Transpupillary collagen photocrosslinking for targeted modulation of ocular biomechanics.

The central vision-threatening event in glaucoma is dysfunction and loss of retinal ganglion cells (RGCs), thought to be promoted by local tissue deformations. Here, we sought to reduce tissue deformation near the optic nerve head by selectively stiffening the peripapillary sclera, i.e. the scleral region immediately adjacent to the optic nerve head. Previous scleral stiffening studies to treat glaucoma or myopia have used either pan-scleral stiffening (not regionally selective) or regionally selective stiffening with limited access to the posterior globe. We present a method for selectively stiffening the peripapillary sclera using a transpupillary annular light beam to activate methylene blue administered by retrobulbar injection. Unlike prior approaches to photocrosslinking in the eye, this approach avoids the damaging effects of ultraviolet light by employing red light. This targeted photocrosslinking approach successfully stiffened the peripapillary sclera at 6 weeks post-treatment, as measured by whole globe inflation testing. Specifically, strain was reduced by 47% when comparing treated vs. untreated sclera within the same eye (n = 7, p=0.0064) and by 54% when comparing the peripapillary sclera of treated vs. untreated eyes (n = 7, p<0.0001). Post-treatment characterization of RGCs (optic nerve axon counts/density, and grading), retinal function (electroretinography), and retinal histology revealed that photocrosslinking was associated with some ocular toxicity. We conclude that a transpupillary photocrosslinking approach enables selective scleral stiffening targeted to the peripapillary region that may be useful in future treatments of glaucoma.

The role of citizen science in addressing grand challenges in food and agriculture research.

The power of citizen science to contribute to both science and society is gaining increased recognition, particularly in physics and biology. Although there is a long history of public engagement in agriculture and food science, the term 'citizen science' has rarely been applied to these efforts. Similarly, in the emerging field of citizen science, most new citizen science projects do not focus on food or agriculture. Here, we convened thought leaders from a broad range of fields related to citizen science, agriculture, and food science to highlight key opportunities for bridging these overlapping yet disconnected communities/fields and identify ways to leverage their respective strengths. Specifically, we show that (i) citizen science projects are addressing many grand challenges facing our food systems, as outlined by the United States National Institute of Food and Agriculture, as well as broader Sustainable Development Goals set by the United Nations Development Programme, (ii) there exist emerging opportunities and unique challenges for citizen science in agriculture/food research, and (iii) the greatest opportunities for the development of citizen science projects in agriculture and food science will be gained by using the existing infrastructure and tools of Extension programmes and through the engagement of urban communities. Further, we argue there is no better time to foster greater collaboration between these fields given the trend of shrinking Extension programmes, the increasing need to apply innovative solutions to address rising demands on agricultural systems, and the exponential growth of the field of citizen science.

Worker decisions to purchase health insurance.

Studying worker health insurance choices is usually limited by the absence of price data for workers who decline their employer's offer. This paper uses a new Medical Expenditure Panel Survey file which links household and employer survey respondents, supplying data for both employer insurance takers and declines. We test for whether out-of-pocket or total premium better explains worker behavior, estimate price elasticities with observed prices and with imputed prices, and test for worker sorting among jobs with and without health insurance. We find that out-of-pocket price dominates, that there is some upward bias from estimating elasticities with imputed premiums rather than observed premiums, and that workers do sort among jobs but this does not affect elasticity estimates appreciably. Like earlier studies with less representative worker samples, we find worker price elasticity of demand to be quite low. This suggests that any premium subsidies must be large to elicit much change in worker take-up behavior.

The health status of workers who decline employer-sponsored insurance.

This paper uses data from the 1997 National Health Interview Survey to compare workers who decline employers' offers of health insurance (decliners) with comparison groups of workers who take up offers of employer coverage and those who do not have such offers. Uninsured decliners fare much worse than coverage takers on every mental health measure. While the evidence on physical health measures is somewhat mixed, decliners who are not healthy appear to have greater difficulty obtaining needed services than do workers who take up employer coverage, although decliners tend to have somewhat better access than do the uninsured who are not offered such coverage.

Who really wants price competition in Medicare managed care?

There is much policy talk about making Medicare more competitive, like private markets. But when reform proposals near implementation, local opponents of competition are often able to stop reform experiments. This paper reports on one recent example, the Competitive Pricing Advisory Committee, created by the 1997 Balanced Budget Act (BBA) to bring competitive bidding to Medicare + Choice plans. After design and site-selection choices were announced, members representing local interests were able to delay and perhaps kill competitive bidding before it could start, once again. A public report of this story may save future market-based Medicare reforms from a similar fate.

Nonprofit conversion: theory, evidence, and state policy options.

OBJECTIVE: To describe the contributions of nonprofit hospitals and health plans to healthcare markets and to analyze state policy options with regard to the conversion of nonprofits to for-profit status. DATA SOURCES/STUDY SETTING: Secondary national and state data from a variety of sources, 1980-present. STUDY DESIGN: Policy analysis. DATA COLLECTION/EXTRACTION METHODS: Development of a conceptual economic framework; analysis of empirical, legal, and theoretical literature; and review of statutes, rules, and court decisions. PRINCIPAL FINDINGS: Three main rationales support special status for nonprofits, especially hospitals: charity care, other community benefits, and consumer protection. The main social rationale for for-profits is their incentives for better efficiency. There are reasons to expect that nonprofit and for-profit goals differ; however, measured differences in community hospital cost, prices, and quality between nonprofit and for-profit hospitals are undetectable or inconclusive. Nonprofit hospitals do provide more uncompensated care than for-profit hospitals. Similarities between nonprofit and for-profit hospitals may exist because nonprofits may set norms that for-profits follow to some degree. States have substantial power and discretion in overseeing nonprofit conversions. Some have regularized oversight through new legislation that constrains, but does not eliminate, state officials' discretion. These statutes may be deferential to converting entities and their buyers or may be very restrictive of them. CONCLUSIONS: Overseeing the appropriate disposition of nonprofit assets in individual conversions is extremely important. States should also monitor local market conditions through community benefits assessments and other data collection, however, to accurately assess (and possibly redress) what is lost or gained from conversion. Local market conditions are likely more important in determining hospital behavior than ownership form. Potentially, a mix of for-profit and nonprofit hospitals in a given market may improve market performance due to constraints the two ownership types may exercise over one another. If nonprofits disappear, the states may need to maintain quality and access norms through regulation.

A different kind of 'new federalism'? The Health Insurance Portability and Accountability Act of 1996.

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 has been praised and criticized for asserting federal authority to regulate health insurance. We review the history of federalism and insurance regulation and find that HIPAA is less of a departure from traditional federal authority than it is an application of existing tools to meet evolving health policy goals. This interpretation could clarify future health policy debates about appropriate federal and state responsibilities. We also report on the insurance environments and the HIPAA implementation choices of thirteen states. We conclude with criteria for judging the success of HIPAA and the evolving federal/state partnership in health insurance regulation.

The Health Insurance Portability and Accountability Act of 1996: summary of provisions and anticipated effects.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA; PL 104-191), popularly known as the Kassebaum-Kennedy legislation, contains a broad array of provisions with collective implications for a large segment of the population. The legislation contains provisions affecting the private insurance markets, the federal tax code, and strategies for decreasing fraud and abuse and for increasing the simplification of administrative procedures. Two objectives hold together the disparate pieces of this legislation. The first objective is to improve the accessibility of insurance for individuals with preexisting medical conditions. The second objective is to make health insurance and health services more affordable. This article is designed to provide an overview of the multiple components of HIPAA, and to identify the parties that are likely to be affected by each component. It concludes with a discussion of how well HIPAA can be expected to fulfill its two goals.

The resurgence of selective contracting restrictions.

As managed care has spread, so has legislation to force plans to contract with any willing provider (AWP) and give patients freedom of choice (FOC). Managed care organizations' selective networks and provider integration reduce patient access to providers, along with provider access to paying patients, so many providers have lobbied for AWP-FOC laws. In opposition are managed care organizations (MCOs), which want full freedom to contract selectively to control prices and utilization. This article comprehensively describes laws in all fifty-one jurisdictions, classifies their relative strength, and assesses the implications of the laws. Most are relatively weak forms and all are limited in application by ERISA and the federal HMO Act. The article also uses an associative multivariate analysis to relate the selective contracting environments to HMO penetration rates, rural population, physician density, and other variables. States with weak laws also have higher HMO penetration and higher physician density, but smaller rural populations. We conclude that the strongest laws overly restrict the management of care, to the likely detriment of cost control. But where market power is rapidly concentrating, not restricting selective contracting could diminish long-term competition and patient access to care. In the face of uncertainty about the impact of these laws, an intermediate approach may be better than all or nothing. States should consider mandating that plans offer point-of-service options, for a separate premium. This option expands patient choice of plans at the time of enrollment and of providers at the time of care, yet maintains plans' ability to control core providers.

Winners and losers under medical savings accounts.

As legislators wait to see how the MSA approach to health care reform plays out in the laboratory of the states, authors Marilyn Moon, Len M. Nichols and Susan Wall have put the numbers to work. The researchers simulated the effects of introducing MSAs into the health insurance market. What they found is what critics of MSAs suspected: As the young and healthy shift to MSAs, the premiums for those left in the remaining insurance pool will escalate. However, the authors conclude that if you are male, young and healthy, you stand to gain a lot from the MSA experiment.

First, do no harm: developing health insurance market reform packages.

Health insurance reform is complex, and discussions about preferred reforms are often marked by confusion. This paper focuses on the fundamental issue: how best to address adverse selection. We develop four reform packages that could improve insurance market performance without aggravating risk selection problems. We then compare the principles applied in our packages with two specific proposals that formed the basis for the compromise federal legislation passed in August 1996. We also review the evidence to date on the effects of small-group reforms on health insurance markets in various states, and conclude with suggestions for further research.

Patient choice of physician: do health insurance and physician characteristics matter?

Generous health insurance coverage is widely believed to have contributed to both high and rising health care costs. This paper tests the hypothesis that better insured patients will demand higher "quality" by choosing more often to visit specialists rather than generalist physicians. We model the conditional decision to seek care from a specialist physician as a function of health insurance status, physician characteristics, and other socioeconomic factors. Analysis of data from the 1987 National Medical Expenditure Survey and the American Medical Association suggests that the presence of insurance coverage does not affect choice of physician. The results do show that people enrolled in health maintenance organizations (HMOs) see specialists less often than other patients.

How are net health insurance benefits distributed in the employment-related insurance market?

The recent health care reform debate has questioned whether the health insurance market effectively pools risks and transfers income across states of health. We use data from the 1987 National Medical Expenditure Survey to examine how net health insurance benefits are distributed in the employment-related insurance market. We find this market to transfer income from those in good health to those with health problems and the tax subsidy from employer health insurance contributions to be a crucial determinant of the net benefit distribution. To the extent society views these transfers as meritorious, our findings suggest caution regarding initiatives to limit or eliminate the tax subsidy.

A mutation in ribosomal protein L9 affects ribosomal hopping during translation of gene 60 from bacteriophage T4.

Ribosomes hop over a 50-nt coding gap during translation of gene 60 mRNA from bacteriophage T4. This event occurs with near-unitary efficiency when gene 60-lacZ fusions are expressed in Escherichia coli. One of the components necessary for this hop is an RNA hairpin structure containing the 5' junction of the 50-nt coding gap. A mutant E. coli was isolated and found to significantly increase hopping when carrying gene 60-lacZ constructs with altered hairpins. The mutation, hop-1, changed Ser93 to Phe in rplI, the gene coding for ribosomal large-subunit protein L9. Ribosomal hopping on a synthetic sequence in the absence of a hairpin was also increased by this mutation. These data suggest that hop-1 may substitute for the function of the hairpin during ribosomal hopping.