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COVID-19 pandemic: the effects of quarantine on cardiovascular risk




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Correction: Humanized bone facilitates prostate cancer metastasis and recapitulates therapeutic effects of Zoledronic acid in vivo




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The Twin Crises and the Prospects for Political Sectarianism in Lebanon

LCPS solicited the opinion of key experts to answer one question: “Will the financial crisis, exacerbated further by COVID-19, strengthen or loosen the power of Lebanon’s governing political parties?” 




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The Twin Crises and the Prospects for Political Sectarianism in Lebanon

LCPS solicited the opinion of key experts to answer one question: “Will the financial crisis, exacerbated further by COVID-19, strengthen or loosen the power of Lebanon’s governing political parties?” 




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COVID’s Broader Impacts: Risks and Recommendations

While the world’s health and economy are the clearest victims of COVID-19, the pandemic has impacted nearly every aspect of society – from national security to international relationships. We asked several of our experts to share their thoughts on risks and/or recommendations that policymakers and the public should consider in the coming weeks and months.




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COVID’s Broader Impacts: Risks and Recommendations

While the world’s health and economy are the clearest victims of COVID-19, the pandemic has impacted nearly every aspect of society – from national security to international relationships. We asked several of our experts to share their thoughts on risks and/or recommendations that policymakers and the public should consider in the coming weeks and months.




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COVID’s Broader Impacts: Risks and Recommendations

While the world’s health and economy are the clearest victims of COVID-19, the pandemic has impacted nearly every aspect of society – from national security to international relationships. We asked several of our experts to share their thoughts on risks and/or recommendations that policymakers and the public should consider in the coming weeks and months.




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COVID’s Broader Impacts: Risks and Recommendations

While the world’s health and economy are the clearest victims of COVID-19, the pandemic has impacted nearly every aspect of society – from national security to international relationships. We asked several of our experts to share their thoughts on risks and/or recommendations that policymakers and the public should consider in the coming weeks and months.




cts

COVID’s Broader Impacts: Risks and Recommendations

While the world’s health and economy are the clearest victims of COVID-19, the pandemic has impacted nearly every aspect of society – from national security to international relationships. We asked several of our experts to share their thoughts on risks and/or recommendations that policymakers and the public should consider in the coming weeks and months.




cts

COVID’s Broader Impacts: Risks and Recommendations

While the world’s health and economy are the clearest victims of COVID-19, the pandemic has impacted nearly every aspect of society – from national security to international relationships. We asked several of our experts to share their thoughts on risks and/or recommendations that policymakers and the public should consider in the coming weeks and months.




cts

The Twin Crises and the Prospects for Political Sectarianism in Lebanon

LCPS solicited the opinion of key experts to answer one question: “Will the financial crisis, exacerbated further by COVID-19, strengthen or loosen the power of Lebanon’s governing political parties?” 




cts

COVID’s Broader Impacts: Risks and Recommendations

While the world’s health and economy are the clearest victims of COVID-19, the pandemic has impacted nearly every aspect of society – from national security to international relationships. We asked several of our experts to share their thoughts on risks and/or recommendations that policymakers and the public should consider in the coming weeks and months.




cts

COVID’s Broader Impacts: Risks and Recommendations

While the world’s health and economy are the clearest victims of COVID-19, the pandemic has impacted nearly every aspect of society – from national security to international relationships. We asked several of our experts to share their thoughts on risks and/or recommendations that policymakers and the public should consider in the coming weeks and months.




cts

COVID’s Broader Impacts: Risks and Recommendations

While the world’s health and economy are the clearest victims of COVID-19, the pandemic has impacted nearly every aspect of society – from national security to international relationships. We asked several of our experts to share their thoughts on risks and/or recommendations that policymakers and the public should consider in the coming weeks and months.




cts

COVID’s Broader Impacts: Risks and Recommendations

While the world’s health and economy are the clearest victims of COVID-19, the pandemic has impacted nearly every aspect of society – from national security to international relationships. We asked several of our experts to share their thoughts on risks and/or recommendations that policymakers and the public should consider in the coming weeks and months.







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COVID’s Broader Impacts: Risks and Recommendations

While the world’s health and economy are the clearest victims of COVID-19, the pandemic has impacted nearly every aspect of society – from national security to international relationships. We asked several of our experts to share their thoughts on risks and/or recommendations that policymakers and the public should consider in the coming weeks and months.




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Massa expects 'big fight' with Ferrari

Felipe Massa expects a tough fight from Ferrari in Melbourne for the final spot on the podium and says it would be foolish to write off Red Bull after one tricky weekend




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Lauda expects Ferrari 'pasting'

Former three-time world champion Niki Lauda believes Ferrari will "get a pasting" when they face the sport's governing body next month over allegations of race fixing




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COVID’s Broader Impacts: Risks and Recommendations

While the world’s health and economy are the clearest victims of COVID-19, the pandemic has impacted nearly every aspect of society – from national security to international relationships. We asked several of our experts to share their thoughts on risks and/or recommendations that policymakers and the public should consider in the coming weeks and months.




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Africa in the news: New EU-Africa strategy, impacts of the oil price crash, and spread of coronavirus

The European Union unveils its new Africa strategy On Monday, March 9, the European Union unveiled its new Africa engagement strategy, which the EU hopes will shift the relationship to one of more equal partnership. The new “Strategy with Africa” will focus on six areas of partnership: energy (especially green energy) access; digital transformation; sustainable…

       




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Africa in the news: COVID-19 impacts African economies and daily lives; clashes in the Sahel

African governments begin borrowing from IMF, World Bank to soften hit from COVID-19 This week, several countries and multilateral organizations announced additional measures to combat the economic fallout from COVID-19 in Africa. Among the actions taken by countries, Uganda’s central bank cut its benchmark interest rate by 1 percentage point to 8 percent and directed…

       




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How the AfCFTA will improve access to ‘essential products’ and bolster Africa’s resilience to respond to future pandemics

Africa’s extreme vulnerability to the disruption of international supply chains during the COVID-19 pandemic highlights the need to reduce the continent’s dependence on non-African trading partners and unlock Africa’s business potential. While African countries are right to focus their energy on managing the immediate health crisis, they must not lose sight of finalizing the Africa…

       




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The Twin Crises and the Prospects for Political Sectarianism in Lebanon

LCPS solicited the opinion of key experts to answer one question: “Will the financial crisis, exacerbated further by COVID-19, strengthen or loosen the power of Lebanon’s governing political parties?” 




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FIA inspects US F1 factory

The FIA has sent technical delegate Charlie Whiting to inspect US F1's factory, after reports suggested the Charlotte-based squad is way behind on its chassis build and in financial trouble




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The Twin Crises and the Prospects for Political Sectarianism in Lebanon

LCPS solicited the opinion of key experts to answer one question: “Will the financial crisis, exacerbated further by COVID-19, strengthen or loosen the power of Lebanon’s governing political parties?” 




cts

COVID’s Broader Impacts: Risks and Recommendations

While the world’s health and economy are the clearest victims of COVID-19, the pandemic has impacted nearly every aspect of society – from national security to international relationships. We asked several of our experts to share their thoughts on risks and/or recommendations that policymakers and the public should consider in the coming weeks and months.




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Perez expects to learn on job in Australia

Sergio Perez says Force India will be learning on the job at the Australian Grand Prix but feels confident the team knows the areas it needs to improve on the VJM08




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The Twin Crises and the Prospects for Political Sectarianism in Lebanon

LCPS solicited the opinion of key experts to answer one question: “Will the financial crisis, exacerbated further by COVID-19, strengthen or loosen the power of Lebanon’s governing political parties?” 




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Hamilton says title still possible and reflects on accident

Lewis Hamilton is not writing off this year's championship despite notching up his second retirement in a row and dropping 20 points off Mark Webber at the Singapore Grand Prix




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How to fix the Paycheck Protection Program: Make sure it actually protects paychecks

Amid the finger-pointing and blame-throwing about the mess that is the Paycheck Protection Program, the U.S. Treasury and Small Business Administration seem to have forgotten why Congress enacted it: so businesses would keep people on payroll instead of laying them off. The PPP idea is simple: rather than have businesses lay off tens of millions…

       




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How to fix the Paycheck Protection Program: Make sure it actually protects paychecks

Amid the finger-pointing and blame-throwing about the mess that is the Paycheck Protection Program, the U.S. Treasury and Small Business Administration seem to have forgotten why Congress enacted it: so businesses would keep people on payroll instead of laying them off. The PPP idea is simple: rather than have businesses lay off tens of millions…

       




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COVID in the Maghreb: Responses and impacts

       




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The Terms They Are A-Changin'...: Watching Cloud Computing Contracts Take Shape


EXECUTIVE SUMMARY

Many web services are examples of cloud computing, from storage and backup sites such as Flickr and Dropbox to online business productivity services such as Google Docs and Salesforce.com. Cloud computing offers a potentially attractive solution to customers keen to acquire computing infrastructure without large up-front investment, particularly in cases where their demand may be variable and unpredictable, as a means of achieving financial savings, productivity improvements and the wider flexibility that accompanies Internet-hosting of data and applications.

The greater flexibility of a cloud computing service as compared with a traditional outsourcing contract may be offset by reduced certainty for the customer in terms of the location of data placed into the cloud and the legal foundations of any contract with the provider. There may be unforeseen costs and risks hidden in the terms and conditions of such services.

This document reports on a detailed survey and analysis of the terms and conditions offered by cloud computing providers.

The survey formed part of the Cloud Legal Project at the Centre for Commercial Law Studies (CCLS), within the School of Law at Queen Mary, University of London, UK. Funded by a donation from Microsoft, but academically independent, the project is examining a wide range of legal and regulatory issues arising from cloud computing. The project's survey of 31 cloud computing contracts from 27 different providers, based on their standard terms of service as offered to customers in the E.U. and U.K., found that many include clauses that could have a significant impact, often negative, on the rights and interests of customers. The ease and convenience with which cloud computing arrangements can be set up may lull customers into overlooking the significant issues that can arise when key data and processes are entrusted to cloud service providers. The main lesson to be drawn from the Cloud Legal Project’s survey is that customers should review the terms and conditions of a cloud service carefully before signing up to it.

The survey found that some contracts, for instance, have clauses disclaiming responsibility for keeping the user’s data secure or intact. Others reserve the right to terminate accounts for apparent lack of use (potentially important if they are used for occasional backup or disaster recovery purposes), for violation of the provider’s Acceptable Use Policy, or indeed for any or no reason at all. Furthermore, whilst some providers promise only to hand over customer data if served with a court order, others state that they will do so on much wider grounds, including it simply being in their own business interests to disclose the data. Cloud providers also often exclude liability for loss of data, or strictly limit the damages that can be claimed against them – damages that might otherwise be substantial if a failure brought down an e-commerce web site.

Although in some U.S. states, in E.U. countries and in various other jurisdictions the validity of such terms may be challenged under consumer protection laws, users of cloud services may face practical obstacles to bringing a claim for data loss or privacy breach against a provider that seems local online but is, in fact, based in another continent. Indeed, service providers usually claim that their contracts are subject to the laws of the place where they have their main place of business. In many cases this is a US state, with a stipulation that any dispute must be heard in the provider’s local courts, regardless of the customer’s location.

Perhaps the most disconcerting discovery of the Cloud Legal Project’s survey was that many providers claimed to be able to amend their contracts unilaterally, simply by posting an updated version on the web. In effect, customers are put on notice to download lengthy and complex contracts, on a regular basis, and to compare them against their own copies of earlier versions to look for changes.

The cloud computing market is still developing rapidly, and potential cloud customers should be aware that there may be a mismatch between their expectations and the reality of cloud providers' service terms, and be alive to the possibility of unexpected changes to the terms.

Downloads

Authors

  • Simon Bradshaw
  • Christopher Millard
  • Ian Walden
Image Source: Natalie Racioppa
     
 
 




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The End of Sykes-Picot? Reflections on the Prospects of the Arab State System


During much of the past three years, the Syrian civil war has been the most prominent item on the Middle Eastern political agenda and has dominated the political-diplomatic discourse in the region and among policy makers, analysts and pundits interested in its affairs. 

Preoccupation with the Syrian crisis has derived from the sense, apparent since its early phases, that it was much more than a domestic issue. It has, indeed, become a conflict by-proxy between Iran and its regional rivals and the arena of American-Russian competition. It has also had a spillover effect on several neighboring countries and has been a bellwether for the state of the Arab Spring.

As the conflict festered it also prompted a broader discussion and debate over the future of the Arab State system. The collapse of Syria, the ongoing fighting in Iraq, and the general instability in the Middle East has led some observers to question whether the very geography of the region will be changed. Robin Wright, a journalist and scholar at the Woodrow Wilson International Center for Scholars, argues that “the map of the modern Middle East, a political and economic pivot in the international order, is in tatters.” Wright also warns that competing groups and ideologies are pulling the region apart: “A different map would be a strategic game changer for just about everybody, potentially reconfiguring alliances, security challenges, trade and energy flows for much of the world, too.”  Similarly, Parag Khanna, a senior fellow at the New America Foundation, argues, “Nowhere is a rethinking of “the state” more necessary than in the Middle East.” He contends that “The Arab world will not be resurrected to its old glory until its map is redrawn to resemble a collection of autonomous national oases linked by Silk Roads of commerce.” Lt. Colonel Joel Rayburn, writing from the Hoover Institution, points out that the alternative may not be new states but rather simply collapse. “If watching the fall or near-fall of half a dozen regimes in the Arab Spring has taught us anything, it should be that the Arab states that appeared serenely stable to outsiders for the past half century were more brittle than we have understood,” warning darkly, “This conflict could very well touch us all, perhaps becoming an engine of jihad that spews forth attackers bent on bombing western embassies and cities or disrupting Persian Gulf oil markets long before the fire burns out.” 

This discussion touches on a key question: Will the collapse of one or several other Arab states produce a new order in the region? 

The regional order has been threatened before, but today’s challenge is unique. Syria is what has prompted the latest reevaluation of the Skyes-Picot borders, but many of the problems predated the Syrian civil war. Ambitious monarchs in the 1930s and 1940s challenged the order after the colonial period. The doctrine of Pan-Arab Nationalism and Gamal Abd al-Nasir’s messianic leadership in the 1950s and by Saddam Hussein in 1990 again posed a threat. Now it is now challenged not by a powerful state or a sweeping ideology but by the weakness of several Arab states that seem to be on the verge of implosion or disintegration.

This paper assesses the situation in Syria, with an emphasis on what might lead to its de facto partition or lasting collapse. It then examines Syria’s neighbors and their prospects for stability. The paper concludes by exploring how the United States, Israel and Iran might affect this tenuous balance.

Downloads

Image Source: © Muzaffar Salman / Reuters
      
 
 




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How to fix the Paycheck Protection Program: Make sure it actually protects paychecks

Amid the finger-pointing and blame-throwing about the mess that is the Paycheck Protection Program, the U.S. Treasury and Small Business Administration seem to have forgotten why Congress enacted it: so businesses would keep people on payroll instead of laying them off. The PPP idea is simple: rather than have businesses lay off tens of millions…

       




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10 facts about Social Security and retirement saving


“Social security is not going broke,” said Carolyn Colvin, acting commissioner of the Social Security Administration, at a Brookings Retirement Security Project event this week. She was joined by Consumer Financial Protection Bureau Director Richard Cordray to discuss retirement planning and to unveil a new retirement calculator. “Social Security is the only guaranteed monthly income for a majority of older consumers,” Cordray said.

After their keynote addresses, a panel of retirement security experts moderated by Guest Scholar Joshua Gotbaum discussed efforts to improve retirement planning and what knowledge the average American needs to make retirement planning achievable. Ted Gayer, VP and director of Economic Studies at Brookings, introduced the event.

Here are 10 facts about Social Security and retirement planning mentioned during the event. Full video is available below and on the event’s page.

1/3 of U.S. households spend all of their available resources in every pay period

60 million people received Social Security benefits in September 2015

For the average worker, Social Security replaces only about 40 percent of pre-retirement earnings

45 million people are already 65 or order, and 10,000 people are turning 65 each day

The average American now spends about 20 years in retirement
(in 1950, the average was about 4 years)

4 in 10 Americans aged 51-59 are reaching retirement with limited or no savings,
and are projected to face a saving shortfall

~2/3 of the 40 million Americans 65 and older who receive Social Security benefits
depend on those benefits for ½ or more of their retirement income

It’s about 70 percent or more of income for those 80 or older

Only 60 percent of people who retire claim to have done any retirement planning at all

Delaying claiming Social Security “buys” people 6-8 percent more real benefits per year once they do take it

Olivia Mitchell, a professor at the Wharton School, University of Pennsylvania, explained this last point, noting that if a person stopped working at 62 but waited to claim benefits until 70, he or she would receive a benefit 76 percent higher in (real) dollars per month for life. “When to claim Social Security is many older Americans’ most important financial decision they will ever make in their lifetimes,” according to Mitchell.

Learn more about the event here and watch the video:

Helping America plan for retirement: Keynote remarks

Video

Authors

  • Fred Dews
     
 
 




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Taiwan’s January 2020 elections: Prospects and implications for China and the United States

EXECutive Summary Taiwan will hold its presidential and legislative elections on January 11, 2020. The incumbent president, Tsai Ing-wen of the Democratic Progressive Party (DPP), appears increasingly likely to prevail over her main challenger, Han Kuo-yu of the Kuomintang (KMT). In the legislative campaign, the DPP now has better than even odds to retain its…

       




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Impacts and implications of the 2020 Taiwan general elections

Taiwan held elections for the president and all the members of the Legislative Yuan on January 11. Although President Tsai Ing-wen had maintained a strong lead in the polls, there were questions about the reliability of some polls. Moreover, the outcome of the legislative elections was very uncertain. China, which has long made clear its…

       




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Facebook can’t resolve conflicts in Myanmar and Sri Lanka on its own

Facebook CEO Mark Zuckerberg has been caught up in a whirlwind in recent months, giving congressional testimony and public statements defending Facebook against allegations that it has been too lax in combating online hate speech and disinformation. International criticism has rightly brought attention to the urgent need to address Facebook’s role in stoking ethnic and…

      
 
 




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Health care market consolidations: Impacts on costs, quality and access


Editor's note: On March 16, Paul B. Ginsburg testified before the California Senate Committee on Health on fostering competition in consolidated markets. Download the full testimony here.

Mr. Chairman, Madame Vice Chairman and Members of the Committee, I am honored to be invited to testify before this committee on this very important topic. I am a professor of health policy at the University of Southern California and director of public policy at the USC Schaeffer Center for Health Policy and Economics. I am also a Senior Fellow and the Leonard D. Schaeffer Chair in Health Policy Studies at The Brookings Institution, where I direct the Center for Health Policy. Much of my time is now devoted to leading the new Schaeffer Initiative for Innovation in Health Policy, which is a partnership between USC and the Brookings Institution. I am best known in California for the numerous community site visits over many years that I led in the state while I was president of the Center for Studying Health System Change; most of those studies were funded by the California HealthCare Foundation.

The key points in my testimony today are:

    • Health care markets are becoming more consolidated, causing price increases for purchasers of health services, and this trend will continue for the foreseeable future despite anti-trust enforcement; 
    • Government can still play an effective role in addressing higher prices that come from consolidation by pursuing policies that foster increased competition in health care markets. Many of these policies can be effective even in markets with high degrees of concentration, such as in Northern California.

Consolidation in health care has been increasing for some time and is now quite extensive in many markets. Some of this comes from mergers and acquisitions, but an important part also comes from larger organizations gaining market share from smaller competitors. The degree of consolidation varies by market. In California, most observers believe that metropolitan areas in the northern part of the state have provider markets that are far more consolidated than those in the southern part of the state. Insurer markets tend to be statewide and are less consolidated than those in many other states. The research literature on hospital mergers is now substantial and shows that mergers lead to higher prices, although without any measured impact on quality.[1]

The trend is accelerating for reasons that are apparent. For providers, it is becoming an increasingly challenging environment to be a small hospital or medical practice. There is more pressure on payment rates. New contracting models, such as Accountable Care Organizations (ACOs), tend to require more scale. The system is going through a challenging transition to electronic medical records, which is expensive and requires specialized expertise to avoid pitfalls. Lifestyle choices by younger physicians lead them to pursue employment in large organizations rather than solo ownerships or partnerships in small practices.

The environment is also challenging for small insurers. Multi-state employers prefer to contract with insurers that can serve all of their employees throughout the country. Scale economies are important in building the analytic capabilities that hold so much promise for effectively managing care. Insurer scale is important to make it worthwhile for providers to contract with them under alternative payment models. The implication of these trends is an expectation of increasing consolidation. There is need for both public and private sector initiatives in addition to anti-trust enforcement to foster greater competition on price and quality.

How can competition be fostered? For the insurance market, public exchanges created under the Affordable Care Act (ACA) and private insurance exchanges that serve employers can foster competition among insurers in a number of ways. Exchanges reduce entry barriers by reducing the fixed costs of getting an insurer’s products in front of potential customers. Building a brand is less important when your products will be presented to consumers on an exchange along with information on the benefit design, the actuarial value and the provider network. Exchanges make it easier for consumers to make informed choices across plans. This, in turn, makes the insurance market more competitive. Among public exchanges, Covered California has stood out for making this segment of the insurance market more competitive and helping consumers make choices that are better informed.

The rest of my statement is devoted to fostering competition among providers. I believe that fostering competition among providers is a higher priority because the consequences of lack of competition are potentially larger. In addition, a significant regulatory tool, minimum medical loss ratios, part of the ACA, is now in place and can limit the degree to which purchasers pay too much for health insurance in markets with insufficient competition.

Fostering competition in provider markets involves two prongs—broadened anti-trust policy and other policies to foster market forces. Anti-trust policy, at least at the federal level, to date has not addressed hospital acquisitions of physician practices. These acquisitions lead to higher prices to physicians because hospitals can negotiate higher prices for their employed physicians than the physicians were getting in small practices. Although not yet extensive, a developing research literature is measuring the price impact.[2] Hospital employment of physicians can also be a barrier to physicians steering patients to high-value providers (another hospital or a freestanding provider). To the degree that it reduces the chance of larger physician groups or independent practice associations forming, hospital employment of physicians reduces potential competitors in contracting under alternative payment models.

Another area not addressed by anti-trust policy is cross-market mergers. The concern is that a “must have” hospital in a multi-market system could lead to higher rates for system hospitals elsewhere. Anti-trust enforcement agencies have tended to look at markets separately, so this issue tends not to enter their analyses.

Many have seen price and quality transparency as a tool to foster competition among providers. Clearly, transparency has become a societal value and people increasingly expect more information about organizations that are important to them in both the public and private sector. But transparency is often oversold as a strategy to foster competition in health care provider markets. For one thing, many benefit designs have few incentives to favor providers with lower prices. Copays are the same for all providers and with coinsurance, the insurer covers most of the price difference. Even high deductibles are limited in their incentives because almost all in-patient stays exceed large deductibles and out-of-pocket maximums also come into play for many who are hospitalized. Another issue is that the complexity of comparing prices is a “heavy lift” for many consumers. Insurers and employers now have excellent web tools designed to make it easier for patients to compare prices, but indications are that the tools do not get a lot of use.

Network strategies have the potential to be more effective. The concept behind them is that the insurer is acting as a purchasing agent for enrollees. To the extent that they have the potential to shift volume from high-priced providers to low-priced providers, money can be saved in three distinct ways. The first is the higher proportion of services coming from lower-priced providers. The second is the additional discounts from providers seeking to become part of the limited or preferred network. Finally, if a large enough proportion of patients are enrolled in plans with these incentives, providers will likely increase the priority given to cost containment. In creating networks, insurers are increasingly using broader and more sophisticated measures of price as well as some measures of quality. Cost per patient per year or cost for all services involved in an episode is likely to have more relevance than unit prices. Using such measures to judge providers for networks has strong analytic parallels to reformed payment approaches, such as ACOs and bundled payments for episodes of care. Network strategies also create more opportunities for integration of care. For example, a limited network or a preferred tier in a broader network could be mostly limited to providers affiliated with a large health care system. Indeed, some health systems are developing their own health plan or partnering with an insurer to offer plans that favor their own providers.

In this testimony, I discuss two distinct network strategies. One is the limited network, which includes fewer providers than has been the norm in private insurance. The other is the tiered network, where the network is broad but a subset of providers are included in a preferred tier. Patients pay less in cost sharing when they use the preferred providers. Limited networks are a more powerful tool to obtain lower prices because patient incentives are stronger. If patients opt for a provider not in the limited network, they are subject to higher cost sharing and might have to pay the provider the difference between the charge and what the plan allows. Results of these stronger incentives are seen in a number of studies by McKinsey and Co. that have shown that on the public exchanges, limited network plans have premiums about 15 percent lower than plans with broader networks.

Public and private exchanges are an ideal environment for limited network plans. The fixed contributions or subsidies to purchase coverage mean that consumers’ incentives to choose a plan with a lower premium are not diluted—they save the full difference in premium. Exchanges do not have the “one size fits all” requirement that constrains many employers in using this strategy. If an employer is offering only one or two plans, it is important that an overwhelming majority of employees find the network acceptable. But a limited network on an exchange could appeal to fewer than half of those purchasing on the exchange and still be very successful. In addition, tools provided by exchanges to support consumers facilitate comparisons of plans by having each plan’s network accessible on a single web site.

In contrast, tiered networks have the potential to appeal to a larger consumer audience. Rather than making annual choices of which providers can be accessed in network, tiered networks allow these decisions on a point-of-service basis. So the consumer always has the option to draw on the full network. Considering the greater popularity of PPOs than HMOs and the fact that tiered formularies for prescription drugs are far more popular than closed formularies, the potential market for tiered networks might be much larger. But this has not happened. In many markets, dominant providers have blocked the offering of tiered networks by refusal to contract with insurers that do not place them in the preferred tier. This phenomenon was seen in Massachusetts, where 2010 legislation prohibiting this practice led to rapid growth in insurance products with tiered networks.

Some Californians are familiar with a related approach of reference pricing due to the pioneering work that CalPERS has done in this area for state and local employees. Reference pricing is really an “extra strength” version of the tiered network approach. An insurer sets a reference price and patients using providers that charge more are responsible for the difference (although providers sometimes do not charge patients in such plans any more than the reference price). So the incentive to avoid providers whose price exceeds the reference price is quite strong. While CalPERS has had success with joint replacements and some other procedures, a key question is what proportion of medical spending might be suitable to this approach. For reference pricing to be suitable, the services must be “shoppable,” meaning that they must be discretionary with the patient and can be planned in advance. One analysis estimates that only one third of health spending is “shoppable.”[3]

While network approaches have a lot of potential for fostering competition in health care markets, including those that are consolidated, they face a number of challenges that must be addressed. First, transparency about networks must be improved. Consumers need accurate information on which providers are in a network when they choose plans and when they choose providers for care. Accommodation is needed for patients under treatment if their provider should drop out of a network or be dropped from one. Network adequacy regulations are needed to protect consumers from networks that lack access to some specialties or do not have providers close enough to their residence. They are also important to preclude strategies that create networks unlikely to be attractive to patients with expensive, chronic diseases. But if network adequacy regulation is too aggressive, it risks seriously undermining a very promising tool for cost saving. So regulators must very carefully balance consumer protection with cost containment.

Some consider the problem of “surprise” balance bills, charges by out-of-network providers that patients do not choose, to be more significant in limited networks. This may be the case, but the problem is substantial in broader networks as well, and its policy response should apply throughout private insurance.

Another approach to foster competition in provider markets involves steps to foster independent medical practices. Medicare has taken steps to ease requirements for medical practices to contract as ACOs. It recently took some steps to limit the circumstances in which hospital-employed physicians get higher Medicare rates than those in office-based practice. Private insurers have provided support to some practices to incorporate electronic medical records into their practices. To the degree that independent practice can be made more attractive relative to hospital employment, competition in provider markets is likely to increase.

Additional restrictions on anti-competitive behavior by providers can also foster competition. These behaviors include “all or nothing” contracting requirements in which a hospital system requires insurers to contract with all hospitals in the system and “most favored nation” clauses in which insurers get providers to agree not to establish lower rates for other insurers.

Although the focus of discussion about policy in this testimony has been about fostering competition, regulatory alternatives that substitute for competition should not be ignored. At this time, two states—Maryland and West Virginia—regulate hospital rates. Some states, mostly in the Northeast, have been looking at this approach. Although I respect what some states have accomplished with this approach in the past, I need to point out that the current environment poses additional challenges for rate setting. The notion that rates would be the same for all payers, a longstanding component in Maryland, is unlikely to be practical today because rate differences between private insurance, Medicare and Medicaid are so large. So differences would likely have to be “grandfathered.” More practical would be to limit regulation to commercial rates, as West Virginia has done since the 1980s.

Another challenge is that with broad enthusiasm about the prospects for reformed payment, those contemplating rate setting need to make sure that the mechanism encourages payment reform rather than blocks it. Maryland has been quite careful about this and its recent initiative to broaden its program seems promising. But with the recent emphasis on multi-provider approaches to payment, such as ACOs and bundled payment, the limitation of regulatory authority to hospital rates could be a problem.

So what are my bottom lines for legislative priorities? I have two. States should address restrictions on anti-competitive practices such as anti-tiering restrictions, all-or-none contracting restrictions, and most favored nation clauses. My second is to regulate network adequacy wisely. It is a potent tool for fostering competition, even in consolidated markets. Network strategies do have problems that need to be addressed, but it must be done while preserving much of the potency of the approach.

A concluding thought involves acknowledging that provider payment reform approaches are likely to contribute to consolidation. Small hospitals and medical practices are not well positioned to participate, although virtual approaches can often be used in place of mergers, for example as California’s independent practice associations have enabled many small practices to participate. But I see payment reform as having major potential over time to reduce costs and increase quality. So my advice is to proceed with payment reform but also take steps to foster competition. Rate setting is best seen as a “stick in the closet” to use if market approaches should fail to control costs.


[1] Gaynor, M., and R. Town, The Impact of Hospital Consolidation – Update, Robert Wood Johnson Foundation Synthesis Report (June 2012).

[2] Baker, L. C., M.K Bundorf and D.P. Kessler, “Vertical Integration: Hospital Ownership Of Physician Practices Is Associated With Higher Prices And Spending,” Health Affairs, Vol. 35, No 5 (May 2014).

[3] Chapin White and Megan Egouchi, Reference Pricing: A Small Piece of the Health Care Pricing and Quality Puzzle. National Institute for Health Care Reform, Research Brief No. 18, October 2014.

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Africa in the news: COVID-19 impacts African economies and daily lives; clashes in the Sahel

African governments begin borrowing from IMF, World Bank to soften hit from COVID-19 This week, several countries and multilateral organizations announced additional measures to combat the economic fallout from COVID-19 in Africa. Among the actions taken by countries, Uganda’s central bank cut its benchmark interest rate by 1 percentage point to 8 percent and directed…

       




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Why local governments should prepare for the fiscal effects of a dwindling coal industry

       




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The Summit of the Americas and prospects for inter-American relations


Event Information

April 3, 2015
9:00 AM - 10:15 AM EDT

Saul/Zilkha Rooms
Brookings Institution
1775 Massachusetts Avenue NW
Washington, DC 20036

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On April 10 and 11, 2015, the Seventh Summit of the Americas will bring together the heads of state and government of every country in the Western Hemisphere for the first time. Recent efforts by the United States to reform immigration policy, re-establish diplomatic relations with Cuba, and reform our approach to drug policies at home and abroad have generated greater optimism about the future of inter-American relations. This Summit provides an opportunity to spark greater collaboration on development, social inclusion, democracy, education, and energy security.

However, this Summit of the Americas is also convening at a time when the hemisphere is characterized by competing visions for economic development, democracy and human rights, and regional cooperation through various institutions such as the Organization of American States, the Union of South American Nations, and the Community of Latin American and Caribbean States.

On Friday, April 3, the Latin America Initiative at Brookings hosted Assistant Secretary of State Roberta S. Jacobson for a discussion on the Seventh Summit of the Americas and what it portends for the future of hemispheric relations.

Join the conversation on Twitter using #VIISummit

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Perceived Impacts of International Service on Volunteers

International volunteer service is defined as an organized period of engagement and contribution to society by individuals who volunteer across an international border. There is growing interest in the potential of international service to foster international understanding between peoples and nations and to promote global citizenship and intercultural cooperation. Studies suggest that international service develops skills, mindsets, behaviors and networks that prepare volunteers for living and working in a knowledge-based global economy. Many believe that even short-term experiences abroad can begin to prepare participants for longer-term engagement and future international service.

International service may be growing in prevalence worldwide. In the United States, more than one million Americans reported volunteering abroad in 2008. Despite the scale of international service, its impacts are not well understood. Although there is a growing body of descriptive evidence about the various models and intended outcomes of international service, the overwhelming majority of research is based on case and cross-sectional studies, which do not permit conclusions about the impacts of international service. Scholars and practitioners in the field have called for rigorous research that documents impacts.

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  • Amanda Moore McBride
  • Benjamin J. Lough
  • Margaret Sherrard Sherraden
     
 
 




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Impacts of Malaria Interventions and their Potential Additional Humanitarian Benefits in Sub-Saharan Africa


INTRODUCTION

Over the past decade, the focused attention of African nations, the United States, U.N. agencies and other multilateral partners has brought significant progress toward achievement of the Millennium Development Goals (MDGs) in health and malaria control and elimination. The potential contribution of these strategies to long-term peace-building objectives and overall regional prosperity is of paramount significance in sub-regions such as the Horn of Africa and Western Africa that are facing the challenges of malaria and other health crises compounded by identity-based conflicts.

National campaigns to address health Millennium Development Goals through cross-ethnic campaigns tackling basic hygiene and malaria have proven effective in reducing child infant mortality while also contributing to comprehensive efforts to overcome health disparities and achieve higher levels of societal well-being.

There is also growing if nascent research to suggest that health and other humanitarian interventions can result in additional benefits to both recipients and donors alike.

The social, economic and political fault lines of conflicts, according to a new study, are most pronounced in Africa within nations (as opposed to international conflicts). Addressing issues of disparate resource allocations in areas such as health could be a primary factor in mitigating such intra-national conflicts. However, to date there has been insufficient research on and policy attention to the potential for wedding proven life-saving health solutions such as malaria intervention to conflict mitigation or other non-health benefits.

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Image Source: © Handout . / Reuters
      
 
 




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Webinar: The effects of the coronavirus outbreak on marginalized communities

As the coronavirus outbreak rapidly spreads, existing social and economic inequalities in society have been exposed and exacerbated. State and local governments across the country, on the advice of public health officials, have shuttered businesses of all types and implemented other social distancing recommendations. Such measures assume a certain basic level of affluence, which many…

       




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How the AfCFTA will improve access to ‘essential products’ and bolster Africa’s resilience to respond to future pandemics

Africa’s extreme vulnerability to the disruption of international supply chains during the COVID-19 pandemic highlights the need to reduce the continent’s dependence on non-African trading partners and unlock Africa’s business potential. While African countries are right to focus their energy on managing the immediate health crisis, they must not lose sight of finalizing the Africa…