Large Upfront Costs Research Articles

Solar PV and Its Future Impact: Consumer Benefit and Grid Reliability

Interest and availability of photovoltaic solar (solar PV) as a source of renewable electricity generation is rapidly increasing across the country; however, its penetration on a national scale remains very low. There are many natural constraints that can serve as factors, including large upfront module costs, locations that do not receive enough sunlight throughout the year, and the inability to be self‐sufficient from using solar PV power alone. Although the use of this specific distributed energy resource (DER) universally throughout the United States in the near future is improbable, it is interesting to ponder a future where solar PV and other DERs are as common as the current methods we use to generate, transmit, distribute, and consume power. Thinking this way helps identify where we are prone to imprecisely estimating outcomes that could have far‐reaching impacts.

Organizing and analyzing the activity data in NHANES.

The NHANES study contains objectively measured physical activity data collected using hip-worn accelerometers from multiple cohorts. However, using the accelerometry data has proven daunting because: 1) currently, there are no agreed upon standard protocols for data storage and analysis; 2) data exhibit heterogeneous patterns of missingness due to varying degrees of adherence to wear-time protocols; 3) sampling weights need to be carefully adjusted and accounted for in individual analyses; 4) there is a lack of reproducible software that transforms the data from its published format into analytic form; and 5) the high dimensional nature of accelerometry data complicates analyses. Here, we provide a framework for processing, storing, and analyzing the NHANES accelerometry data for the 2003-2004 and 2005-2006 surveys. We also provide an NHANES data package in R, to help disseminate high quality, processed activity data combined with mortality and demographic information. Thus, we provide the tools to transition from "available data online" to "easily accessible and usable data", which substantially reduces the large upfront costs of initiating studies of association between physical activity and human health outcomes using NHANES. We apply these tools in an analysis showing that accelerometry features have the potential to predict 5-year all cause mortality better than known risk factors such as age, cigarette smoking, and various comorbidities.

Better With Time: An Economic Assessment of Long-Term Mechanical Circulatory Support in a Population Surviving at Least 1 Year with a Left Ventricular Assist Device

This study aims to identify the major components of left ventricular assist device (LVAD)-related costs in a population on long-term mechanical circulatory support to gain insight into opportunities for improvements in quality, safety, and efficiency of care for end-stage heart failure patients. This was a single institution, retrospective cost analysis of patients who received a Heartmate II or HeartWare LVAD between November 2005 and October 2015. Payments for hospitalization for device implantation and subsequent readmissions were represented as the institution's 2015 Medicare reimbursement rate. The incidence, average Medicare reimbursement, and length of stay of readmissions were analyzed for the first year postimplant. A full year of LVAD-related hospitalizations in patients surviving ≥12 months, has a median Medicare reimbursement of $247,208. The most common complications related to ventricular assist devices were gastrointestinal bleeding, driveline infection, stroke, and pump thrombosis. Over 90% of total costs were incurred during the initial hospitalization. Seventy-five percent of first-time readmissions occurred within the first 4 months post discharge. Intensive care unit costs accounted for the single largest cost category during readmissions for all of the 4 most common complications. The trends demonstrated suggest that longer lengths of LVAD support in appropriately selected patients results in progressively decreasing cost-per-month up to 12 months, given the large upfront cost of device implantation and relatively modest additional costs of readmissions. This analysis emphasizes the importance of devices with improved complication profiles and clinical protocols to reduce unnecessary intensive care unit stays to increase the cost effectiveness of long-term ventricular assist device therapy.

Estimating the cost-effectiveness of an infant 13-valent pneumococcal conjugate vaccine national immunization program in China.

BackgroundThe burden of pneumococcal disease in China is high, and a 13-valent pneumococcal conjugate vaccine (PCV13) recently received regulatory approval and is available to Chinese infants. PCV13 protects against the most prevalent serotypes causing invasive pneumococcal disease (IPD) in China, but will not provide full societal benefits until made broadly available through a national immunization program (NIP).ObjectiveTo estimate clinical and economic benefits of introducing PCV13 into a NIP in China using local cost estimates and accounting for variability in vaccine uptake and indirect (herd protection) effects.MethodsWe developed a population model to estimate the effect of PCV13 introduction in China. Modeled health states included meningitis, bacteremia, pneumonia (PNE), acute otitis media, death and sequelae, and no disease. Direct healthcare costs and disease incidence data for IPD and PNE were derived from the China Health Insurance and Research Association database; all other parameters were derived from published literature. We estimated total disease cases and associated costs, quality-adjusted life years (QALYs), and deaths for three scenarios from a Chinese Payer Perspective: (1) direct effects only, (2) direct+indirect effects for IPD only, and (3) direct+indirect effects for IPD and inpatient PNE.ResultsScenario (1) resulted in 370.3 thousand QALYs gained and 12.8 thousand deaths avoided versus no vaccination. In scenarios (2) and (3), the PCV13 NIP gained 383.2 thousand and 3,580 thousand QALYs, and avoided 13.1 thousand and 147.5 thousand deaths versus no vaccination, respectively. In all three scenarios, the vaccination cost was offset by cost reductions from prevented disease yielding net costs of ¥29,362.32 million, ¥29,334.29 million, and ¥13,524.72 million, respectively. All resulting incremental cost-effectiveness ratios fell below a 2x China GDP cost-effectiveness threshold across a range of potential vaccine prices.DiscussionInitiation of a PCV13 NIP in China incurs large upfront costs but is good value for money, and is likely to prevent substantial cases of disease among children and non-vaccinated individuals.

Paying for Cures: How Can We Afford It? Managed Care Pharmacy Stakeholder Perceptions of Policy Options to Address Affordability of Prescription Drugs.

High-priced medications with curative potential, such as the newer hepatitis C therapies, have contributed to the recent growth in pharmaceutical expenditure. Despite the obvious benefits, health care decision makers are just beginning to grapple with questions of how to value and pay for curative therapies that may feature large upfront cost, followed by health benefits that are reaped over a patient's lifespan. Alternative policy options have been proposed to promote high value and financially sustainable use of these therapies. It is unclear which policy options would be most acceptable to health care payer and biomedical manufacturer stakeholders. To (a) briefly review pharmaceutical policy options to address health system affordability and (b) assess the acceptability of alternative policy options to health care payers and biomedical manufacturers before and after an Academy of Managed Care Pharmacy (AMCP) continuing pharmacy education (CPE) session. We searched MEDLINE and Cochran databases for pharmaceutical policy options addressing affordability. With input from a focus group of managed care professionals, we developed CPE session content and an 8-question survey focusing on the most promising policy options. We fielded the survey before and after the CPE session, which occurred as part of the 2016 AMCP Annual Meeting. We first conducted a chi-squared goodness-of-fit test to assess response distributions. Next, we tested how responses differed before and after by using an ordered logit and a multinomial logit to model Likert scale and unordered responses, respectively. Although risk-sharing payments over time remained the most favorable choice before (37%) and after (35%) the CPE session, this choice was closely followed by HealthCoin after the session, which increased in favorability from 4% to 33% of responses (P = 0.001). About half of the respondents (54%) indicated that legislative change is the most significant barrier to the implementation of any policy. As high-cost curative drugs reach the market, managed care stakeholders need information from a balanced education source regarding alternative policies to address affordability. We found that after the AMCP CPE session, risk-sharing payments over time and HealthCoin were the most favorable options. No funding was provided for this research. Carlson reports consulting fees from Genentech, Pfizer, and Seattle Genetics. The other authors have nothing to disclose. Study concept and design were contributed by Yeung, Garrison, and Carlson. Yeung collected the data, which were interpreted by Yeung and Basu. The manuscript was written by Yeung, Suh, and Bansal and revised by Yeung. A portion of this research was presented at the Academy of Managed Care & Specialty Pharmacy Annual Meeting as a continuing education session entitled "Paying for Cures: How Can We Afford It?" on April 20, 2016, in San Francisco, California.

Consumers’ Attitudes towards Surcharges on Distributed Renewable Energy Generation and Energy Efficiency Programs

Increasing penetration of energy efficiency programs and distributed renewable energy generation has imposed significant challenges for utilities to recoup their large upfront costs. There is a heated debate on what surcharges should be implemented to help the utilities recover their fixed costs; however, very few studies focus on consumers’ attitudes regarding this topic. This study surveys about 190 residential consumers throughout the United States in November 2015, investigating their preferences and attitudes towards extra demand charges and volumetric energy price increases. We apply probit models and regress consumers’ attitudes on selected socio-demographic and behavioral variables. The results indicate the homeowners are more likely to prefer demand charges when compared to renters. The demographic and behavioral factors impact consumers’ perception of bill savings from energy efficiency programs or solar panel installation and also influence how consumers perceive the fairness of utilities recovering revenue losses by increasing volumetric energy price. In this paper, we demonstrate there is preference heterogeneity among consumers and that policy makers should be aware of such preference heterogeneity and apply policy targeting based on the identified demographics and behavioral factors impacting consumer preferences.

Cost Effectiveness of Characterised Chondrocyte Implantation for Treatment of Cartilage Defects of the Knee in the UK.

Until recently, treatment options for damage to cartilage in the knee were limited to the use of microfracture or, occasionally, mosaicplasty. The developments of autologous and characterised chondrocyte implantation have provided new treatment options but have large upfront costs. The objective of this study was to estimate the cost effectiveness of characterised chondrocyte implantation in the UK National Health Service. An economic model was constructed in Microsoft Excel®, with patients undergoing either microfracture or chondrocyte implantation. Following treatment failure, patients can undergo a series of interventions, ultimately ending in knee replacement. Effectiveness and utility were modelled using clinical trial data, which were supplemented with synthesised registry data, and costs were taken from published sources. Results were expressed in clinical events, quality-adjusted life-years (QALYs) and British pounds. Both costs and outcomes were discounted at 3.5% per year. Chondrocyte implantation is estimated to reduce the lifetime probability of knee replacement by 50% in comparison with microfracture, and to increase QALYs by 0.72 (16.57 vs. 15.85). Costs were estimated to be £23,307 for chondrocyte implantation, and £8008 for microfracture, with the incremental cost of £15,299 for chondrocyte implantation reflecting reduced resource use offsetting some of the procedure cost. These values gave a cost per QALY gained of £21,245. Chondrocyte implantation is estimated to provide substantial patient benefits over a lifetime horizon, with a considerable increase in QALYs. Despite the increase in costs, the procedure is cost effective at standard thresholds used in the UK.

Information markets over trust networks

Information markets are inefficient. Information products have large upfront development costs, yet their duplication costs are negligibly small; and they are experience goods with high costs of marketing and promotion. As a result, either winner-take-all markets are created through large and expensive promotional campaigns, or artificial monopoly power is conferred by the government through copyright protection, or both, to prevent the collapse of these markets from intense price competition and piracy. Such inefficiency creates opportunities to design more efficient markets by utilizing new technologies. Trust networks provide such an opportunity where the network infrastructure acts not only as a distribution system for information products, but also as an advertising and promotion medium, a payment and pricing mechanism, a guarantee and insurance service, and a copyright enforcement and dispute resolution tool. Such a network-centric market place is proposed to remedy many of the shortcomings of mass markets by relying on peer-to-peer distribution, peer-to-peer payments, and peer-to-peer enforcement of trust and integrity. Analytical models are presented to show that such a market place for information goods can scale up to satisfy large markets without expensive promotions and advertising campaigns, create customized products with dynamic pricing, reduce entry costs by eliminating the distinction between buyers and sellers, and eliminate the need for copyright protection.

UTILITY OWNERSHIP OF COMBINED HEAT AND POWER: AN ECONOMIC MODEL BASED APPROACH

This paper proposes, and reviews, an Excel based model to evaluate the cost effectiveness for utility ownership of Combined Heat and Power (CHP) plants. CHP plants provide highly efficient use of fuel for production of electric power and useful heat. This efficient use of fuel can lead to lower energy bills for a company, or group of companies, utilizing a CHP plant, though at a large upfront cost. In order to provide the needed capital, cash reserves or debt can be used. This large capital experiments leads to longer payback periods, which may make CHP plant unattractive investments for end users, but fits perfectly into Electric power utilities investment strategy. This model was developed as a tool for an electric utility to determine if an investment into a CHP plant and selling the waste heat to an end user, would be an attractive investment worthy of further engineering investigation. For this paper, simulations where ran at seven different power hubs in five different power markets in the United States. Overall, the model showed that CHP plant would be an attractive investment in the New York City region and Boston regions, but not in Midwest. These differences are driven by lower power and lower capacity prices in the Midwest compared to the North East.

The Economics of Memory: How Copyright Decides Which Books Do (and Donnt) Become Classics

Legal scholars usually analyze copyright as an incentive and sometime obstacle to creation. This encourages us to see publishers as middlemen who siphon off rents that would be better spent on authors. By comparison, recent social science research emphasizes that word-of-mouth markets are highly imperfect. This means that many deserving titles will never find readers unless some publisher takes the trouble to market them. But this second view is deeply subversive. After all, the need for publishers – and reward – does not end when a book is published. At least in principle, copyright should last forever. The trouble with this argument is that it assumes what ought to be proven. How much effort do publishers really invest in finding forgotten titles? And does vigorous marketing attract more readers than high copyright prices deter? This article looks for answers in the history of 20th Century print publishers and today’s Print-on-Demand and eBook markets. We argue that, far from promoting dissemination, copyright frequently operates to suppress works that would otherwise erode the price of new titles. This pathology has gotten dramatically worse in the Age of eBooks. Meanwhile, public domain publishers are facing their own crisis. Mid-20th Century books had large up-front costs. This deterred copyists. By comparison, digital technologies make it easy for copyists to enter the market. This has suppressed profits to the point where many public domain publishers spend little or nothing on forgotten titles.The article concludes by reviewing possible reforms. Partial solutions include clarifying antitrust law so that firms have more freedom to implement price discrimination; modifying copyright so that consumers can re-sell used eBooks; letting on-line markets limit the number of publishers allowed to post redundant public domain titles on their sites; and strengthening non-commercial institutions for finding, curating, and delivering quality titles to readers.

Performance analysis of data intensive cloud systems based on data management and replication: a survey

As we delve deeper into the `Digital Age', we witness an explosive growth in the volume, velocity, and variety of the data available on the Internet. For example, in 2012 about 2.5 quintillion bytes of data was created on a daily basis that originated from myriad of sources and applications including mobile devices, sensors, individual archives, social networks, Internet of Things, enterprises, cameras, software logs, etc. Such `Data Explosions' has led to one of the most challenging research issues of the current Information and Communication Technology era: how to optimally manage (e.g., store, replicated, filter, and the like) such large amount of data and identify new ways to analyze large amounts of data for unlocking information. It is clear that such large data streams cannot be managed by setting up on-premises enterprise database systems as it leads to a large up-front cost in buying and administering the hardware and software systems. Therefore, next generation data management systems must be deployed on cloud. The cloud computing paradigm provides scalable and elastic resources, such as data and services accessible over the Internet Every Cloud Service Provider must assure that data is efficiently processed and distributed in a way that does not compromise end-users' Quality of Service (QoS) in terms of data availability, data search delay, data analysis delay, and the like. In the aforementioned perspective, data replication is used in the cloud for improving the performance (e.g., read and write delay) of applications that access data. Through replication a data intensive application or system can achieve high availability, better fault tolerance, and data recovery. In this paper, we survey data management and replication approaches (from 2007 to 2011) that are developed by both industrial and research communities. The focus of the survey is to discuss and characterize the existing approaches of data replication and management that tackle the resource usage and QoS provisioning with different levels of efficiencies. Moreover, the breakdown of both influential expressions (data replication and management) to provide different QoS attributes is deliberated. Furthermore, the performance advantages and disadvantages of data replication and management approaches in the cloud computing environments are analyzed. Open issues and future challenges related to data consistency, scalability, load balancing, processing and placement are also reported.

Clinical players and healthcare payers: aligning perspectives on the cost-effectiveness of next-generation sequencing in oncology.

Background Recent discussion surrounding the clinical implementation of genome sequencing has touted its cost–effectiveness [1]. However, the simplistic assumption that lowering the cost of next-generation sequencing (NGS) testing equates to cost–effectiveness is misguided and lacks evidence. Wide spread NGS testing in oncology will incur large upfront screening costs; potentially with no impact on treatment outcomes. In those instances where valuable information is revealed the use of an expensive targeted therapy is likely to be indicated. Therefore, it is essential to have reliable clinical and economic evidence supporting the clinical implementation of tumor-focused NGS testing. Inappropriate use could result in inefficiencies; reducing societies’ ability to provide (quality) healthcare to others. There are a number of challenges facing cancer centers looking to implement NGS and healthcare payers responsible for its reimbursement. Cancer centers need to determine the most suitable patient populations to receive NGS testing, where suitability is supported by the test’s analytical validity, clinical utility and cost–effectiveness. Payers will require this supporting evidence to determine if testing results in beneficial and cost-effective outcomes. Additionally, the uncertainty surrounding test outcomes, means payers will need to be more flexible in their approach to reimbursement – that is, share the risk with the cancer centers providing testing. This editorial reflects on these issues as they relate to the economic evaluation and eventual clinical implementation of tumorfocused whole-genome sequencing. From the onset we acknowledge that there are potential ethical issues and economic impacts of reporting incidental findings from the normal sample of a tumor-normal sequenced dyad (see Parsons et al. [2]).

The big to do about "big data".

The big to do about "big data".

The potential uptake of domestic woodfuel heating systems and its contribution to tackling climate change: A case study from the North East Scotland

This study explores the scope for increasing the contribution of woody biomass for private space and water heating in the North East Scotland, which corresponds to the administrative districts of Aberdeen, Aberdeenshire and Moray. It assesses the potential benefits in terms of carbon dioxide (CO2) emissions reduction of a partial shift from non-renewable heat sources to wood energy. Woody biomass is an interesting case to study because it is a source of renewable energy that directly depends on the rural land use sector. At the same time woody biomass can play an important role in fuel poverty reduction. North East Scotland has good potential for woody biomass production but the trade-off between food security and energy production has to be taken into account if more woodland creation is sought. Forests occupy 19% of the land area, and a number of towns and villages are close to extensive forested areas. North East Scotland administrative districts have supported the development of wood energy through the development of woodfuel-based public service heating and institutional structure is broadly conducive. Fuel poverty and greenhouse gas emissions from space and water heating could be drastically reduced through the wide adoption of heating systems in the region. However, large up-front capital costs, delays in establishing support systems, and the nature of support offered to contribute to the likely failure to deliver policy targets such as for reduced fuel poverty and CO2 emissions reduction.

Cost-Effectiveness of Fluocinolone Acetonide Implant versus Systemic Therapy for Noninfectious Intermediate, Posterior, and Panuveitis

To evaluate the 3-year incremental cost-effectiveness of fluocinolone acetonide implant versus systemic therapy for the treatment of noninfectious intermediate, posterior, and panuveitis. Randomized, controlled, clinical trial. Patients with active or recently active intermediate, posterior, or panuveitis enrolled in the Multicenter Uveitis Steroid Treatment Trial. Data on cost and health utility during 3 years after randomization were evaluated at 6-month intervals. Analyses were stratified by disease laterality at randomization (31 unilateral vs 224 bilateral) because of the large upfront cost of the implant. The primary outcome was the incremental cost-effectiveness ratio (ICER) over 3 years: the ratio of the difference in cost (in United States dollars) to the difference in quality-adjusted life-years (QALYs). Costs of medications, surgeries, hospitalizations, and regular procedures (e.g., laboratory monitoring for systemic therapy) were included. We computed QALYs as a weighted average of EQ-5D scores over 3 years of follow-up. The ICER at 3 years was $297,800/QALY for bilateral disease, driven by the high cost of implant therapy (difference implant - systemic [Δ]: $16,900; P < 0.001) and the modest gains in QALYs (Δ = 0.057; P = 0.22). The probability of the ICER being cost-effective at thresholds of $50,000/QALY and $100,000/QALY was 0.003 and 0.04, respectively. The ICER for unilateral disease was more favorable, namely, $41,200/QALY at 3 years, because of a smaller difference in cost between the 2 therapies (Δ = $5300; P = 0.44) and a larger benefit in QALYs with the implant (Δ = 0.130; P = 0.12). The probability of the ICER being cost-effective at thresholds of $50,000/QALY and $100,000/QALY was 0.53 and 0.74, respectively. Fluocinolone acetonide implant therapy was reasonably cost-effective compared with systemic therapy for individuals with unilateral intermediate, posterior, or panuveitis but not for those with bilateral disease. These results do not apply to the use of implant therapy when systemic therapy has failed or is contraindicated. Should the duration of implant effect prove to be substantially >3 years or should large changes in therapy pricing occur, the cost-effectiveness of implant versus systemic therapy would need to be reevaluated.

Innovation and risk-averse firms: Options on carbon allowances as a hedging tool

In a regulated world where government seeks to decarbonize the energy sector, firms face both indirect and direct costs of emitting CO2. This study seeks to take the perspective of the firm, which needs to maximize profits implying minimization of (carbon) cost as well. In this study, the firm can compose the cost-optimal portfolio of (a) investing into carbon-saving technology, which is currently expensive, (b) investing into carbon-saving technology R&D and adopt this technology at a later point, (c) buying allowances per ton of emitted CO2 in a carbon market (alternatively this could be formulated as a tax), and (d) buying offsets traded in the same market, which are based on reduced emissions from deforestation and degradation (REDD+). Uncertainties in the cost of carbon coming from a lack of commitment in policy-making leading to fluctuations in markets and uncertainty in the payoff of R&D activities could provide disincentives to incur large up-front sunk cost and raise the economic value of being flexible. We apply a real options approach with stochastic carbon-saving technology costs and stochastic CO2 costs. Assuming that firms are risk-averse, they will not only value flexibility, but also risk reductions from diversification over the different (carbon mitigation) options.

DISCUS: an end-to-end solution for ubiquitous broadband optical access

Fiber to the premises has promised to increase the capacity in telecommunications access networks for well over 30 years. While it is widely recognized that optical-fiber-based access networks will be a necessity in the shortto medium-term future, its large upfront cost and regulatory issues are pushing many operators to further postpone its deployment, while installing intermediate unambitious solutions such as fiber to the cabinet. Such high investment cost of both network access and core capacity upgrade often derives from poor planning strategies that do not consider the necessity to adequately modify the network architecture to fully exploit the cost benefit that a fiber-centric solution can bring. DISCUS is a European Framework 7 Integrated Project that, building on optical-centric solutions such as long-reach passive optical access and flat optical core, aims to deliver a cost-effective architecture for ubiquitous broadband services. DISCUS analyzes, designs, and demonstrates end-to-end architectures and technologies capable of saving cost and energy by reducing the number of electronic terminations in the network and sharing the deployment costs among a larger number of users compared to current fiber access systems. This article describes the network architecture and the supporting technologies behind DISCUS, giving an overview of the concepts and methodologies that will be used to deliver our end-to-end network solution.

Technology Adoption, Job Matching Frictions and Business Creation

We study the impact of a General Purpose Technology that changes the cost structure turning fixed costs into variable ones in most sectors. A major recent example is cloud computing, whose adoption allows firms to avoid large up-front costs in IT and to rent computing capability online. We study the macroeconomic impact of the adoption of such an innovation in a DSGE model with endogenous market structures in the goods market and search and matching frictions in the labor market. To start a business, firms need to hire workers from the pool of unemployed agents and set up a stock of IT capital: the new technology allows them to rent computing capabilities reducing entry costs. Such an innovation can have a substantial impact on business and job creation.

A Novel Approach to 3D Chip Stacking

Designers seeking electronic package miniaturization but lacking the resources to utilize custom ASIC or complex 3D integration approaches can now take advantage of chip stacking technology for integrating a range of devices into small, system-in-package (SiP) structures. A robust, innovative approach, suitable for supporting low- to medium-volume applications, has been developed which avoids the cost and/or size penalties typically encountered using traditional multi-chip packaging techniques. Using bare die and vertical interconnect/interposer structures, this stacking technology permits the design of multi-chip assemblies with either identical or dissimilar die, co-packaged with discrete and/or integrated passive devices. The approach is independent of ASIC foundry process and does not require through-silicon via (TSV) technology, and is therefore well-suited for designs incorporating multiple IC's from different semiconductor processes or manufacturing sources. Relative to system-on-chip (SoC) ASIC implementations, which carry large upfront NRE costs and long development cycles, 3D co-packaging of heterogeneous devices in customized SiP packages offers a proven, cost-effective alternative with greater design flexibility and reduced time to market. This presentation will describe this novel 3D packaging approach, and how it can be used in conjunction with discrete and integrated passive components to address package designs where size, weight, and/or performance are at a premium.

Achieving conservation objectives through production forestry: The case of Acacia koa on Hawaii Island

Abstract The future of Earth's natural capital, and the ecosystem service benefits it supplies humanity, hinges on whether conservation and restoration become economically attractive and commonplace on lands managed for profit. Sustainable forestry is a potential means of making restoration profitable; in most of the world, it remains the only way to reforest large areas while maintaining economic viability for the landowner. Here we explore the potential benefits and limitations of native tree forestry as an economically viable conservation tool in the context of a case study—koa forestry on Hawaii Island. We conducted interviews with practitioners and scientists to evaluate koa forestry as means of restoring natural capital in Hawaii. Our interviews demonstrated strong interest in the ecological and economic potential of koa, but the respondents also cited a litany of concerns. Koa's attractiveness to private landowners is hampered by a lack of silvicultural information (particularly on native trees such as koa), the challenge of balancing profit and biodiversity, wariness of government involvement, and perhaps most importantly, large upfront costs and having to wait several decades for revenue from timber harvest. Establishing new revenue streams for non-timber ecosystem services of koa forests – through government or private sector payments – could greatly enhance the attractiveness of this land use to a diverse set of landowners.