Cost Trajectories Research Articles

Salinity Management in the Murray‐Darling Basin: A Transaction Cost Study

AbstractTransaction costs are fundamental to implementing, evaluating, and monitoring public policy/programs for social, economic, and/or environmental welfare. Empirical accounting for transaction costs helps identify and evaluate adaptive public policy or program arrangements that improve future institutional choices under uncertainty. However, examples of empirical transaction cost studies are few, due largely to persistent measurement challenges and limits to transaction cost comprehension. A lack of studies limits both insights into the importance of transaction costs in institutional design and validation of theories surrounding cost trajectories over time under different institutional arrangements. In this paper we apply time series analysis to a unique database of public salinity management program transaction costs in Australia's Murray‐Darling Basin. Our study provides insights into the role of transaction costs in institutional efficiency and on empirical approaches to considering relationships between observed transaction cost trajectories and the efficiency of associated institutions. Our results indicate that the Murray‐Darling Basin salinity management program succeeded in generating persistent declines in transaction costs and river salinity levels over time. We suggest some possible reasons for this that are associated with institutional design and reflect on what these findings may mean for other jurisdictions.

PND35 - HEALTHCARE, SICKNESS ABSENCE, AND DISABILITY PENSION COST TRAJECTORIES IN FIVE YEARS FOLLOWING MS DIAGNOSIS: REGISTER-BASED PROSPECTIVE COHORT STUDIES IN SWEDEN

To explore healthcare, sickness absence (SA), and disability pension (DP) cost trajectories among people with multiple sclerosis (PwMS) following diagnosis, accounting for socioeconomic characteristics and comorbidities. All PwMS in Sweden, 25-60 years old at MS diagnosis, according to the National Patient Register, were included. Microdata were linked from several nationwide registers. Four cohorts, based on diagnosis year (2006-2009) were followed prospectively, for 5 years, regarding 1) direct costs: healthcare and out-of-pocket expenditure, and prescribed drugs, and 2) indirect costs: SA and DP. Average per patient costs were calculated, in 2017 Swedish Krona (SEK). A group-based trajectory Poisson model was used, mapping cost progression and assessing heterogeneity based on socioeconomic characteristics (age, gender, education, type of living area, geographic region, country of birth, marital status), and comorbidities at diagnosis year. Five cost trajectories were identified among the 3272 PwMS. One, where 32.2% of PwMS belonged, had high direct and indirect costs, first increasing and then decreasing. This was in line with the average direct costs in the overall study population, increasing the 1st year, and then declining 3 years after (e.g., for the 2009 cohort, from SEK 87,796 to 97,801, and then to 80,394). Another trajectory had low direct and indirect costs, first decreasing and then increasing, possibly explained by the decrease in SA over time and increase in DP, indicating a shift from short-term to long-term social security benefits. A 3rd trajectory, where only 2.4% of PwMS belonged, had high direct and indirect costs, which decreased substantially after 4 years. Finally, the last two trajectories had either high direct or indirect costs. Socioeconomic consequences and comorbidities differed significantly across trajectory groups. There is heterogeneity across sub-groups of newly diagnosed PwMS; their socioeconomic and health outcomes differ significantly, leading to different cost trajectories over time.

Medicaid Cost Trajectories for Children With Serious Emotional Disturbance: The HCBS Waiver Program Versus Targeted Case Management.

The study compared Medicaid cost-effectiveness for children with serious emotional disturbance receiving services from two programs operated by the New York State Office of Mental Health: the Home and Community-Based Services (HCBS) Waiver program and targeted case management (TCM). Children ages four to 18 who received services from the HCBS Waiver program (N=1,602) or TCM (N=2,740) during 2009-2012 were selected. A quasi-experimental study design with propensity score-matched comparison groups was used to examine Medicaid costs (per member per month [PMPM] total cost) before admission to and after discharge from the HCBS Waiver and TCM programs. Exponential smoothing models were used to examine Medicaid cost trends before and after each program. Difference-in-difference techniques were used to estimate the average annual difference in PMPM Medicaid cost. Trends for PMPM total Medicaid cost for HCBS Waiver-enrolled children after discharge decreased by 25%, whereas postdischarge costs for TCM-enrolled children increased by 15%. The adjusted pre-to-post difference in PMPM total Medicaid cost for HCBS Waiver children decreased by $498 and increased for TCM children by $448-a statistically significant decline of $946 (range $927-$963) in average PMPM Medicaid cost for HCBS Waiver children compared with TCM children. The PMPM Medicaid cost for children during HCBS Waiver enrollment was higher than for similar children enrolled in TCM. However, Medicaid cost savings for the HCBS Waiver group after the program may support investment in the more intensive HCBS Waiver program for children with comparable psychiatric needs.

Long-term cost trajectories for biofuels in China projected to 2050

Biofuels mitigate and offset greenhouse gases. A long-term levelized cost of energy (LCOE) estimation for biofuels in China was carried out, using a novel probabilistic model to analyze the likelihood of biofuels economically outrunning fossil fuels. This model calculated LCOE based on five uncertain input parameters fed into a Monte Carlo simulation, namely, discount rate, firm size, feedstock price, product yield and catalyst/enzyme cost, while key assumptions were used to determine their probability distributions. Model results show that the mean levelized costs of most biofuel technologies will fall below 9500 Chinese Yuan per ton by 2030 and below 9000 Chinese Yuan per ton by 2050; it is highly possible for most biofuel technologies to gain economic feasibility and competitiveness by around 2025–2030 in China. The LCOE reduction of 1.5-generation (1.5G) biofuels is feedstock-driven, while that of 2nd-generation (2G) biofuels is technology-driven. Meanwhile, 1.5G biofuels are more sensitive to crude oil price changes than 2G biofuels, with a drop in crude oil price having a greater effect on 2G biofuels than a rise. On average, every 10% rise in crude oil price accelerates their economic feasibility by 2–3 years, while every 10% drop delays this feasibility by 3–5 years.

Trajectories of medical care cost by service type for recurrent and de novo advanced cancer patients.

6611Background: Understanding cost trajectories for advanced cancer patients may identify drivers of high cost transitions and inform cost reduction efforts. Total medical care costs were measured ...

Cost effectiveness vs. affordability in the age of immuno-oncology cancer drugs

ABSTRACTIntroduction: After years of setback, cancer immunotherapy has begun to yield clinical dividends, which are changing the treatment landscape and offering cancer patients the potential for long-term survival, reduced treatment-related toxicity and improved quality-of-life. Using the immune system to treat cancer is known as ‘Immuno-oncology’ (IO) and agents are sub-classified by their ability to enhance anti-tumor response or to direct the immune system to attack cancer cells via tumor-associated antigens.Areas covered: Clinical trials have demonstrated the effectiveness of several IO agents in many disease sites such as early and advanced stage melanoma, advanced non-small cell lung cancer, bladder, head and neck, gastric, kidney as well as Hodgkin’s lymphoma. Notwithstanding the therapeutic excitement generated for patients and clinicians alike, an important consideration is treatment cost, which can reach more than $US100,000 per patient annually. The cost of the drugs, coupled with high disease prevalence and the ever-expanding number of indications, means the current cost trajectory is untenable for most healthcare systems to sustain.Expert commentary: In this paper, the approved IO drugs and those in clinical development are reviewed. The issue of cost effectiveness vs. affordability is then addressed and suggestions that facilitate patient access and long-term sustainability are presented.

PaFloChar: An Innovating Approach to Characterise Patient Flows in Myocardial Infarction.

A better knowledge of patient flows would improve decision making in health planning. In this article, we propose a method to characterise patients flows and also to highlight profiles of care pathways considering times and costs. From medico-administrative data, we extracted spatio-temporal patterns. Then, we clustered time between hospitalisations and cost trajectories in order to identify profiles of change over time. This approach may support renewed management strategies.

Semiparametric Estimation of Longitudinal Medical Cost Trajectory

ABSTRACTEstimating the average monthly medical costs from disease diagnosis to a terminal event such as death for an incident cohort of patients is a topic of immense interest to researchers in health policy and health economics because patterns of average monthly costs over time reveal how medical costs vary across phases of care. The statistical challenges to estimating monthly medical costs longitudinally are multifold; the longitudinal cost trajectory (formed by plotting the average monthly costs from diagnosis to the terminal event) is likely to be nonlinear, with its shape depending on the time of the terminal event, which can be subject to right censoring. The goal of this article is to tackle this statistically challenging topic by estimating the conditional mean cost at any month t given the time of the terminal event s. The longitudinal cost trajectories with different terminal event times form a bivariate surface of t and s, under the constraint t ⩽ s. We propose to estimate this surface using bivariate penalized splines in an expectation-maximization algorithm that treats the censored terminal event times as missing data. We evaluate the proposed model and estimation method in simulations and apply the method to the medical cost data of an incident cohort of stage IV breast cancer patients from the Surveillance, Epidemiology, and End Results–Medicare Linked Database. Supplementary materials for this article are available online.

The role of electricity storage and hydrogen technologies in enabling global low-carbon energy transitions

Previous studies have noted the importance of electricity storage and hydrogen technologies for enabling large-scale variable renewable energy (VRE) deployment in long-term climate change mitigation scenarios. However, global studies, which typically use integrated assessment models, assume a fixed cost trajectory for storage and hydrogen technologies; thereby ignoring the sensitivity of VRE deployment and/or mitigation costs to uncertainties in future storage and hydrogen technology costs. Yet there is vast uncertainty in the future costs of these technologies, as reflected in the range of projected costs in the literature. This study uses the integrated assessment model, MESSAGE, to explore the implications of future storage and hydrogen technology costs for low-carbon energy transitions across the reported range of projected technology costs. Techno-economic representations of electricity storage and hydrogen technologies, including utility-scale batteries, pumped hydro storage (PHS), compressed air energy storage (CAES), and hydrogen electrolysis, are introduced to MESSAGE and scenarios are used to assess the sensitivity of long-term VRE deployment and mitigation costs across the range of projected technology costs. The results demonstrate that large-scale deployment of electricity storage technologies only occurs when techno-economic assumptions are optimistic. Although pessimistic storage and hydrogen costs reduce the deployment of these technologies, large VRE shares are supported in carbon-constrained futures by the deployment of other low-carbon flexible technologies, such as hydrogen combustion turbines and concentrating solar power with thermal storage. However, the cost of the required energy transition is larger. In the absence of carbon policy, pessimistic hydrogen and storage costs significantly decrease VRE deployment while increasing coal-based electricity generation. Thus, R&D investments that lower the costs of storage and hydrogen technologies are important for reducing emissions in the absence of climate policy and for reducing mitigation costs in the presence of climate policy.

The association of neurologists with headache health care utilization and costs.

To determine the association of a neurologist visit with headache health care utilization and costs. Utilizing a large privately insured health care claims database, we identified patients with an incident headache diagnosis (ICD-9 codes 339.xx, 784.0x, 306.81) with at least 5 years follow-up. Patients with a subsequent neurologist visit were matched to controls without a neurologist visit using propensity score matching, accounting for 54 potential confounders and regional variation in neurologist density. Co-primary outcomes were emergency department (ED) visits and hospitalizations for headache. Secondary outcomes were quality measures (abortive, prophylactic, and opioid prescriptions) and costs (total, headache-related, and non-headache-related). Generalized estimating equations assessed differences in longitudinal outcomes between cases and controls. We identified 28,585 cases and 57,170 controls. ED visits did not differ between cases and controls (p = 0.05). Hospitalizations were more common in cases in year 0-1 (0.2%, 95% confidence interval [CI] 0.2%-0.3% vs 0.01%, 95% CI 0.01%-0.02%; p < 0.01), with minimal differences in subsequent years. Costs (including non-headache-related costs) and high-quality and low-quality medication utilization were higher in cases in the first year and decreased toward control costs in subsequent years with small differences persisting over 5 years. Opioid prescriptions increased over time in both cases and controls. Compared with those without a neurologist, headache patients who visit neurologists had a transient increase in hospitalizations, but the same ED utilization. Confounding by severity is the most likely explanation given the non-headache-related cost trajectory. Claims-based risk adjustment will likely underestimate disease severity of headache patients seen by neurologists.

Fighting the inevitable: infrastructure investment and coastal community adaptation to sea level rise

AbstractCoastal communities are crafting adaptation strategies to confront sea level rise (SLR). Unfortunately, cost–benefit analyses that assess SLR risks often fail to capture important political and social feedbacks. For example, adaptation measures (e.g., beach nourishment) can trigger greater development, undermining the value of adaptation infrastructure, incentivizing development, and increasing risks. We integrate diverse literature and data to develop a hypothesis and system dynamics model of coastal community responses to SLR. We apply the model to two U.S. communities, showing how political influence drives trajectories of infrastructure provision, cost, and vulnerability. We find that delayed feedbacks between perceived SLR risk and infrastructure investments mediate relationships between political capital, migration, and economic development. Community wealth and political influence may only delay the overshoot and collapse of its population and economy, as the “virtuous cycles” linking growth with infrastructure investment give way to “vicious cycles” of mounting infrastructure costs, political resistance to additional investment, and greater vulnerability.Copyright © 2018 System Dynamics Society

Інноваційно-інвестиційні механізми регулювання економічної безпеки держави

Мета роботи – формалізувати інноваційно-інвестиційні механізми регулювання економічної безпеки держави та обґрунтувати перспективи їх розвитку на основі сучасних економічних підходів.&#x0D; Дизайн/Метод/Підхід дослідження. Застосовано системний підхід, загальнонаукові методи аналізу і синтезу; інформаційною основою є нормативно-правова база та звітні дані Державної служби статистики України.&#x0D; Результати дослідження. Формалізовано зміст інноваційно-інвестиційних механізмів регулювання економічної безпеки держави як сукупності форм, методів, інструментів стимулювання створення, впровадження у виробництво та просування на ринок продуктових, технологічних, організаційно-управлінських та інших нововведень відповідно до стратегічних пріоритетів національної безпеки.&#x0D; Теоретичне значення дослідження. Визначено пріоритети інноваційно-інвестиційних механізмів регулювання економічної безпеки: організаційно-правовий, фінансовий, виробничо-технологічний, кадровий, експертно-консалтинговий.&#x0D; Практичне значення результатів дослідження. Розроблено рекомендації органам державного управління в частині реалізації комплексу економічних і адміністративних заходів, спрямованих на захист національних інтересів України у сфері відтворення і збереження вітчизняного науково-технічного і технологічного потенціалу.&#x0D; Соціальне значення результатів дослідження. Виявляється у зміцненні економічної складової забезпечення конституційних гарантій громадян на безпеку, захист їх життя, здоров’я, честі, гідності, недоторканості на основі зростання інноваційно-інвестиційного потенціалу держави.&#x0D; Оригінальність/Цінність/Наукова новизна дослідження. Визначено точки дотику теорій залежності від траєкторії попереднього розвитку та трансакційних витрат, що сприятиме виходу України з інституціональної пастки.&#x0D; Обмеження дослідження. Недосконалість методу, вибірки даних, неможливість доступу до певних інноваційно-інвестиційних механізмів при аналізі стану економічної безпеки України унаслідок державної таємниці.&#x0D; Перспективи подальших досліджень. Розвивати теорію трансакційних витрат і адаптувати її до зовнішньоекономічних аспектів державного регулювання національної безпеки.&#x0D; Тип статті – теоретична.

Payment Reform to Enhance Collaboration of Primary Care and Cardiology

The US health care system faces an unsustainable trajectory of high costs and inconsistent outcomes. The fee-for-service payment model has contributed to inefficiency, and new payment methods are a promising approach to improving value. Health reforms are needed to increase patient access, reduce costs, and improve health care quality, and the landmark Medicare Access and CHIP Reauthorization Act presents a roadmap for reform. The product of a collaboration between primary care and cardiology clinicians, this review describes a conceptual approach to delivery and payment reforms that aim to better support primary care-cardiology comanagement of chronic cardiovascular disease (CVD). Few existing alternative payment models specifically address long-term management of CVD. Primary care medical homes and accountable care organizations come closest, but both emphasize primary care, and cardiologists have often not been well engaged. A collaborative care framework should articulate distinct roles and responsibilities for primary care and cardiology in CVD comanagement. Finally, a series of payment models aim to better support clinicians in providing accountable, seamless, and patient-centered cardiac care. Clinical leadership is essential during this time of change in the health care system. Patients often struggle to navigate a fragmented and expensive system, whereas clinicians often practice with incomplete information about tests, treatments, and recommendations by their colleagues. The payment models described in this review offer an opportunity to create more satisfying approaches to patient care while improving value. These models have potential to support more effective coordination and to facilitate broader health care system transformation.

A Direct Manufacturing Cost Model for Solid‐Oxide Fuel Cell Stacks

AbstractThis work details efforts to estimate the direct manufacturing cost of solid oxide fuel cell (SOFC) stack components for combined heat and power applications. The main research goals are to identify the major contributors to fuel cell stack manufacturing costs, examine the influence of both production volume and stack size on cost, and compare the results of the cost trajectories with the U.S. Department of Energy SOFC stack manufacturing cost target of $238 kWe−1 (in 2015) and industry reported cost projections and to identify critical areas for manufacturing research and development. Stack component direct manufacturing costs are modeled for net electricity capacity of 1, 10, 50, 100 and 250 kWe across annual production volumes of 10, 1,000, 10,000 and 50,000 systems per year. Overall stack manufacturing costs range from $5,387 kWe−1 to a minimum of about $166 kWe−1 for a 250 kWe system at 50,000 systems per year. To meet the manufacturing cost target of $238 kWe−1, a minimum annual production of 100–250 MWe per year would be required. Reduction opportunities for stack cost are expected to be available, mainly with the adoption of thinner cells and stack components, higher levels of factory automation, and more sensitive in‐line defect diagnostics.

Complexity of Chronic Conditions' Impact on End-of-Life Expense Trajectories of Medicare Decedents.

The aim of this study is to determine if the pattern of monthly medical expense can be used to identify individuals at risk of dying, thus supporting providers in proactively engaging in advanced care planning discussions. Identifying the right time to discuss end of life can be difficult. Improved predictive capacity has made it possible for nurse leaders to use large data sets to guide clinical decision making. We examined the patterns of monthly medical expense of Medicare beneficiaries with life-limiting illness during the last 24 months of life using analysis of variance, t tests, and stepwise hierarchical linear modeling. In the final year of life, monthly medical expense increases rapidly for all disease groupings and forms distinct patterns of change. Type of condition can be used to classify decedents into distinctly different cost trajectories. Conditions including chronic disease, system failure, or cancer may be used to identify patients who may benefit from supportive care.

End of life care trajectories – hospital inpatient care in last two years of life

Introduction : End of life (EOL) care trajectories have been found to differ by cause of death categories representing different trajectories of functional decline (Fassbender et al. 2009). The aim of our study is to use the same categorisation of causes of death (terminal illness, organ failure, frailty, sudden deaths, other) to investigate hospital inpatient care utilisation patterns in the last two years of life in Norway. Methods : Data on cause of death, place of death, age and gender for all decedents in 2011 from the Norwegian cause of deaths registry were linked by unique person identifier with data from Norwegian Patient register on inpatient hospital utilisation in the last 730 days before death. Statistical analysis of differences in care utilisation in different time periods before death, as well as graphical analysis of time pattern in service use were performed. Results : The highest median number of inpatient days over the last two years before death was found for terminal illness, more than double compared to organ failure, which in turn was the double of frailty and sudden death. For all trajectory groups the proportion being in hospital on a particular day before death increases steeply in the last months of life, starting earlier for terminal illness than for organ failure, which in turn started earlier than for frailty and sudden death. Nearly 70 percent of decedents dying of terminal illness had hospital stay within the last 30 days of life. The corresponding proportions was 50% for organ failure, and about 1/3 for frailty and sudden death. Differences in utilisation as well as time pattern within trajectory groups varied with age as well as place of death. Typically, the highest number of hospital days was found for hospital deaths and lowest for home deaths, and the number of days in hospital decreased with higher age among the elderly decedents. Discussions : The overall results are in line with the findings in Fassbender et al. (2009) which found the same ranking of cost for inpatient care between terminal illness, organ failure and frailty. Conclusions : Cause of death trajectories categories help to differentiate patterns of hospital utilisation before death. Lessons learned : Care trajectories differ by place of death already several month or even years before death, which could reflect that place of death is an indication of differences in functional decline of decedents within the cause of death trajectory categories. Care trajectories should also be studied separately for different age groups. Limitations : The study only looks at inpatient hospital use, other health and care services could serve as alternatives to hospital admission. Suggestions for future research : In our future research, we will include other health and care services. References : 1- Fassbender K, Fainsinger RL, Carson M and Finegan BA. Cost trajectories at the end of life: the Canadian experience. J Pain Symptom Manag. 2009; 38: 75-80.

Trajectories of Injectable Cancer Drug Costs After Launch in the United States.

Purpose Cancer drug prices at launch have increased in recent years. It is unclear how individual drug prices change over time after launch and what market determinants influence these changes. We measured the price trajectories of a cohort of cancer drugs after their launch into the US market and assessed the influence of market structure on price changes. Methods We studied the changes in mean monthly costs for a cohort of 24 patented, injectable anticancer drugs that were approved by the US Food and Drug Administration between 1996 and 2012. To account for discounts and rebates, we used the average sales prices published by the Centers for Medicare and Medicaid Services. Costs were adjusted to US general and health-related inflation rates. For each drug, we calculated the cumulative and annual drug cost changes. We then used a multivariable regression model to evaluate the association between market and cost changes over time. Results With a mean follow-up period of 8 years, the mean percent change in cost for all drugs was +25% (range, -14% to +96%). After adjusting for inflation, the mean cost change was +18% (range, -16% to +59%). Rituximab and trastuzumab followed a similar pattern in cost increases over time, and the inflation-adjusted monthly costs rose since approval by 49% and 44%, respectively. New supplemental US Food and Drug Administration approvals, new off-label indications, and new competitors did not influence the annual cost change rates. Conclusion Anticancer drug costs may change substantially after launch. Regardless of competition or supplemental indications, there is a steady increase in costs of patented anticancer agents over time. New regulations may be needed to prevent additional increases in drug costs after launch.

Hierarchical MPC of batch reactors with shared resources

Multi-reactor semi-batch plants are widespread in the chemical and pharmaceutical industry, since they can produce more flexibly and depending on the product also more profitably than continuous plants. Such reactors usually share resources that are constrained, as for instance raw materials or cooling and heating media. In order to maximize the productivity while respecting product quality constraints, equipment limitations, as well as constraints on the utilization of the shared resources, the feeding policies and temperature profiles in such semi-batch reactors are increasingly optimized online. This can be done by a plant-wide optimizing controller, however, due to robustness, flexibility, and reduced computational effort, distributed schemes that solve the combined trajectory optimization and resource assignment problem are of high interest. In this contribution, we present a hierarchical model predictive control scheme that computes cost and resource optimal trajectories online for a set of semi-batch reactors. Each reactor maximizes its profit function locally by maximizing the amount of product while incurring a cost for the use of the shared resources. On the coordinator level, the future availability of the shared resources is taken into account and the prices are adjusted iteratively, such that the feasibility of the joint operation of all reactors is guaranteed.We show that the problem can be solved using the alternating direction method of multipliers (ADMM), modified for inequality constraints, and compare the performance of this scheme to a decentralized one. Furthermore, the need to coordinate over the whole prediction horizon is discussed and a reduced coordination horizon and its selection are investigated.

Opioid Abuse: A Detailed Examination of Cost Drivers over a 24-Month Follow-up Period.

Previous work has documented the considerable economic burden associated with opioid abuse, dependence, and overdose/poisoning (hereafter, "abuse"). Recent analyses have provided insights into the trajectory and drivers of the excess costs of abuse both before and after diagnosis, showing the important role of other substance abuse, mental health issues, and painful conditions. To build on the recently published study by Kirson et al. (2017) and extend its findings by (a) evaluating the trajectory of excess costs of abuse for an additional year after an incident abuse diagnosis and (b) exploring the diagnosis-level drivers of excess costs over time in greater detail. Using administrative medical and pharmacy claims, which included payment amounts, for beneficiaries covered by large self-insured companies throughout the United States, abusers were matched to controls using the same methods as in Kirson et al. Excess health care costs were assessed over a 24-month follow-up period, which comprised the 6 months before the initial abuse diagnosis and the 18 months after. Drivers of excess costs were then evaluated by diagnosis (grouped at the 3-digit ICD-9-CM level). This study analyzed 9,345 matched pairs of abusers and non-abusers. Similar to the previous study, mean per-patient excess health care costs were found to rise considerably leading up to and shortly after the incident diagnosis of abuse, reaching $15,764 over the first half of the follow-up period. Over the newly extended follow-up period (months 6 to 18 after diagnosis), excess costs remained elevated ($7,346) and did not return to baseline levels. Over time, an increasing share of excess costs was observed for outpatient services and prescription drug use, relative to acute care settings. A detailed examination of cost drivers suggested elevated costs in several clinical categories (e.g., gastrointestinal, respiratory conditions) beyond those previously identified. This research finds that the excess medical costs of abuse extend for at least 1 more year than previously documented, reflecting the need for considerable follow-up care over time. The identification of several other clinical categories with elevated excess costs suggests important areas for future research into the interaction of opioid abuse with the management of other conditions. This study was funded by Purdue Pharma. Howard was an employee of Purdue Pharma at the time that this study was conducted. Kirson, Scarpati, Jia, and Wen are employees of Analysis Group, which received funding from Purdue Pharma to conduct this study. Study concept and design were contributed by Kirson, Scarpati, and Howard, along with Jia and Wen. Jia and Wen took the lead in data collection, with assistance from Scarpati and Kirson. Data interpretation was performed by Scarpati, Kirson, and Howard, with assistance from Jia and Wen. The manuscript was written and revised by Scarpati, Kirson, and Howard.

The relative (un)certainty of subnational population decline

“Prediction is very difficult, especially about the future.” This quote is attributed to Danish physicist and Nobel prize winner Niels Bohr, but the difficulty of making predictions does not stop us from making forecasts of economic, demographic, and other variables. Investors, businesses, policy makers and others use these forecasts to inform their decisions about investments and policy settings where understanding of the future trajectory and levels of costs and benefits are essential. One key example is forecasts of future population. The size and distribution (whether geographic, age, ethnic, or some other distribution) of the future population is a critical input into urban and other planning. Understanding the methods and limitations of forecasts is an important but often underappreciated task for planners and policymakers.