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The Low-Yield Nuclear Warhead: A Dangerous Weapon Based on Bad Strategic Thinking

In the unintuitive world of nuclear weapons strategy, it’s often difficult to identify which decisions can serve to decrease the risk of a devastating nuclear conflict and which might instead increase it. Such complexity stems from the very foundation of the field: Nuclear weapons are widely seen as bombs built never to be used. Historically, granular—even seemingly mundane—decisions about force structure, research efforts, or communicated strategy have confounded planners, sometimes causing the opposite of the intended effect.




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Rosberg fastest ahead of qualifying

Nico Rosberg set the pace in the final practice session for the Malaysian Grand Prix ahead of qualifying, although Mercedes stranglehold on the top appeared to loosen slightly as six cars managed to lap within a second over the hour




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The Low-Yield Nuclear Warhead: A Dangerous Weapon Based on Bad Strategic Thinking

In the unintuitive world of nuclear weapons strategy, it’s often difficult to identify which decisions can serve to decrease the risk of a devastating nuclear conflict and which might instead increase it. Such complexity stems from the very foundation of the field: Nuclear weapons are widely seen as bombs built never to be used. Historically, granular—even seemingly mundane—decisions about force structure, research efforts, or communicated strategy have confounded planners, sometimes causing the opposite of the intended effect.




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The Low-Yield Nuclear Warhead: A Dangerous Weapon Based on Bad Strategic Thinking

In the unintuitive world of nuclear weapons strategy, it’s often difficult to identify which decisions can serve to decrease the risk of a devastating nuclear conflict and which might instead increase it. Such complexity stems from the very foundation of the field: Nuclear weapons are widely seen as bombs built never to be used. Historically, granular—even seemingly mundane—decisions about force structure, research efforts, or communicated strategy have confounded planners, sometimes causing the opposite of the intended effect.




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U.S. chairmanship of the Arctic Council: The challenges ahead


This weekend the United States will assume the chairmanship of the Arctic Council for a two-year term. While the Obama administration has been preparing for this for several years, it remains to be seen how the president will balance the concerns of most Arctic residents who view development of the region as vital to improving their economic and social livelihood and those individuals inside and outside the administration who want to limit development out of concern for the how economic development may cause local environmental degradation while also accelerating climate change.

The National Strategy for the Arctic Region

As part of this preparation, in May 2013, the president launched a new National Strategy for the Arctic Region based on three principles

  1. Advancement of U.S. security interests defined as ensuring the ability of our aircraft and vessels to operate, in a manner consistent with international law through, under, and over the airspace and waters of the Arctic; to support lawful commerce; to achieve greater awareness of activities in the region; and to intelligently evolve our Arctic infrastructure and capabilities including ice-capable platforms as needed;
  2. Pursue responsible Arctic regional stewardship defined as protection of the Arctic environment and conservation of its resources, establishment of an integrated Arctic management framework, charting of the Arctic region, and employment of scientific research and traditional knowledge to increase understanding of the Arctic;
  3. Strengthen international cooperation defined as working through bilateral relationships and multilateral institutions, including the Arctic Council, to advance collective interests, promote shared Arctic state prosperity, protect the Arctic environment, and enhance regional security, and to work toward U.S. accession to the United Nations Convention on the Law of the Sea.

Undergirding these principles were commitments to make decisions using the best available information, to foster cooperation with the state of Alaska, other international partners, the private sector, and to consult and coordinate with Alaskan natives to gain traditional knowledge. As part of this new strategy, the president appointed Admiral Robert J. Papp Jr. as the U.S. special representative for the Arctic in July 2014. Shortly after his appointment, and in several major speeches since, including one at Brookings, the admiral has stated that the administration’s agenda centers on stewardship of the Arctic Ocean including insuring its safety and security, improving economic and living conditions for the regions’ inhabitants, and addressing the impacts of climate change on the region. 

The administration’s new policy was buttressed in January 2015 by an executive order designed to enhance coordination of all the various agencies responsible for different aspects of federal oversight of the Arctic (Alaska). Paradoxically, however, the fact that the reorganization came nearly in tandem with the announcement of new wilderness restrictions on the exploration of oil and gas in the Arctic National Wildlife Refuge (ANWR) and the Arctic Coastal Plain. This announcement left many Alaskans skeptical on how further restrictions on development of the state’s resources could be viewed as improving economic and living conditions of people in the region. In a February 2015 meeting of Arctic Council Senior Arctic Officials (SAOs) in Yellowknife, Canada, the administration looked to put meat on the bones of what it intended to pursue upon assumption of the chairmanship of the Arctic Council. This resulted in an additional elucidation of 15 broad themes that had originally been presented in a Virtual Stakeholder Outreach Forum on December 2, 2014 in Washington, D.C..

Streamlining Arctic policy and key questions

The announced reorganization of government agencies and lines of authority dealing with U.S. Arctic and Arctic Council policy has done little or nothing to streamline the overlapping and sometimes conflicting policies governing natural resource development or energy projects in Alaska. These overlapping jurisdictions are well highlighted in a major new National Petroleum Council (NPC) report, Arctic Potential: Realizing the Promise of U.S. Arctic Oil and Gas Resources. This report was prepared at the request of Energy Secretary Moniz to address how best to pursue prudent development of Alaska’s offshore oil and gas resources and ironically issued shortly after the president’s closing of ANWR. Whether or not the White House was even aware of the NPC’s report, which represented months of substantive work by many people, remains open to question.

The Arctic reorganization plan did little to resolve some key questions as to actually who is in charge of Arctic policy in the United States. While Admiral Papp was named “Coordinator” of the U.S. Arctic Council Chairmanship, this position is not listed in the Council’s enabling documents. Historically, the foreign minister or the secretary of state of the country chairs the Council while a career diplomat chairs the meetings of the senior officials dealing with the day-to-day activities of the Council. It appears that Admiral Papp has neither of these positions. In any case, it looks from the organizational chart that the White House science advisor will be the real coordinator of U.S. Arctic policy.

The chief problem that U.S. Arctic policy must resolve is that while in the Arctic Council we have to address issues affecting the entire Circumpolar North, our domestic Arctic policy centers only on Alaska, where a slew of domestic agencies have overlapping and often conflicting oversight and regulatory responsibilities. The situation is made still more complex by the large amount of the state that is owned by the federal government. This makes it almost inevitable that any resource development project by private or state interests will run into federal government restrictions, in terms of needing to cross federal land to get a resource to market, permitting to ensure that water resources are not polluted, or making sure that fish and wildlife habitats are not disturbed, etc.

Our Arctic policy also suffers from an acute lack of awareness by most Americans that we are an Arctic nation with a huge maritime boundary and very limited resources (ice-worthy ships, proper navigation charts and aids, lack of port facilities, lack of search and rescue capabilities, lack of knowledge of what fishery resources we possess) to protect it. While many of these issues lie outside the scope of the Arctic Council, many are cross-cutting with our Arctic neighbors, most notably with increased traffic in the region (from tourism, fishing, energy development, and shipping) comes the increased possibility of an accident. Currently, the United States does not have the capable means (both in terms of timely response and adequate infrastructure) to respond to an accident in the Arctic, which could be catastrophic, as all of these industries are active and gaining popularity every day.

Core questions for the administration

As the United States takes the helm of the Arctic Council, there are several core issues that the administration must address. Some critical questions are: What is the U.S. position on the development of the Arctic’s oil, gas, mineral, and fishery resources? What specific action is the United States prepared to support in the Arctic Council to uplift the standard of living of Arctic people across the Circumpolar North? Given that each icebreaker costs at least $700 million and that we only have one in operation, what resources are we prepared to expand to build a fleet capable to respond to events in the Arctic? Should any of these expenses be viewed as vital to our national security and defense, and if so, which budget should they be taken out of? What role does the United States in its chairmanship role see for closer interaction between the Arctic Council and the Arctic Economic Council? Would the United States support the closing off of certain ecologically sensitive parts of the Arctic to all commercial exploitation? Finally, how does the administration in its Arctic Council leadership role get its Arctic policy in sync with that of the state of Alaska in its recently released Alaska Arctic Policy Implementation Plan?

Other Arctic nations surpass the United States in terms of Arctic policies. Norway, Russia, Canada, and even Denmark (through complicated ties with Greenland’s claim on the Arctic) all have the Arctic at the front and center of policymaking decisions. I hope to see these issues addressed as the United States moves to enact effective policy on the Arctic over the next two years as the alternative is too great a risk and too great a wasted opportunity. 

     
 
 




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Mobile financial services are making headway in WAEMU


Electronic money, or e-money, emerged in the countries of the West African Economic and Monetary Union (WAEMU) following the adoption, in 2006, of a Central Bank Instruction establishing a flexible regulatory framework aimed at encouraging e-money business. The activity expanded in 2009 with the involvement of telecommunications operators in the provision of mobile telephone-based financial services, which increased the number of users and the volume of transactions.

A growing business

At the end of September 2015, 22 million people, or nearly a quarter of the people in the union, subscribed to financial services via mobile phone. Approximately 30 percent of those subscribers carried out at least one transaction per 90-day period.

Some 500 million transactions took place over the first nine months of 2015. The cumulative value of the transactions was 5 trillion CFA francs ($8.5 billion) by the end of September 2015, a growth of 142 percent from September 2014. Between September 2013 and September 2014, this value grew from CFA 1 trillion to CFA 2.068 trillion, an increase of 107 percent.

The mobile phone financial services distribution network followed a similar upward trend, rising from 93,621 points of services in 2014 to more than 132,658 at the end of September 2015.

Figure 1. Trends in the value of transactions

The socioeconomic environment in the union goes a long way to explaining the success of mobile telephone payment services. Indeed, this method of providing money transfer or payment services is particularly well suited to people who lack access to the mainstream banking system, and also affords non-bank institutions the opportunity to offer users non-cash money against cash deposits, which can then be used for a variety of financial transactions.

The growing involvement of telecommunications operators

The market is increasingly dominated by partnerships between banks and telecommunications operators, which represented 25 of the 33 licensed or authorized e-money issuers at the end of December 2015. In the framework of this model, known as the bank model, the bank has responsibility for issuing the e-money.

The other seven non-bank institutions, under the non-bank model, are authorized to issue electronic money as “Electronic Money Institutions” (EMIs) [1].

In WAEMU, e-money issuers are supported by a regulatory framework that was revised in 2015 to ensure increased security and quality of payment services backed by electronic money.

Figure 2. E-money issuers in WAEMU

Note: DFS denotes microfinance institutions.

A revised regulatory framework

With the expansion of mobile phone financial services and the growing involvement of telecommunications operators, the Central Bank has revised its regulatory framework with the aim of enhancing the security and quality of payment services backed by electronic money. The most salient improvements must focus on:

  • Increasing issuer accountability by clarifying users’ roles in partnerships with technical service providers. With this goal in mind, the activities of technical service providers have been restricted to technical processing or the distribution of e-money under the responsibility of the issuer. In addition, issuers are responsible for the integrity, reliability, security, confidentiality, and traceability of all transactions carried out by all of their distributors; Stimulating competition through transparent pricing with an obligation for issuers to publish their rates;

  • Specific requirements in terms of governance and internal and external audits for electronic money institutions, standards of integrity on the part of the management, professional secrecy and regular infrastructure audits;

  • Increased protection for bearers of electronic money, including keeping funds in dedicated accounts, requiring a constant equivalence between the amount of e-money and the balances in the dedicated accounts, and mandatory creation of a mechanism to take in and deal with complaints by bearers of electronic money;

  • Reinforcement of the supervisory mechanism by reducing deadlines for reporting on issuers’ activities to the Central Bank and adopting sanctions for violations of regulatory provisions.

Provision of mobile-phone-based financial services

Mobile-phone-based financial services provided in WAEMU include three categories of services, namely services involving the use of cash (banknotes and coins), e-money services, and so-called “second generation” services.

The first type of service essentially involves deposits of cash or refilling of electronic wallets, as well as withdrawals. This type of service represents 24 percent of user transactions. Cash deposits predominate; they allow customers to provision their electronic money accounts.

Seventy-six percent of the funds deposited into e-money accounts are used, above all, for purchases of telephone credit, payment of bills, person-to-person money transfers, and money transfers from individuals to businesses and from individuals to government agencies. The main payment services found in WAEMU pertain to payment of water or electricity bills, payment of satellite television subscriptions, and purchases of goods in supermarkets or fuel at service stations.

Payments of taxes or income taxes to government agencies and payments of micro-loan installments are also made through mobile phone financial services, but are much less common.

So-called “second generation” services, namely micro-insurance, micro-savings, and micro-credit, are currently emerging in WAEMU. Their development could be an opportunity to provide access to the banking system for the users of the services.

Finally, interoperability is just beginning to be implemented based on bilateral agreements between stakeholders, particularly with a view to offering cross-border payment services between member states of the union.

Challenges

A review of the development of mobile phone financial services in WAEMU reveals some obstacles to the rapid development of this type of financial service within WAEMU. They include:

  • a low number of active users, due to the high cost of the services;
  • the fact that the services are not well known due to inadequate financial education;
  • the low rate of digitization of government agencies’ payment systems; and
  • insufficient partnerships between bank and non-bank issuers with a view to developing a more inclusive range of “second-generation” services.

In collaboration with all stakeholders, the Central Bank has developed a financial inclusion strategy to continuously improve, access to and use of diverse, tailored and affordable financial services. The implementation of these actions as described in the Central Bank of West African States (BCEAO) financial inclusion strategy should support the challenges mentioned above.

Read in French »


[1] EMI: any legal entity, other than a bank, financial payment institution, or decentralized financial system, that is authorized to issue payment instruments in the form of electronic money and whose business activities are restricted to electronic money issuing and distribution.

Authors

  • Tiémoko Meyliet Koné
      
 
 




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Behind the headlines: 15 memos on race and opportunity


This year shone a bleak light on the deep racial divides of the U.S. The flash-points of Ferguson, Baltimore and Chicago gave new impetus to movements to reform the criminal justice system and policing. But behind the headlines, the evidence for wide, stubborn race gaps on economic and social indicators is perhaps more troubling still. 

Especially for black Americans, race gaps in family formation, employment, household income, wealth, educational quality, and neighborhood segregation have shown little­—if any—sign of improvement in recent years. The very first Social Mobility Memos was about the barriers to black upward mobility, and in recent months, we have been focusing increasingly on issues of race, place, and opportunity, and here, to close 2015, we recap 15 of our pieces on the subject, including pieces from our colleague Jonathan Rothwell on college, drugs and neighborhoods, and the first Brookings piece from our new nonresident scholar, William Julius Wilson. 

Our hope is that 2016 will see a much greater focus on race and opportunity in America. 

1. Five Bleak Facts on Black Opportunity, Richard V. Reeves and Edward Rodrigue

What would Martin Luther King Jr. think of America in 2015 if he’d lived to see his eighty-sixth birthday? No doubt, he’d be pleased by the legal and political advances of black Americans, crowned by the election and re-election of President Obama.

2. Four charts that show the opportunity gap isn’t going away, Richard V. Reeves

Child poverty rates are coming down slowly, according to figures from the Pew Research Center, except among one racial group: African Americans. This is the latest reminder that the economic gap between black and white Americans is not closing over time. Indeed, on some dimensions, it is widening.

3. Obama’s Post-Presidency? Tackling the Social Mobility Challenge for Black Men, Richard V. Reeves

President Obama’s initiative to boost opportunities for young black men—My Brother’s Keeper—looks to be a post-presidential plan, as much as presidential one. Valerie Jarrett, his closest aide, said that it was a vocation the president and first lady Michelle Obama will undertake “for the rest of their lives…That’s a moral, social responsibility that they feel will transcend the time that he’s president.”

4. School readiness gaps are improving, except for black kids, Richard V. Reeves

Between 1998 and 2010, inequality in school readiness—in terms of math, reading, and behavior—declined quite significantly, according to Reardon and Portilla’s analysis of ECLS data, being presented today at the Association for Public Policy Analysis and Management Annual Conference. This positive trend can be seen for gaps in both income and race (or at least, for Hispanic-white differences).

5. Rich Neighborhood, Poor Neighborhood: How Segregation Threatens Social Mobility, Patrick Sharkey

Racial segregation in American cities has declined slowly, but steadily over the past four decades. This is good news. Over the same timeframe, however, the level of economic segregation has been rising. Compared to 1970, the rich are now much more likely to live in different communities than the poor.

6. Segregation and concentrated poverty in the nation’s capital, Stuart M. Butler and Jonathan Grabinsky

The social mobility gap between black and white Americans has barely narrowed in the last decades, and sharp differences in access to opportunity persist. This racial opportunity gap can, in part, be traced back to the neighborhoods where whites and blacks grow up: research from urban sociologists like Patrick Sharkey and Robert Sampson shows the damaging effects racial segregation and concentrated neighborhood poverty can have on children’s life chances. Washington, D.C. is a case in point.

7. The other side of Black Lives Matter, William Julius Wilson

Several decades ago I spoke with a grieving mother living in one of the poorest inner-city neighborhoods on Chicago’s South Side. A stray bullet from a gang fight had killed her son, who was not a gang member. She lamented that his death was not reported in any of the Chicago newspapers or in the Chicago electronic media.

8. Guns and race: The different worlds of black and white Americans, Richard V. Reeves and Sarah Holmes

“The nation’s consciousness has been raised by the repeated acts of police brutality against blacks. But the problem of public space violence—seen in the extraordinary distress, trauma and pain many poor inner-city families experience following the killing of a family member or close relative—also deserves our special attention.”

9. Measuring the Racial Opportunity Gap, Richard V. Reeves and Quentin Karpilow

The U.S. is sharply divided by race, not least in terms of the opportunities for children—a point that a new report from the Annie E. Casey Foundation vividly shows. At every life stage, there are gaps between kids of different colors.

10. How the War on Drugs Damages Black Social Mobility, Jonathan Rothwell

The social mobility of black Americans has suffered collateral damage from the “War on Drugs.” Being convicted of a crime has devastating effects on the employment prospects and incomes of ex-felons and their children, as my Brookings colleagues and other scholars have found. These findings are often used to motivate efforts to reduce criminal behavior. They should also motivate changes in our criminal justice system, which unfairly punishes black Americans—often for victimless crimes that whites are at least as likely to commit.

11. Black Students at Top Colleges: Exceptions, Not the Rule, Jonathan Rothwell

A generation has been lost in the journey towards race equality in terms of income. The income gap between blacks and whites has been stuck since 1980. Why? Dozens of factors count, of course, but one in particular is worth further exploration: the underrepresentation of black students in elite colleges. As I noted in a previous blog, this could help to explain why blacks earn less than whites, even in the same occupation and with the same level of education.

12. The stubborn race and class gaps in college quality, Jonathan Rothwell

Increasing the number of low-income adults going to—and through—college is an important step towards greater social mobility and reduced income inequality. College is also an important tool for tackling race gaps. But the challenge is not just about quantity: college quality counts for a good deal, too.

13. Single black female BA seeks educated husband: Race, assortative mating and inequality, Edward Rodrigue and Richard V. Reeves

There is a growing trend in the United States towards assortative mating—a clunky phrase that refers to people’s tendency to choose spouses with similar educational attainment. Rising numbers of college-educated women play a key role in this change. It is much easier for college graduates to find and marry each other when there are more equal numbers of each gender within an educational bracket.

14. Sociology’s revenge: Moving to Opportunity (MTO) revisited, Jonathan Rothwell

Neighborhoods remain the crucible of social life, even in the internet age. Children do not stream lectures—they go to school. They play together in parks and homes, not over Skype. Crime and fear of crime are experienced locally, as is the police response to it.

15. Space, place, race: Six policies to improve social mobility, Richard V. Reeves and Allegra Pocinki

Place matters: that’s the main message of Professor Raj Chetty’s latest research. This supports the findings of a rich body of evidence from social scientists, but Chetty is able to use a large dataset to provide an even stronger empirical foundation. Specifically, he finds that children who move from one place to another have very different outcomes, depending on whether they move to a low-opportunity city or a high-opportunity one.
Image Source: © David Ryder / Reuters
     
 
 




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Bioscience will accelerate East-West convergence in the century ahead


If current economic growth trends persist, the “great divergence” between Western Europe and East and South Asia in per capita income that commenced 200 years ago will close sometime this century. Key to the closing will be greater accessibility to technology, higher education in East and South Asia, and the relentless diffusion of knowledge including in the biosciences. Advances in the biosciences are poised to contribute in a major way to English economist Thomas Malthus’s four necessities of human life–food, fiber, fuel, and building materials–as well as to human and animal health, biodiversity conservation, and environmental remediation and sustainability.

As my coauthor Leo Furcht and I recently wrote in “Divergence, Convergence, and Innovation: East-West Bioscience in an Anxious Age”, 21st century history will describe the great economic and technological convergence between East and West. It will also further entwine the economic and ecological storylines of the human experience as the vast populations of China and India strive to enter the middle class. Environmentally sustainable economic growth will require putting knowledge of life code, cellular processes, biosynthesis, and biological regeneration to practical use. That prospect is at hand because the biosciences are in the midst of their own convergence–with information technology, nanotechnology, microelectronics, materials, artificial intelligence, robotics, architecture, and design.

From William Hoffman and Leo Furcht, "The Biologist’s Imagination: Innovation in the Biosciences" (Oxford University Press, 2014)

Biomolecules, brainpower, and Malthusian limits

Products arising from molecular biology constitute a growing share of the global economy with each passing year as technologies evolve, production processes improve, and markets expand. In recent years industrial biotechnology has grown faster than the biologic drugs and agricultural biotech sectors in the U.S.

 

U.S. biotech revenue in billions of U.S. dollars.
Source: Robert Carlson, "Nature Biotechnology", In press

Industrial biotechnology employs greener and cleaner technologies to make chemicals, solvents, fuels, and materials such as biocomposites and bioplastics. Growth in this sector can weaken the link between economic growth, environmental pollution, and greenhouse gas emissions. Genomics, synthetic biology and metabolic engineering are poised to accelerate growth in the design and manufacture of industrial enzymes and renewable bio-based products. East and South Asian production and consumption of industrial enzymes are on the rise as the Asian middle class expands.

Bioscience is enabling major cereal crops such as wheat, rice, and corn to adapt to a changing climate. Cereal crop yields need to grow by an estimated 70 percent by mid-century to feed the projected nine billion people expected to then inhabit our planet. The challenge of feeding nine billion people without further deforestation and environmental degradation has resurrected the specter of Malthusian limits to our planet’s ecological carrying capacity. These limits are expressed in food and water shortages, forced migrations, political instability, armed conflict, abatement and cleanup activities, and health care related to pollution and climate change. Even with the powerful tools of food crop bioscience–marker-assisted selection, targeted mutation-selection, genetic modification, and others–maintaining crop production levels at expected higher temperatures and with less water is highly questionable.

Precise genomic editing of cereal grains could equip rice, wheat, and corn with nitrogen fixation capabilities, thus reducing the need for synthetic fertilizers with their environmental and atmospheric costs. East and South Asia, facing major food production challenges, ecological limits, pollution from fertilizer use, and drought from climate change, may take the lead over the West in adopting innovative food crop technologies.

Meanwhile, hundreds of thousands of human beings of many ethnicities have had their genomes decoded over the past decade, with the number expected to increase exponentially as sequencing technologies grow in productivity and decline in price. Genomic information coupled with precise genomic editing and bioregenerative tools give us unprecedented power to shape the course of evolution, including our own.

             

Cost trend of sequencing a human-sized genome and Moore’s Law 2001 – 2015.
Source: Kris A. Wetterstrand, DNA Sequencing Costs: Data from the NHGRI Genome Sequencing Program.

The practice of technological innovation in the industrial era – the systematic application of ideas, inventions and technology to markets, trade, and social systems–is now being joined with the code of life, DNA, and the basic unit of life, the cell. Even as the economic gap between East and West narrows, no other convergence has such profound implications for our future and the future health of living systems and ecosystems. That makes the task for policymakers a daunting one.

Authors

  • William Hoffman
Image Source: © Rebecca Cook / Reuters
       




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Danger ahead? Taiwan’s politics, China’s ambitions, and US policy

It is a great honor for me to speak today at the Hamilton Lugar School, not only because I worked for Congressman Lee Hamilton for two and a half years, but also because he and Senator Lugar have represented something very important about the politics of U.S. foreign policy. They were in their time two…

       




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Ask the Expert: Former CMS Head Breaks Down ACO Lessons to Date

A new approach to delivering -- and paying for -- health care made its debut three years ago and has been picking up steam ever since. Accountable care organizations (ACOs) are growing rapidly nationwide, offering the promise of coordinated patient care at a lower cost.

Yet, making the transition away from operating as a single, discrete practice unit according to a fee-for-service payment model can, admittedly, be difficult. Created as part of the Patient Protection and Affordable Care Act, ACOs are drawing close scrutiny from many different stakeholders.

Mark McClellan, M.D., Ph.D., recently discussed with AAFP News some early returns on ACOs, including the fact that many physician-led groups are moving to the new payment model. A former administrator of CMS, McClellan now serves as director of the Health Care Innovation and Value Initiative at the Brookings Institution in Washington.

Q: Are ACOs just a repackaged version of HMOs from the 1990s?

A: No, they are different. First, the ACOs directly involve clinicians in accountability for a population of patients rather than simply relying on the health plan. Second, in contrast with the cost-control approach of many managed care plans in the 1990s, there are now more effective tools to do clinical management and handle some form of capitation-based payments.

Q: How does a physician practice make the transition to an ACO?

A: It's a shift from the fee-for-service model whereby the practice starts to take on the overall financial risk for their patients. This means their approach to care has to change to reduce costs, but it also means they have new resources to make those changes financially sustainable.

Access to physicians or nurses in the practice should increase, ideally, to have 24/7 staffing to help avoid costly complications and avoidable admissions. A patient registry of individuals with chronic diseases or risk factors can help identify where and how to intervene. These are the types of things that, under a fee-for-service payment system, you don't get paid for, but in an ACO model, you can.

Q: How would you characterize the growth in ACOs to date and into the future?

A: I think accountable care will continue to grow, including payments that are tied more directly to results and that give clinicians more flexibility in how they deliver care. Many ACOs are integrated organizations like Health Care Partners, Monarch HealthCare and the University of Michigan.

But recently, there has been more growth in smaller ACOs led by physician groups, often primary care (physicians). These ACOs may consist of 20 to 30 doctors and are not affiliated with a hospital. They are still physician-owned, but they may be jointly financed by other co-investing organizations, like health plans or practice management programs, that also share in the savings.

Q: Can smaller physician groups be successful within the ACO model?

A: There are some promising ACOs made up of small practices. Some of these practices formed an ACO in a way that builds upon the traditional IPA (independent practice association) model. One of the advantages of the newer, physician-led ACOs is that they have clearer financial benefits to the physicians when they are able to reduce costs.

In contrast to traditional fee-for-service payment, in a physician ACO, when the group takes steps to reduce outpatient visits or hospital visits, they capture the savings. For hospital-affiliated ACOs, some of those savings are offset by reduced payments to the hospital.

There is new, hard work that needs to be done in terms of tracking patients. It's not just about insurance claims. These smaller ACOs are collaborating on population health management tools and information technology tools. You do need technology infrastructure to support specific changes in care to improve outcomes for your patient.

Q: Can ACOs with no hospital affiliation succeed?

A: Yes. Some of these ACOs are achieving impressive early results, and a lot of physician-led groups are more comfortable taking on population risks. Our research indicates that physician-led ACOs do not have to have a huge impact on care to succeed. For example, a physician-led ACO that reduces hospital visits by 1 percent to 2 percent can double the net revenues for its physicians. It's a very promising opportunity. A lot of physician groups are interested, and we're learning more about what it takes to succeed.

Q: What's an average timeline for an ACO to be declared successful?

A: For those that do succeed, it's likely to be a marathon and not a sprint. Some ACOs are already reporting gains in terms of improved quality of care, care coordination and cost reduction through steps like better management of high-risk patients and modifying referral and admission patterns. Other steps may take longer. For diabetes management, it could take about 12 to 24 months for improvements in care to translate into significant cost savings. With congestive heart failure, it can happen sooner.

As clinicians in ACOs get more experienced and comfortable with coordinating care and managing a patient's overall care experience, it's likely that they will want to implement additional payment reforms to move away from fee-for-service, which, in turn, means more resources for innovative approaches to care.

Q: Overall, how is the first wave of ACOs doing in enhancing quality and reducing costs?

A: In general, the ACOs are doing pretty well in terms of quality of care and improving on important quality measures. Financially, about half of the 114 ACOs participating in the Medicare Shared Savings Program reported that they reduced Medicare spending in their first year of operation.

About 29 percent of physician-led ACOs and 20 percent of hospital ACOs demonstrated large enough savings to qualify for the shared-savings payments. Some private-sector ACOs, like the Alternative Quality Contract developed by Massachusetts Blue Cross, show growing effects on costs over time. It's likely to be the case that some ACOs won't succeed and others will.

Q: How do the shared-savings models used by Medicare today compare with ACOs in terms of moving away from fee-for-service?

A: Many private-sector ACO plans and some Medicaid programs are offering bigger shifts away from fee-for-service. As ACOs gain more experience, I think these payment reforms will be more attractive. In addition, some private-sector health plans are including financial and other incentives to attract patients. They might offer discounted premiums or copay discounts for patients who stay engaged with their ACO. In other words, the patients can share in the savings, too. As care continues to get more individualized, patient engagement in the ACO initiatives will be increasingly important.

Publication: AAFP News
      




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The Road Ahead for China’s Economy

Event Information

April 16, 2013
9:00 AM - 4:30 PM EDT

Falk Auditorium
Brookings Institution
1775 Massachusetts Avenue NW
Washington, DC 20036

Register for the Event

In recent years, China has increasingly confronted new challenges in economic policy, including rising labor costs, low household consumption, rapid urbanization and inefficient domestic investment. While it is now widely acknowledged in Beijing that major structural adjustments are needed to address these issues, implementing serious reforms pose major challenges for the newly installed leadership.

On April 16, the John L. Thornton China Center at Brookings and China’s Caixin Media Group hosted a conference to examine the daunting challenges confronting China’s new leaders. The morning panels featured a discussion of the financial sector as well as the relationship between the domestic agenda for financial reform and China’s evolving strategy for outbound investment. The afternoon panels took a close look at the political obstacles to implementing major economic reform in areas such as tax policy, the household registration system and land transfers, as well as explore the impact of environmental and natural resource constraints on China’s economic growth.

Audio

Transcript

Event Materials

     
 
 




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COP 21 at Paris: The issues, the actors, and the road ahead on climate change

At the end of the month, governments from nearly 200 nations will convene in Paris, France for the 21st annual U.N. climate conference (COP21). Expectations are high for COP21 as leaders aim to achieve a legally binding and universal agreement on limiting global temperature increases for the first time in over 20 years. Ahead of this…

       




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Immigration and the U.S. labor market: A look ahead

       




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COP 21 at Paris: The issues, the actors, and the road ahead on climate change

At the end of the month, governments from nearly 200 nations will convene in Paris, France for the 21st annual U.N. climate conference (COP21). Expectations are high for COP21 as leaders aim to achieve a legally binding and universal agreement on limiting global temperature increases for the first time in over 20 years. Ahead of this…

       




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COP 21 at Paris: The issues, the actors, and the road ahead on climate change

At the end of the month, governments from nearly 200 nations will convene in Paris, France for the 21st annual U.N. climate conference (COP21). Expectations are high for COP21 as leaders aim to achieve a legally binding and universal agreement on limiting global temperature increases for the first time in over 20 years. Ahead of this…

       




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40 years later: America’s energy path and the road ahead

In a 1976 Foreign Affairs article, Amory Lovins offered a novel—and controversial—vision for America’s energy strategy. With U.S. security and energy independence threatened by oil market instability, Lovins urged policymakers to move away from fossil fuels and nuclear and towards efficiency and renewable energy. This “soft energy path,” he argued, offered a myriad of clear…

       




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Iran-P5+1 Nuclear Negotiations: The Road Ahead

A year of negotiations between Iran and the P5+1 partners based on the Joint Plan of Action (JPOA), adopted in Geneva in November 2013, has produced significant progress, but a comprehensive deal has so far proved elusive. With important differences reportedly remaining but with the parties actively engaged in the run-up to the JPOA’s current…

       




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Gisele Bündchen and Don Cheadle have an environmental challenge for you

Celebrity ambassadors call for support for the UN’s World Environment Day.




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Climate Care Heads Down Under

Australians may be world leaders in terms of greenhouse gas emissions, but with their new government signing Kyoto as one of its first acts in power, it seems change may well be in the air. So, is Australia about to go green in a big way? UK-based




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Bear's Head Freed From Jar After Three-Week Search

Late last month, when officer Shelley Hammonds of the Tennessee Wildlife Resources Agency received word of an animal in distress, it might have sounded like a routine rescue operation. Witnesses described




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Turkish Fisherman Shot in Head as Fight Against Unsustainable Fishing Gets Ugly in Istanbul

A fisherman who had criticized illegal fishing practices loses an eye in an armed attack as diminishing fish stocks and increased debts create a volatile atmosphere.




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Flipping anti-bike arguments on their heads (+funny video)

More bikers take to Twitter to mock bike haters.




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Selenium Contamination Linked to Two-Headed Trout Near Idaho Phosphate Mine

A government report has found that selenium contamination is connected to fish deformities, including two-headed trout.




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Terrapax Bags: Ahead of Their Time?

With the demise of Nau, many commentators have been suggesting the trouble was that the company was ahead of its time. We respectfully disagree. Firstly, if ever there was a time for businesses to flourish, who are environmentally and socially




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Have we reached Peak Curtains? IKEA's head of sustainability thinks so.

We have lots of stuff, it's just unevenly distributed.




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'Headless chicken monster' filmed for the first time near Antarctica

Scientists hope the technology that filmed it can make fishing more sustainable.




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Go ahead and AVA Byte of fresh produce from this countertop garden

This soil-free smart garden promises fresh greens and veggies that are grown as local as it gets.




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Let's stop calling the new headquarters for Apple, Facebook and Google "Green": Look at the parking ratios

You just have to look at the parking ratios to know they are environmental disaster areas.




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Throwaway Economy Headed for Junk Heap of History

The challenge is to re-evaluate the materials we consume and the way we manufacture products so as to cut down on waste.




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Apple kills the headphone jack on the iPhone. Good idea or planned obsolescence?

There are a lot of good reasons to get rid of that old plug.




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House of Marley makes bamboo headphones and speakers

And they don't stop there. Their products also feature recycled plastic, fabric, silicone, and more.




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What's all that stuff on Sir Adam Beck's head?

It's an interesting art installation that brings some attention to an electrifying man.




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How a cheap plywood temporary building became the inspiration for Google's new headquarters

It may well be more Jane Jacobs and Stewart Brand than it is Bjarke Ingells.




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Google Glass heads into the operating room

The optical display device that is often the subject of ridicule has proven itself to be a very valuable asset to surgeons.




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Bird's head of sustainability on the future of micromobility

Melinda Hanson talks to TreeHugger about taking back the streets.




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BMW Vision EfficientDynamics Unveiled Ahead of Frankfurt Show

Ahead of the Frankfurt Auto Show starting 14 September, BMW is drumming up buzz for a completely new concept car, the Vision EfficientDynamics. BMW today released a video (over the fold) promising all the sporty driving fun of the BMW M3 in




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Radiohead's Thom Yorke releases song to help Antarctica (video)

In support of Greenpeace's Antarctic campaign, this may be the prettiest video I've ever watched – and the cause couldn't be more important.




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Coke's UK head of sustainability says we don't have a packaging problem, we have a waste and litter problem

This is the "guns don't kill people, people kill people" defense.




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Porsche American Headquarters Has Green Roof, Natural Ventilation

There is something contradictory about building a Green Porsche Headquarters at an Aeropolis, but whatever.




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Headline of the week: Suburbs will thrive forever

Forever is a very long time.




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Campbell's Says It's Heading BPA-Free

Under pressure from parents and breast cancer groups, Campbell's Soup says it has transition plan away from BPA in motion




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Radio Nacional de España's Headquarters Are Solar Controlled (Photos)

Here's a building that saves up to 50% CO2 by controlling the sunlight with screens on its facade.




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What Were They Thinking? USGBC in Connecticut Gives Award to Nestle Waters' Headquarters

The bottled water company responsible for profound and pointless waste of water and fossil fuels is praised for low flush toilets and white roofs.




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SugarSky headbands are handmade and handsome

Add some pizzazz to your hairdo with these fun, colorful accessories, all made in USA.




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Slice of paradise created for critically endangered toad-headed turtle

A 297-acre property in rural northern Colombia will become the first and only reserve for the conservation of the Dahl’s toad-headed turtle.




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Summertime means heading to the shore, in both town and country

Katherine lives in rural Ontario. Margaret lives in New York City. The way they enjoy their summers is bound to be drastically different.




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When did we stop wearing toilets on our heads?

How did a piece of fabric become a porcelain bowl?




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Hate your job? Pack it up, pack it in - it's time to head out West - Monster and Brandwatch break down exactly how Americans are feeling about their jobs

Monster and Brandwatch break down exactly how Americans are feeling about their jobs.





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belVita Introduces A New Way To Get Ahead, With A Fake British Accent - belVita British Business Man

Alongside new “British Businessman” digital spot, belVita debuts its latest tool to help you fake it ‘til you make it.