Narrow Networks Research Articles

The accuracy of dermatology network physician directories posted by Medicare Advantage health plans in an era of narrow networks.

IMPORTANCE Insurers are increasingly deploying “narrow networks” with fewer contracted physicians both in health plans offered in new state exchanges under the Affordable Care Act and in Medicare Advantage (MA) plans, which are commercial alternatives offered to Medicare beneficiaries. Patients choosing health plans rely on the accuracy of network directories posted by insurers. The MA plans must meet network adequacy requirements,and inaccurate directories of participating physicians might prejudice those determinations.OBJECTIVE To determine the accuracy of MA plan directories of participating dermatologists,and the appointment availability of listed physicians.DESIGN, SETTING, AND PARTICIPANTS Scripted telephone calls were placed to every dermatologist listed in directories for the largest MA plans in 12 US metropolitan areas. The caller sought an appointment on behalf of his fictitious father who had severe itch for several months, asked whether the dermatologist accepted the relevant plan, and asked for the next available appointment date.MAIN OUTCOMES AND MEASURES Appointment availability and wait time.RESULTS Among 4754 total physician listings, 45.5%represented duplicates in the same plan directory. Among the remaining unique listings, 48.9% of physicians were reachable,accepted the listed plan, and offered an appointment for our fictitious patient. Many of the dermatologists listed had incorrect contact information, were deceased, retired, or had moved, were not accepting new patients, did not accept the insurance plan, or were subspecialized. The mean (range) wait time for appointments among the remaining listings was 45.5 (1-414) days. Both the accuracy of network directories and the appointment wait times varied substantially by health plan and metropolitan area. For 1 plan, our caller was unable to obtain an appointment with any listed dermatologist. CONCLUSIONS AND RELEVANCE Medicare Advantage physician directories for dermatology in many areas substantially overestimate the number of in-network physicians available to treat patients with medical skin conditions. These inaccuracies occurred in areas with long appointment wait times and where plans are terminating selected physician contracts. This suggests a lack of capacity that would be exacerbated by further network narrowing.Accurate physician directories are essential for proper oversight of network adequacy, and for patients who rely on these listings to evaluate health plan options during open enrollment.

Deep networks are effective encoders of periodicity.

We present a comparative theoretical analysis of representation in artificial neural networks with two extreme architectures, a shallow wide network and a deep narrow network, devised to maximally decouple their representative power due to layer width and network depth. We show that, given a specific activation function, models with comparable VC-dimension are required to guarantee zero error modeling of real functions over a binary input. However, functions that exhibit repeating patterns can be encoded much more efficiently in the deep representation, resulting in significant reduction in complexity. This paper provides some initial theoretical evidence of when and how depth can be extremely effective.

Health benefits in 2014: stability in premiums and coverage for employer-sponsored plans.

The annual Kaiser Family Foundation/Health Research and Educational Trust Employer Health Benefits Survey found that in 2014 the average annual premium (employer and worker contributions combined) for single coverage was $6,025, similar to 2013. The premium for family coverage was $16,834--3 percent higher than a year ago. Average deductibles and most other cost-sharing amounts were similar to those in 2013. On average, in 2014 covered workers paid nearly $5,000 per year for family health insurance premiums, and 18 percent of covered workers were in a plan with an annual single coverage deductible of $2,000 or more. Fifty-five percent of employers offered health benefits in 2014, similar to 2013. The Affordable Care Act has not yet led to substantial changes in the employer-based market. However, the next few years could present a different picture as delayed provisions and other changes take effect. This year's survey included new questions on firms' policies related to enrolling spouses and dependents, enrollment in private exchanges, and the use of narrow networks and financial incentives for wellness programs.

Male Transfer Student Athletes and Schlossberg’s Transition Theory

The purpose of this study was to examine transfer student athletes’ perceptions of their transition experience. Studies of student athletes typically focus on “traditional” student athletes who matriculate to college directly from high school. This study sought to fill the void in the research literature. Schlossberg’s Transition Theory was used as the conceptual framework for this study. Twelve male transfer student athletes from a Midwestern Division I university were interviewed regarding their transition experience. The findings would suggest that Schlossberg’s Transition Theory provides a relevant framework within which to examine the transition experience of transfer student athletes. The findings indicate that transfer student athletes are relatively self-reliant relying on a narrow support network consisting of family and members of the athletic department including teammates. These athletes reported that they had a limited amount of engagement with the broader university community. All of the athletes in the study reported that they were motivated to transfer by athletic rather than academic reasons, which may account for their reliance on a rather limited support network focused on the athletic department. A surprising finding was that a number of participants indicated that due to NCAA rules they were forced to become “swirlers” (4-2-4 transfers) in order to make degree progress and remain athletically eligible.

Obstructive Sleep Apnea and Health Benefits Purchasing: An Employer Perspective

Obstructive Sleep Apnea and Health Benefits Purchasing: An Employer Perspective

Streaming media service based on fuzzy similarity in wireless mobile networks

Owing to the recent development in mobile network technologies, users may enjoy streaming media services anytime, anywhere using personal mobile communication devices. Wireless mobile streaming media services, however, have such problems as delay, congestion, and crosstalk due to narrow network bandwidth and limited resources. These problems degrade not only Quality of Service (QoS), but also responsiveness and reliability of the streaming media service. To solve this problem, this paper proposes a Fuzzy Similarity-Based Transcoding Proxy (FSTP) mechanism. The proposed FSTP mechanism analyzes the fuzzy similarity of partitioned segment versions of media objects to construct a Fuzzy Similarity-Based Transcoding Graph (FSTG). The constructed FSTG determines transcoding for the partitioned media object segment versions. The determined transcoding improves Delay Saving Ratios (DSR), Cache Hit Precision Ratio (CHPR), and Cache Hit Recall Ratio (CHRR). Therefore, the more relevant media object segment versions, determined by the fuzzy similarity, are transcoded and cached first to reduce the start delay time and network traffic. The proposed mechanism is simulated to evaluate various performance parameters. The simulation results show that the proposed mechanism achieves improved performance in DSR, CHPR, and CHRR compared with those of other existing mechanisms.

조선왕조 가계 인물 네트워크

Family member network of kings in Chosun dynasty shows scale free network properties as if most social networks do. One of distinct topological properties of the network is relatively high diameter that reflects dataset composed of the one generation continuously falling to next one. When k-core algorithm as a useful tool for obtaining a core network from the complex family member network was employed, it is possible to obtain hidden and valuable information from a complex network. Unfortunately, it is found that k-core algorithm is not useful tool for applying narrow and deep structural network. The family member network is composed of kings, queens, princes, and princesses. It is possible to separate sub-family members and to construct sub-family member networks such as queen-centered, prince-centered, and princess-centered networks. Sub-family member networks provide an useful and hidden information. These results provide new insight that is analyzed by network-based approaches for the family member of the kings in the Chosun dynasty.

An Evaluation of Road Network Patterns Based on the Criteria for Fire-Fighting

We propose the following method for evaluating road network patterns. An evaluation of these patterns is important not only for an understanding of the structure of a city, but also for compliance with the rule in the Building Standards Law (the basic law related to buildings and cities in Japan), that makes it possible to preserve lanes (i.e., narrow roads less than four meters wide). This rule, however, does not provide a method for judging whether or not road network patterns are laid out in a suitable manner. We conducted an interview at a local administrative office and found that this provision is closely related to the need to ensure access for fire-fighting equipment and personnel. Thus, by determining whether, in an area encircled by wide roads, there is a ‘fire-inextinguishable area’ (FIA) more than 140 meters from the nearest wide roads (i.e., an area where fires cannot be put out effectively), we can determine whether or not road networks are appropriately laid out. In addition, we present a mathematical formula showing that if there is no ‘fire-inextinguishable area’ (FIA) in an encircled area, there will not be an unsuitable, blocked position for putting out fires. Observing this difference, as well as the ease in turning right or left at intersections in the areas encircled by wide roads, we found that grid road network patterns are appropriately set up. Also, by using indices based on graph theory as a complementary method for evaluating road network patterns, we found that while almost all narrow road networks are classified as belonging to the tree pattern, some of these narrow networks are considered to be almost in the grid pattern, and are directly connected to wide roads. This indicates that actual road networks in Tokyo have weak connectivity, which may cause difficulties in ensuring two-way escape.

Framework of Geometry Modeling Integrated Platform based on Services for Large-scale Information Visualization

Information visualization in web environment provides an effective visual approach to support cooperative work in the enterprises. However, problems of heterogeneous systems existence and three-dimensional data exchange difficulty make geometry modeling, which is key technology of information visualization a heavy task, especially under the narrow band network condition. Thus, an open geometry modeling integrat ed platform is built based on service- oriente d architecture. Firstly, geometric resource model is constructed as the basic geometric data structure based on X3D component. Then based on domain ontology, operational semantic of geometric resource model is used as referenced framework to construct geometry modeling services, which are generated by composing legacy applications or by encapsulating geometry engine. Lastly a distributed CAD software prototype based on an open geometry engine CASCADE is proposed to verify the framework. The result shows that the framework provides a p romising reference for large-scale information visualization.

Surfactant Distribution in Waterborne Acrylic Films. 1. Bulk Investigation

The distribution of an anionic surfactant, sodium dodecyl sulfate (SDS), in waterborne acrylic films was investigated, focusing on the effects of particle composition and size, and pH of the latex. The observed surfactant distributions could be classified in two categories: homogeneous and heterogeneous, the latter showing SDS aggregates. The shape of the profiles was related to the stability of the latex during drying, at short interparticular distances. The stability of the latex was determined by the presence or not of fixed charges at the surface of the particles. The latices with particles carrying neutralized acrylic acid at high pH (COO(-)) led to homogeneous distributions, whereas the latices with acrylic acid at low pH (COOH) or without acrylic acid led to heterogeneous distributions. Our interpretation is that the stable latices present a narrow network of paths between particles at high polymer volume fraction, limiting the mobility of the surfactant, whereas in the less stable latices wider routes between flocs allow enough mobility for large aggregate formation. Thermal treatments of the dry films confirmed the strong confinement of the surfactant in the dense film structure obtained at high pH and the more open structure, allowing easier surfactant transport and oxygen penetration, observed at low pH. In order to account for the shapes of the profiles more quantitatively, a model was developed based on the diffusion of the surfactant and its transport by the drying front. It was found that the apparent diffusion coefficient of SDS micelles had to be lowered to a great extent (D = 10(-13)-10(-14) m(2)/s) during drying in order to explain aggregate formation. It should be even lower (D = 10(-15) m(2)/s) to interpret homogeneous surfactant profiles. These results are consistent with our hypothesis of the key importance of the surfactant mobility during drying.

Web-based terrain and vector maps visualization for Wenchuan earthquake

This paper presents a Web-based three-dimensional Geographic Information System (3DGIS) for Wenchuan earthquake disaster assessment. With the help of information technology resources, geoscientists are in a position to learn more about the structure of the earthquake in efficient ways. Due to huge spatial datasets of Wenchuan, China and narrow network bandwidth, general-purpose applications are difficult to transmit and visualize these datasets on the network. The application aims to interactively represent and transfer large spatial objects of Wenchuan County, China, as well as for dynamically rendering them in networking environments. Level-of-detail (LOD) terrain models and vector maps are created, and the server–client architecture is presented. The application provides an effective way for powerful access and manipulation of large-scale Wenchuan datasets.

The etiology and treatment of significant societal problems: Behaviorists diving into murky Waters with Strangers.

In January of 2007, I edited an issue of the International Journal of Behavior Consultation and Therapy (IJBCT) (see Golden, 2007) encouraging behavior analysts to consider the problems of children who are non-responders to the typical behavioral techniques and suggested that behavior analysts consider literature and clinical approaches from other sources. Specifically, these children included those with attachment problems, exhibiting difficulties with and behaviors. In this issue, I am again appealing to behavior analysts to broaden their focus to include populations that are not normally the purview of these professionals. In the 2007 issue of the Behavior Analyst, Kangas and Vaidya presented data on the number of presentations that dealt with each of the applied categories of topic areas at the annual conventions of the Association for Behavior Analysis (ABA) from 1980 to 2007. At the 2007 annual convention of the ABA, in the combined categories of Clinical, Family, and Behavioral Medicine (C/F/BM) there were a total of 107 presentations compared to 325 presentations in the combined categories of Developmental Disabilities and Autism (DD/AUT). That means that there were three times as many presentations at the 2007 convention about DD/AUT than there were about C/F/BM. At the 2009 convention, I chaired a symposium in which I outlined likely reasons why behaviorists more frequently deal with individuals with DD/AUT than with other types of disorders or problems. They are as follows: 1. The black box (Uttal, 1999) of their inner world is much less complicated to study. When clinicians deal with individuals with emotional and moral behavioral issues, they have to contend with the possibility of complex underlying psychological constructs such as: higher level cognitions, ambivalent emotions, nuances of social interaction, consciousness, a conscience, and sense of self- and other-perspectives. 2. The identification and delivery of reinforcers and punishers are much easier to identify and control. Clinicians and parents can control computer or TV access, preferred toys or items, social reinforcers and tokens, to name a few reinforcers that work well with children with DD/AUT. It is a lot more difficult (not to mention, unethical) to deliver contingently and/or limit access to tobacco, sexual activity, drugs/alcohol, gambling, prostitution, on-line pornography, the excitement of an ambulance arriving when cut your wrist, charging over your credit card limit, criminal behavior, etc. The point is, the clinician cannot use these as reinforcers, but if these are the individuals' most reinforcing activities, how do you compete with them? 3. The ramifications of following through and being consistent are much less drastic. When individuals with DD/AUT escalate their behavior during a tantrum, the worst ensuing consequences are usually either: aggression toward others, self-injurious behavior or running away to no particular destination. Not to minimize the seriousness of these behaviors, but they can be easily handled through environmental manipulation. However, when individuals with behavioral or problems escalate their behavior, the clinician is faced with consequences such as: threats/hurtful verbal statements, suicide/homicide or threats of these, running away to a life of homelessness, alcohol/substance abuse, elicit sexual activity, false allegations of abuse, triangulation of caregivers, and physical/sexual assault. 4. There exists a much narrower network of negative influences and there are more limited environments. Clinicians helping children with DD/AUT become frustrated when they must change the behavior of family members and school personnel in order help the children they serve. With individuals who have and behavior problems, there is a much wider sphere of influences and there are many more environments that impact behaviors. …

Mapping autism and schizophrenia onto the ontogenesis of social behaviour: A hierarchical-developmental rather than diametrical perspective

AbstractCo-morbidity of schizophrenia and autism is low because interpersonal concerns of schizophrenic patients presuppose developmental achievements that are absent in autism. Autism may arise if primary anxiety is not overcome at a key developmental stage by affective synchronisation between infant and caregiver. Schizophrenic patients will have learned to regulate primitive anxiety by affectively attuning to narrow social networks but remain highly vulnerable to exclusion from larger groups.

Iluze a mýty spojované s hospodářskou emancipací českého národa

Hospodářská emancipace českého národa probíhala v Českých zemích opožděně a přerušovaně od poloviny 19. století. Opírala se o zemědělskou výrobu a potravinářský průmysl v čele s řepným cukrovarnictvím a rozvinuté peněžnictví. Plně se rozvinula až v desetiletí před počátkem první světové války. V těchto letech byl nástup českých podnikatelů současníky označován jako "český zázrak". Podle dobových odhadů však byl tehdejší podíl českého průmyslového kapitálu vůči německému asi třetinový a podle nových poznatků byl spíše pětinový. Jen v cukrovarnictví jako pilíři českého kapitálu totiž vlastnili Češi pouze 24 % z hodnoty závodů. Hospodářsky opožděná a politicky neplnoprávná česká společnost se proto posilovala účelovými iluzemi o své převaze nejen v hlavních oborech potravinářského průmyslu.

Visualization of large spatial data in networking environments

Rendering and interacting with high-resolution geographical data sets and complex models have become integral parts in a 3D GIS, in particular, in a web-based 3D GIS. Due to large data sets and narrow network bandwidth, general-purpose GIS can no longer visualize and manipulate these spatial data over networks in real time. This paper explores a way for building a Web-based 3D GIS application. The application aims to visualize and analyze large spatial data sets. We propose a novel 3D data model for representing the features of the terrain surface and 3D objects. A server–client architecture including progressive transmission methods and multiresolution representations are presented to help create the application. Together with a spatial index, the application provides an effective way for powerful access and manipulation of large-scale data sets. Finally, an experiment is performed using the geo-data to verify that the application works appropriately.

Transparency—Will It Lead Us Back to the Future?

Both Sandy Lutz and Richard Clarke make strong arguments that transparency is here to stay. Meaningful information needs to be provided, and hospitals and providers should take the lead in this effort. It is hard to argue with their conclusions. QUALITY TRANSPARENCY-Is THIS ACHIEVABLE? As we know, most payers have their own quality measurement indicators. Several have proprietary systems to determine the quality ratings of providers and hospitals. These nontransparent systems create distrust between the payer and provider. The numerous nonpayer proprietary quality websites just add to the confusion. Payers and providers need to come together at a national level and agree on a common quality measurement data set. Such an initiative would go a long way to reducing consumer confusion regarding the myriad quality measures available. With the initiation of pay-for-performance programs by Medicare and other payers, each using their own measurement goals, focus becomes difficult, if not impossible, for an organization. Agreement on common measurements would eliminate the black box used by some payers to measure quality, increase trust among the parties, facilitate quality improvement and pay-for-performance initiatives, and provide meaningful quality information to the consumer. PRICE TRANSPARENCY-BACK TO THE FUTURE As Richard Clarke pointed out, hospitals need rational, defensible pricing systems. These systems need to be understandable by patients and easy to administer. The addition of personnel and other overhead costs to facilitate price transparency needs to be avoided. When discounts, case rates, per diem arrangements, and the like were originally negotiated, most markets had surplus capacity and were willing to price to meet the payers' needs to move volume. Networks did not indude everyone. Benefit designs directed business to a narrow network of hospitals and doctors. Times have changed. Today many markets have a shortage of bed capacity. Most health plans have almost all providers in their networks; thus, the various HMOs, PPO, POS plans provide no real direction for business. Add to this the overwhelming desire for price transparency and the desire for the uninsured/underinsured to pay no more than the large insurers, and the time is right for a return to using charges as the pricing methodology for hospitals. Hospitals could take the risk associated with establishing fixed prices for all nonemergency outpatient procedures and for inpatient cases without complication or comorbidity. All other cases, including emergency cases, would be paid based on the charges billed. Hospital charges could be reduced to realistic rates needed to generate a reasonable operating margin and could be posted on the Internet for all to see. This approach of using charges as our real prices has several advantages: I. Using charges as real prices would permit total transparency of prices for any prospective patient, with fixed prices on those services that would likely be price shopped, without any additional overhead costs other than keeping the price list on the website current. This would facilitate a reallocation of resources within hospitals from the managed care and business office functions to staff the new emerging processes needed to obtain the necessary information and collect payment on the front end of the billing process. 2. If hospitals chose not to give discounts in this model, insurance plans would have to compete based on the services they offered. This would permit other insurers to enter the market, since health plans would no longer be competing on the volume-based discounts they could get from the hospital but rather on the services the health plan offered. Opening up the market would increase the health insurance options available for employers and other purchasers of healthcare and would slow the consolidation of the health insurance industry. …

Structure development in amorphous starch as revealed by X‐ray scattering: Influence of the network structure and water content

AbstractThe evolution of the amorphous structure of starch was characterized during the drying process by real‐time X‐ray wide‐angle scattering. The X‐ray diffractograms of injection‐molded starch show two superposed, rather broad, scattering maxima indicative of noncrystalline structures. The location of the two peaks has been associated to disordered starch single helices. A third maximum that arises upon drying the material in vacuum is associated to the scattering emerging from regions containing double helices. A model for the starch network is proposed, assuming a primary and a secondary component. The wider, temperature stable component appearing first, is correlated to the entanglement network of the melt. The narrower network component, which is created later, at lower temperature (secondary network), is explained by the formation of double helix regions that densify the wider primary network. The secondary network is increased strongly by the drying process. X‐ray experiments performed during the penetration of water, provoking a higher molecular mobility, reveal a better‐packed helical structure that becomes the precursor of a double helix crystalline formation. When temperature increases, the secondary network is dissolved and water molecules arrange themselves in better‐organized crystals as strongly bound crystal water. © 2005 Wiley Periodicals, Inc. J Appl Polym Sci 99: 1880–1886, 2006

The coping of an adolescent who has been in psychiatric inpatient care and her mother in everyday life

The purpose of this study was to describe the coping of an adolescent girl who had been psychiatric inpatient care and her mother in everyday life. The case study design was used to gain intimate knowledge of the persons' condition, thoughts, feelings, actions, intentions and environment. The data were collected by interviewing the adolescent and her mother during 1999-2001. The informants were interviewed three times. The data were analysed by inductive content analysis. Six categories were formulated to describe the coping demands faced by the adolescent who had been in psychiatric inpatient care. They were: suicidal behaviour, failing mental health, narrow social network, weakening sense of reality, low self-esteem and negative feedback from others. Her coping strategies were hobbies, praying and occasionally withdrawal into a fantasy world. Emotional support was her most important coping resource. The coping demands faced by the mother concerned her daughter's aggressive behaviour, withdrawal from personal relationships and inability to concentrate. The mother worried about her daughter's unstable mental health and future. She was also extremely concerned about the relationships between the family members. On top of everything else, the mother developed new somatic diseases. The mother took care of herself by studying and doing handiwork. Social life was very important to her. Her main coping resource was emotional support. She got emotional support from friends and members of the family. The family had previously kept in touch with friends, but the husband had broken off all contacts.

Reconstruction of a defect after harvesting a radial forearm flap using a narrow pedicled paraumbilical perforator-based subdermal vascular network (super-thin) flap

The radial forearm flap is one of the most reliable flaps, but it has serious cosmetic donor site morbidity. We therefore reconstruct the defect after harvesting a radial forearm flap using a narrow pedicled paraumbilical perforator-based subdermal vascular network (super-thin) flap to overcome this problem.

Situating Technoscience: An Inquiry into Spatialities

This paper explores the spatial characteristics of science and technology. Originally seen as universal, and therefore outside space and place, studies in science, technology, and society (STS) located it first in specific locations—laboratories—and then in narrow networks linking laboratories. This double location implied that science is caught up in and enacts two topological forms— region and network—since objects in networks hold their shape by freezing relations rather than fixing Euclidean coordinates. More recent STS work suggests that science and technology also exist in and help to enact additional spatial forms. Thus some technoscience objects are fluid, holding their form by shifting their relations. And yet others achieve constancy by enacting simultaneous absence and presence, a topological possibility which we call here fire. The paper concludes by arguing that the ‘global’ includes and is enacted in all four of these topological systems.