Cashing in or driving development? Cross-border traders and maize contract farming in northeast Laos

Contract farming is receiving renewed attention in research and policy in the Mekong region of Southeast Asia, as countries continue to undergo varied agrarian transitions and agri-food production has become increasingly regionalized. In northeast Laos, previously isolated upland communities have experienced rapid transformations resulting from contract production of hybrid maize, mainly for industrial feed processing and livestock in Vietnam. Based on extensive qualitative fieldwork in the Lao-Vietnamese borderlands, this article explores the quasi-“developmental” functions assumed by cross-border traders, in the context of unfulfilled rural policy objectives, in which these “micro-investors” provide informal extension and infrastructure to enable agricultural commercialization. The article examines the extent to which this dynamic is adequately captured by notions of patronage, or whether subtle mutual dependencies are at work, as livelihoods are rebalanced between subsistence and commodity crops in remote border landscapes.     

Budget impact analysis of a novel gene expression assay for the diagnosis of malignant melanoma

Background:

Traditional pathology techniques alone can be insufficient to reliably distinguish between malignant melanoma, dysplastic nevi, and benign nevi in biopsies of suspicious pigmented lesions. Numerous studies have shown high rates of ambiguity when assessing such samples. A novel gene expression assay has been developed to objectively differentiate malignant melanoma from benign nevi.

Objective:

The purpose of this study was to quantify the economic impact of the gene expression assay on a US commercial health plan.

Methods:

The clinical paradigm of care was modeled for a hypothetical cohort of patients with suspicious pigmented lesions that are difficult-to-diagnose. Costs were assigned to each unit of care provided based on 2013 Medicare fee-for-service rates. Patients were followed for 10 years and were modeled to progress according to the natural history of their disease. The total cost of care was calculated for two scenarios: a Reference Scenario, representing current clinical practice, and a Test Scenario, in which each lesion was tested with the gene expression assay and diagnosed. Total cost of care was compared between the two scenarios to determine overall budget impact. Sensitivity analyses were performed to test the robustness of the model.

Results:

The gene expression assay reduces costs by $1268 per patient tested over 10 years, a decrease of 8.3%, after accounting for the cost of the assay. For a health plan with 10 million members, this would translate to over $8 million in savings. The largest portion of this saving comes from reducing the number of missed melanomas, which would otherwise progress to advanced disease. In sensitivity analyses, no single model input changed within a reasonable range of values caused the model to show that the assay was not cost-saving.

Conclusion:

In addition to improving the diagnosis of melanoma, this gene expression assay would likely reduce costs for health plans that choose to cover it.