting assumptions are more meaningful. Here, we introduce a model and prove that the optimal exercise strategy is not a function of the ratio of the project value to the investment V/I – contrary to the GBM case. We also demonstrate that the limiting trigger curve as maturity approaches traces out a nonlinear curve in (V, I) space and derive its explicit form. Finally, we numerically investigate the finite-horizon problem, using the Fourier space time-stepping algorithm of Jaimungal and Surkov [2009. Lev´y based cross-commodity models and derivative valuation. SIAM Journal of Financial Mathematics, to appear. http://www.ssrn.com/abstract=972837]. Numerically, the optimal exercise policies are found to be approximately linear in V/I; however, contrary to the GBM case they are not described by a curve of the form V*/I*=c(t). The option price behavior as well as the trigger curve behavior nicely generalize earlier one-factor model results.     

Dis-Ag-reement: the construction and negotiation of risk in the Swedish controversy over antibacterial silver

What constitutes a potentially hazardous object is often debated. This article analyses the polemic construction and negotiation of risk in the Swedish controversy over the use of antibacterial silver in health care and consumer products. This debate engages the media, government agencies, parliament and government, non-governmental organizations and companies. Texts and websites from these actors were studied using content analysis. Antibacterial silver is construed by some actors as a risk object with harmful effects on a series of objects at risk: the environment, public health, organisms and sewage treatment. In contrast, other actors deny that antibacterial silver is a risk object, instead construing it as mitigating risk. In such a schema, antibacterial silver is conceived of as managing the risk objects of bacteria and micro-organisms, in turn managing the risk objects of infection, bad smell and washing, and in turn helping the environment and public health (objects at risk). The structure of the debate suggests two basic modes of risk communication. First, antibacterial silver is construed as a risk object, endangering a variety of objects at risk, such as organisms, public health, the environment and sewage treatment. Second, this association between antibacterial silver and objects at risk is obstructed, by denying that antibacterial silver is a risk object or by associating silver with the benefit of mitigating risk.     

Sequential decisions with tests

We consider a principal-agent problem where the principal wishes to be endorsed by a sequence of agents, but cannot truthfully reveal type. In the standard “herding” model, the agents learn from each other's decisions, which can lead to cascades on a given decision when later agents' private information is swamped. We augment the standard model to allow the principal to subject herself to a test designed to provide public information about her type. She must decide how tough a test to attempt from a continuum of test types, which involves trading off the higher probability of passing an easier test against the greater impact from passing a tougher test. We find that the principal will always choose to be tested, and will prefer a tough test to a neutral or easy one.     

Private Sector Debt,Financial Constraints,and the Effects of Monetary Policy: Evidence from the US

We characterize the response of U.S. real GDP to monetary policy shocks conditional on the level of private sector debt and the degree to which financial constraints are binding. To incorporate state-dependent effects of monetary policy, we use the local projection framework. We find that although the amount of private sector debt potentially weakens the monetary policy transmission mechanism, policy shocks exert substantially larger effects on output when high private debt coincides with binding financial constraints.     

The political economy of trade and migration: Evidence from the U.S. Congress

We compare the drivers of U.S. congressmen's votes on trade and migration reforms since the 1970s. Standard trade theory suggests that trade reforms that lower barriers to goods from less skilled‐labor abundant countries and migration reforms that lower barriers to low‐skilled migrants should have similar distributional effects, hurting low‐skilled U.S. workers while benefiting high‐skilled workers. In line with this prediction, we find that House members representing more skilled‐labor abundant districts are more likely to support trade and migration reforms that benefit high‐skilled workers. Still, important differences exist: Democrats are less supportive of trade reforms than Republicans, while the opposite is true for migration reforms; welfare state considerations and network effects shape votes on migration, but not on trade.