Unlocking value in healthcare

Managing health expenditure inflation under a single-payer system: Taiwan's National Health Insurance

Leaders in medical education have increasingly called for the incorporation of cost awareness and health care value into health professions curricula. Emerging efforts have thus far focused on physicians, but foundational competencies need to be defined related to health care value that span all health professions and stages of training. The University of California, San Francisco (UCSF) Center for Healthcare Value launched an initiative in 2012 that engaged a group of educators from all four health professions schools at UCSF: Dentistry, Medicine, Nursing, and Pharmacy. This group created and agreed on a multidisciplinary set of comprehensive competencies related to health care value. The term "competency" was used to describe components within the larger domain of providing high-value care. The group then classified the competencies as beginner, proficient, or expert level through an iterative process and group consensus. The group articulated 21 competencies. The beginner competencies include basic principles of health policy, health care delivery, health costs, and insurance. Proficient competencies include real-world applications of concepts to clinical situations, primarily related to the care of individual patients. The expert competencies focus primarily on systems-level design, advocacy, mentorship, and policy. These competencies aim to identify a standard that may help inform the development of curricula across health professions training. These competencies could be translated into the learning objectives and evaluation methods of resources to teach health care value, and they should be considered in educational settings for health care professionals at all levels of training and across a variety of specialties.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) may accelerate the movement of physicians into corporate employment by hospitals and, to a lesser extent, by health insurers and other corporations. This article briefly summarizes the demographics of US physician practice, the potential advantages and disadvantages of physician employment by large corporations, and the evidence to date on the performance of large versus small physician practices and hospital-employed versus independent physicians. It describes the features of MACRA likely to lead physicians to seek corporate employment and the steps the Centers for Medicare and Medicaid Services has taken through MACRA to aid small independent physician practices. I conclude that MACRA's net effect is likely to be accelerated corporate employment of physicians and that there is an urgent need for more evidence on the impact of different types of provider organization on the quality and cost of care, and on patient, physician, and staff experience.

Evidence-Based Decision-Making and Health Technology Assessment in South Korea

The fiscal cliff and opportunities for change☆: El abismo fiscal y las oportunidades de cambio

This paper examines the research problem of how the doctrine of good faith and international arbitration shape negotiation dynamics in international contracting. The purpose of the research is to determine the extent to which these principles provide guidance on the behavior of the contracting parties, protect their expectations, and ensure the enforceability of contracts in different legal systems. Using the comparative doctrinal methodology, the paper contrasts civil law systems, where good faith is a binding obligation throughout the process of negotiations, with the common law systems, where good faith is traditionally circumscribed. The findings suggest that properly formulated good faith clauses and extensive arbitration agreements reduce negotiation failures, enhance contractual certainty, and support efficient dispute avoidance and resolution. The conclusion underlines that integrating both principles into the negotiation process minimizes disputes and strengthens commercial relationships. The contribution of this paper is the connection between the theoretical doctrines of good faith and the practical functions of arbitration, offering insights for more effective and harmonized international trade practices (Cordero-Moss, 2014).

The Road Ahead

The number of patients with COPD is strongly on the rise. This leads to a sharp increase of related workload for both the pulmonologist as well as the GP. In The Netherlands during 2001 the organisations of the GP's (NHG) and the pulmonologists (NVALT) have reached an national co-operative agreement (LTA) on how to effectively and efficiently manage the trias of increase in demand, limited human and financial resources and need for quality of care. This LTA comprises diagnosis, treatment and follow-up and defines both the specific tasks of GP and pulmonologist as well as the areas of co-operation. In The Netherlands (local) experiments to improve the healthcare system have been numerous, but most of these experiments have remained local, due to the original customisation or to its complexity. Therefore the distribution of improvements has been poor and patchy and the effects of the learning curve have been limited. Following a number of pilot experiments, the pulmonologists of the general hospital Het Spittaal in Zutphen decided in December 2001 to develop a transmural care system for COPD patients, which should adhere to the following principles: 1. Approach based upon national clinical COPD guidelines (NHG, LTA). 2. Organisation of a COPD Knowledge Centre in the Hospital to train, coach and assist GP's and their practice assistants or nurse practitioners. 3. Transmural co-operation with at least 50% of all referring GP's. 4. Implementation of a categorical COPD surgery in the participating GP practices to concentrate all routine care (actual organisational work done by an outside agency). 5. Delegation of routine COPD care from the GP to the practice assistant or nurse practitioner with support from the nurse-specialist in the COPD Knowledge Centre. 6. Implementation of a protocolised electronic COPD patient record (DiseaseControl© by Diagnosis4Health), shared between GP and pulmonologist, enabling TeleAdvice by the pulmonologist (software and implementation done by an outside agency). 7. Development of detailed scripts of all principles for easy copying by other hospitals. Globally our care system uses the following approach (supported by the DiseaseControl© software),: COPD patients are invited to the categorical surgery every 6 months for a routine check of their pulmonary status (incl. spirogram) and their well-being. The practice assistant or nurse practitioner executes this check. Every 12th month the GP evaluates key clinical parameters. Only when the patient, the assistant/nurse or the software give a specific reason, the GP is involved for his/her expert opinion. In case the GP is in need of support, he/she can push a software button for a TeleAdvice by the pulmonologist. The logistics and software are supplied by an outside agency, financed by health insurance companies and sponsors. The pulmonologists and the COPD nurses from the COPD Knowledge Centre in Het Spittaal supply the technical know-how. The most important intervention with many COPD patients is to quit smoking. The COPD Knowledge Centre in Het Spittaal offers a Quit Smoking Support programme. Both GPs as well as the pulmonologists may refer smoking COPD patients to this programme. The COPD nurses execute the programme. The objectives of this approach are: 1. COPD patients will suffer fewer exacerbations and preserve their pulmonary function. 2. COPD patient will experience improvements in their quality of life. 3.These results will be reached without additional efforts from GP and pulmonologist. All data will be (anonymously) collected in a dedicated database. This will provide the opportunity to evaluate the results compared to the objectives. Additionally each participating GP is provided with mirror information and benchmarking information. 1. Folmer H. et al: Landelijke Transmurale Afspraak COPD. Huisarts Wet 2001;44(5):220-5 2. Geijer R.M.M. et al: NHG-Standaard COPD en Astma bij Volwassenen: Diagnostiek. Huisarts Wet 2001;44(3):107-17 3. Geijer R.M.M. et al: NHG-Standaard COPD: Behandeling. Huisarts Wet 2001;44(5):209-19 4. Lugt H.A.M.M. van der et al: Behandeling van COPD kan beter, integrale aanpak biedt voordelen. Medisch Contact 2000;55;10:351-2

Systems engineers are equipped to design complex networked systems such as infrastructures. A key goal is cost minimization over a vast solution space. However, finding a minimum‐cost system while comprehensively satisfying different stakeholders is challenging and lacks proper methodological support. Stakeholders often employ their own expert estimations for lack of suitable decision‐support methods. In these settings, systems engineers typically require mid‐fidelity, easy‐to‐use methods. We present a rigorous method that quickly finds minimum‐cost solutions for networks with multiple sources and sinks, focusing on pipeline topology, length, and capacity. It can serve as a discussion tool in multiactor design processes, to demarcate the design space, indicate sources of uncertainty, and provoke further analyses, different designs, or contractual negotiations. It is applicable to a wide variety of cases, including many prominent infrastructures needed to mitigate CO₂. We prove that the optimal layout is a minimum‐cost Gilbert tree, and develop a heuristic based on the Gilbert‐Melzak method. We demonstrate the method's efficacy for a case set regarding solution quality, computational time, and scalability. We also show its efficiency and usefulness for systems engineers in real‐world settings. Systems engineers can use the generated cost‐optimal system designs to benchmark any design changes in real‐world negotiation processes.

Taeyang Energy is a well-known Korean solar energy developer in Indonesia, faces the challenge while doing the business expansion with the M&A structure due to high dependency on Joey, the previous CEO, for their previous all-OLA contract negotiations. This study aims to understand the current negotiation process that is used by Joey and also to structure the negotiation framework for Taeyang Energy post-acquisition. This study implements the single method of qualitative approach by getting insight from interviews with Joey as Taeyang Energy’s previous CEO and also some OLA contract practitioners on the solar energy business. The qualitative findings reveal some of the negotiation processes in dealing with the OLA contract negotiation. The results indicate that Joey has specific negotiation stages for the OLA contract negotiation at Taeyang Energy which consist of initial due diligence, commercial proposal submission, contract drafting and initial explanation, and request client’s feedback on the proposal. The 3D Negotiation offers a practical and comprehensive negotiation framework, considering three dimensions of negotiation: Setup, Deal Design, and Tactics that has been categorized based on the thematic analysis result of the interview excerpts. This study highlights the key success of OLA contract negotiation for Taeyang Energy and will drive the company’s sustainable growth and increase the independence of the new team for post-acquisition. However, the research also acknowledges limitations such as the effectiveness of this framework has not been tested yet. Future research direction is proposed to address the limitation such as measuring the success of the contract using the quantitative approach.

This paper examines a general model of contract in multi-period settings with both external and self-enforcement. In the model, players alternately engage in contract negotiation and take individual actions. A notion of contractual equilibrium, which combines a bargaining solution and individual incentive constraints, is proposed and analyzed. The modeling framework helps identify the relation between the manner in which players negotiate and the outcome of the long-term contractual relationship. In particular, the model shows the importance of accounting for the self-enforced component of contract in the negotiation process. Examples and guidance for applications are provided, along with existence results and a result on a monotone relation between “activeness of contracting” and contractual equilibrium values.

The research aims at establishing an understanding of the influencing factors and their enhancement through a contract enhancement model (CEM) in order to ensure an improved course of contract negotiations between principals and agents in agency relationships in IT outsourcing. The research discusses the phenomenon of hidden actions and their occurrences, challenges and solutions as explained in the agency theory (JENSEN/MECKLING, 1976). The CEM helps to ensure that the phenomenon of hidden actions as well as opportunistic behaviour are reduced and maximation of benefit is given and shared between the parties. To guarantee a better understanding, the research sets the theoretical facts of the agency theory in conjunction with facts of other theories, such as economics and social cognitive science, in order to manifest the content of the CEM and to ensure that the theoretical framework of the research is based on solid grounds. The research contributes to theory and practice. It provides an enhanced approach for solving challenges arising from hidden actions. With the help of the CEM, the research instructs and guides interacting parties in agency relationships in IT outsourcing how to increase the speed, the efficiency and the effectiveness of their contract negotiations to enable them to develop a solid foundation for a long-lasting business relationship, from the very beginning. Previous research has been conducted in the field of enhancing relationships between principals and agents, but such research has focused on enhancing communication and knowledge transfer between the parties (Henrich, 2011). The present research is understood as a continuation of this previous research. As mentioned above, it aims at enhancing contract negotiations by making them more efficient and speeding them up to help principals and agents in agency relationships in IT outsourcing to run through the process of contract negotiations more effectively. Besides focusing on agency theory, the research also draws on literature in the field of outsourcing, trust and information exchange. In the past, various studies have shown that many outsourcing projects have failed to run for a prolonged period or have been interrupted, renegotiated or even terminated (Leimeister, 2010, p. 2). The literature shows that generally research has already contributed to this subject with a wide range of theories about the constitution and characterisation of mutual exchange between organisations (Kuhlmann, 2012, p. 3). Solving the conflict of information asymmetry as described in the agency theory will lead to an increase of total well-being and should be the aspired solution from a utilitarian point of view (Zaggl, 2012, p. 7).

The article deals with the relatively new rules of Art. 434.1 the Civil Code of the Russian Federation on the conduct of negotiations. Taking into account the current wording of the said rule and the experience of foreign legislation on pre-contractual liability, the article argues for different theories justifying the nature of pre-contractual legal relations and liability and gives different positions of the authors on this issue. Proceeding from the doctrinal concept of obligation and characteristics of pre-contractual relations themselves the conclusion is made that these relations, firstly, are regulated by law and, secondly, they are not simply a legal relation but an obligation. It is based on certain actions of the negotiating partners that give rise to such an obliga-tion. As such, any action that is sufficiently certain (in some cases it may be required by law) and expresses the intention of the person to regard himself as negotiating with the addressee, who will in return perform the same sufficiently certain action, can be regarded as such. The specified characteristics of an action allow us to conclude that, from the point of view of classification of legal facts, this action is an act (because it is performed with a certain in-tention evident to other participants of civil turnover) and, moreover, it is also a transaction. Special rules of the Civil Code of the Russian Federation stipulate that the actions performed to enter into negotiations (for example, if the conclusion of a contract is binding on one party) or the actions of both partners entail legal consequences - the obligation to negotiate in good faith. The analysis of these legal relationships identifies three stages in their development, charac-terises them and attempts to answer more precisely the question of who can be a participant in the negotiation process depending on the stage of the negotiation process. The subject matter of an obligation arising during pre-contractual contacts will be actions aimed at negotiating and concluding a contract. The content of the obligation arising in the course of pre-contractual contacts, based on Art. 434.1 of the Civil Code will be the obligation to negotiate in good faith (paragraph 2 of the above rule). Assuming that the legislator provides an indicative list of actions that should fall within the scope of bad faith conduct, an indicative list of the "standard" of good faith conduct at the negotiation stage is given. This includes the obligation to provide full and truthful information to a party, including the reporting of circumstances that, due to the nature of the contract, must be brought to the attention of the other party (e.g. in a sale, all encumbrances on the subject of the contract must be reported). In addition, persons are obliged to negotiate only if they intend to conclude a contract, not to terminate negotiations suddenly and unjustifiably, and to take into account the rights and legitimate interests of the other party to the negotiation. The obligation under this obligation may also include a requirement not to disclose infor-mation obtained during the negotiation of the contract.

As the field of information technology expands, there is a huge need for cloud service providers (CSP). CSP’s vast solutions and services support Cloud, IoT, Fog, and Edge computing. In today’s competitive cloud market, customer satisfaction is critical more than ever. CSP and consumer satisfaction with service level agreement (SLA) fulfillment have always been given more attention. As a result of signing SLA and CSP agreements to supply resources in high demand, customers are now experiencing issues with resource delivery. Cloud and heterogeneous environments necessitate an intelligent recommender and negotiation agent model (IRNAM) to handle responsibilities in the current system. The Recommender system recommends CSP as per users’ priorities, which eases the filtration process. The negotiation process provided by IRNAM ensures that users’ choices are prioritized with maximum jobs to CSP. IRNAM keeps track of the most critical metrics and can reach decisions quickly and for the best possible deal. It uses an analytical concession algorithm that analyzes consumer and CSP choices to find a reliable, secure server with the simplest solution. The negotiation process uses user’s and CSP choice metrics, performance factors, evaluation measures, and success factors in the best execution time to decide. IRNAM provides a flexible and valuable way for selecting CSP and negotiating for services on the user’s terms while considering CSP satisfaction.

This study focuses on the Unified Health System (SUS) in five regions of the state of Rio de Janeiro, Brazil, one of Brazil’s most important states, as part of a comprehensive analysis of a research project, which has generated publications in earlier phases. The objective was to assess users’ perceptions of SUS in terms of access to and the quality of public health services, including primary care and pharmaceutical services. A cross-sectional study was conducted using a structured questionnaire comprising 66 questions, administered to a purposive sample of 1000 participants between August 2023 and August 2024. Data were analyzed using Pearson’s chi-square test with R software version 4.3. Among the participants, 54.5% were female, 62.5% were aged between 26 and 60 years, and 29% reported having private health insurance. Vaccination services were the most frequently used SUS service (25.1% of respondents). Participants who reported more frequent use of SUS services rated access more positively than those who used them less frequently (p = 0.002). The regions that evaluated SUS access and quality most favorably were Middle Paraíba and the metropolitan region, while the Coastal Lowlands region received the most negative assessments. Participants with lower socioeconomic status gave more favorable evaluations of access to public health services (p = 0.001). These findings highlight concerns about access to, and the quality of, SUS healthcare services and regional disparities in users’ perceptions of SUS services in Rio de Janeiro. The results underscore the importance of social participation as a key element in the evaluation and continuous improvement of responsive public healthcare.