National Expenditure Research Articles

Fund gap to high air quality in China: A cost evaluation for PM2.5 abatement based on the Air Pollution Prevention and control Action Plan

The Chinese government promulgated a series of policies on air cleaning due to the severe PM 2.5 pollution. Thereinto, the Air Pollution Prevention and Control Action Plan (the Action Plan) numbers among the toughest-ever environmental protection policy in China, which significantly restrained haze pollution with a huge cost. In a policy-making for air cleaning, cost assessment is crucial. However, current main methods have a common shortcoming for which they neglect the cost on industrial restructurings. Thus, in this work, we proposed a novel approach to assess the comprehensive cost on the long-term PM 2.5 control in China under the Action Plan scenario. First, PM 2.5 pollution abatements and 10 precursor variations in China’s 31 provinces were quantified via the Cohen’s index. Then, provincial expenditures were jointed with their corresponding Cohen’s indices of precursors and PM 2.5 mitigation, and patterns of the Action Plan were identified through machine learning. It was found that boiler regulation and industrial restructuring were the driving forces for most precursor decreases. Finally, the overall PM 2.5 pollution abatement was calculated by the fixed-effect model and jointed with the cumulative national expenditure to construct a cost curve, which can estimate the cost on both front- and end-of-pipe sections. Thus, the maximum budgets for several air quality targets were evaluated, which was found that China has to pay 10.24 and 51.55 trillion CNY within the PM 2.5 concentrations limits of 25 and 10 μg/m 3 , respectively. Our study provided a new insight of fund gaps between different control targets in China and filled the lack of current cost assessment methodologies.

Incidence of lower limb amputation in people with and without diabetes: a nationwide 5-year cohort study in Japan

IntroductionThis study was conducted to investigate the incidence and time trend of lower limb amputation (LLA) among people with and without diabetes.Research design and methodsThis retrospective population-based cohort study was...

Financial system specialization and private research and development expenditure: research for OECD countries

Purpose The purpose of this paper is to analyse the role that different financial sources and financial specialization have on private research and development (R&D) activity in OECD countries. Design/methodology/approach The authors developed several panel regressions choosing as a final model a two-way random effects regression to understand which funding sources are related to the R&D expenditure, and how financial specialization has links to the private portion of R&D aggregated expenditure. The authors include data from the years 2000 to 2016 for OECD countries. Findings The results reinforce the critical role that stock markets have in enhancing private R&D and that bond markets have an inverse relationship with private R&D national expenditures. The authors do not find evidence of a link between bank sources and private R&D. Specialized financial systems (banking or market) support innovation in a better way than a mixed arrangement of those two systems. Practical implications The findings of this study have considerable policy implications. Policymakers need to be aware of these results, given that some variables related to financial markets, seems to boost the inputs for R&D. In the long term, this could be a signal that national and regional systems of innovation need a broad view of the factors hampering scientific activity, and also a signal that there are other ways to impact the results of the complex innovation activity through the development of stronger financial systems backing up national systems of innovation. Originality/value The authors found that the long discussion about the financial system that a country has to choose to enhance growth with R&D&I may have been misleading the public policy. The findings show that rather than a bank or a stock market financial system, economies looking to boost R&D&I, must specialize in one of the two systems, deepen these and generate the appropriate policies to promote science, technology and innovation using those financial markets.

Antidepressant treatment effects and country income: meta-regression analysis of individual participant data from duloxetine trials.

In recent decades, significant numbers of pharmaceutical trials have gradually been relocated to low- and middle-income countries. However, there is little evidence regarding the transferability of trial outcomes across countries. Analysing duloxetine randomised controlled trials (RCTs) conducted in different countries, we investigated whether per capita gross national income (GNI) and healthcare expenditure (HE) are associated with pre-post mean changes of depression severity and differences in duloxetine-placebo effect sizes. Meta-analyses included RCTs investigating duloxetine efficacy in patients with depression. Individual participant data (IPD) from multi-centre duloxetine trials were provided by the manufacturer. Data extracted from published reports also entered analyses in case of trials conducted in only one country. A meta-regression approach was applied to analyse associations of GNI and HE with standardised pre-post mean change using raw score standardisation (SMCR) and comparative effect size, that is, the mean differences (MD) in pre-post effect size between duloxetine and placebo treatment. 23 trials with 8417 randomised participants entered analyses. Regression coefficients indicated a negative linear relationship of SMCR with GNI (z-standardised β=-3.61, R2 =14.8%, p < 0.001) and HE (β=-4.72, R2 =24.8%, p < 0.001) for participants treated with duloxetine. Similar associations were found for placebo treatment (GNI: β=-3.52, R2 =23.8%, p < 0.001; β=-3.34, R2 =21.0% p < 0.001). Neither GNI nor HE was associated with the MD between duloxetine and placebo pre-post differences. Findings challenge the idea of the universal transferability of antidepressant trial outcomes across countries. Understanding the results of antidepressant RCTs demands more sophisticated clarification of context factors involved in determining effectiveness of antidepressant medication and should be discussed with a view to socio-economic context in their countries of origin.

COVID-19 and women's nutrition security: panel data evidence from rural India

In response to the COVID-19 pandemic, India implemented a stringent nationwide lockdown. Although food value chains and allied activities were exempted from the lockdown, there were widespread disruptions in food access and availability. Using two panel-datasets, we distinguish the pandemic's impact on non-staples versus staples in relation to household food availability and women’s diet diversity at the national, state, and district levels in four economically backward districts of Uttar Pradesh (Maharajganj), Bihar (Munger), and Odisha (Kandhamal and Kalahandi). Both the primary and secondary data indicate a decline in household food expenditures and women’s dietary diversity in May 2020 compared to May 2019, particularly for non-staples like meats, eggs, vegetables and fruits. This occurred despite special PDS, direct benefit transfer, and ration from aanganwadis rations reaching 80%, 50%, and 30% of surveyed households, respectively. While national and state-level expenditures recovered to the pre-lockdown levels by June 2020, the district-level expenditures did not recover. Our findings contribute to the growing body of evidence of women's disproportionate vulnerability to economic shocks, the impact of a staple grain focused safety net program, and restricted markets on the access and availability of diverse nutritious foods. This paper makes a case for policy reforms towards PDS diversification to include nutrition-rich foods and market reforms to remove supply-side bottlenecks and expansion of direct benefit transfers for healthy food access. We also highlight the importance of gender-responsive safety nets and their increased coverage for improving intrahousehold nutritional disadvantages.

Health expenditures by services and providers for 195 countries, 2000–2017

IntroductionNational Health Accounts are a significant source of health expenditure data, designed to be comprehensive and comparable across countries. However, there is currently no single repository of this data and...

Analysis of the Effect of Government Expenditures on School Enrollment in Pakistan

Purpose: No one can deny the importance of education as it not only improves living standard but also promotes self-esteem as well as improves social development. The role of the government cannot be overlooked in the development of education. Therefore, the main purpose of this study is to analyses the role of government through national income and government expenditure on education through school enrolment in Pakistan.&#x0D; Design/Methodology/Approach: We have used secondary data over the period of 2000 to 2017 for empirical analysis. We used descriptive statistics analysis, and the method of least squares is used to obtain empirical results. &#x0D; Findings: The result shows that national income and government expenditures have positive effects on school enrollment, indicating when national and government expenditures increase, ultimately school enrolment also increases in the country.&#x0D; Implications/Originality/Value: Our results of this study suggest that national income needs to be increases and government spending also needs to be increases in order to improve education in the country.

The Effects of COVID-19 Pandemic on the Government Revenue in the Extractive Industry in Tanzania

Tanzania has not been unique amid the COVID-19 pandemic in terms of economic impact. Since the first case was announced in March 2020, several thousand cases have been confirmed with several hundred deaths (real-time data). There were a number of transmitting factors and effects that exposed Tanzanian national revenue systems to great economic risk if COVID-19 was not well managed. The paper assesses the level of risks on the total government revenue resource systems, government revenue collections from the extractive industries and national expenditure budget performances. This descriptive paper uses results from the HakiRasilimali field research survey, 2020. The paper found high and increasing levels of negative and perceived risks on the government revenue mobilization, collection and utilization due to the existence of the COVID-19 pandemic. The majority perceived that the COVID-19 pandemic has high levels of risks and negative effects on the national budget expenditure frameworks in medium- and long-term periods. In the short run it is not easy to cut down and stop major recurrent government expenditures in developing economies. The public expenditure resources allocated to the Ministry of Minerals have been increasing during the COVID-19 pandemic to support the on-going mining reforms in Tanzania. Also, the government was compelled to allocate more financial resources to the health sector in order to fight against the COVID-19 pandemic and the aftermath, as well as support other most affected sectors. The paper recommends that the best way of preventing and combating the COVID-19 risks and related public health threats or possibilities is to protect and give capacity to socio-economic entities, sectors and actors’ abilities in achieving their desired short-, medium- and long-term objectives. To support a robust health and economic policy response, Tanzania has in its potential fiscal space relative to other East African countries, stable political environment, high international reserves, larger domestic market and favorable mineral commodity price movements. Tanzania has enhanced political preparedness and containment capacity through measures to strengthen detection, surveillance and combating the current COVID-19 pandemic.

Price and expenditure elasticity of cigarette demand in El Salvador: a household-level analysis and simulation of a tax increase

BackgroundIn El Salvador, 8.8% of adults 15 years and older smoke cigarettes. Little is known about the sensitivity of cigarette consumption among the adults in El Salvador to tax and...

Health accounts from past to present for a political arithmeticContas da saúde do passado ao presente para a aritmética política

RESUMENEste informe describe el proceso de ampliación progresiva de las cuentas de salud para medir los gastos nacionales en salud, desde los primeros intentos de la Asociación Médica Estadounidense en 1926 hasta la actualidad. Se mencionan los hitos en la creación del Sistema de Cuentas de Salud, desde los antecedentes económicos y las acciones iniciales de unos cuantos países y organizaciones a la necesidad de un conjunto de normas de contabilidad para los sistemas de atención de salud y, por último, la consolidación con el Sistema de Cuentas de Salud del 2011. Varias organizaciones internacionales, como la Organización Mundial de la Salud, la Organización para la Cooperación y el Desarrollo Económicos, Eurostat, el Banco Mundial y la Agencia de los Estados Unidos para el Desarrollo Internacional, han sido fundamentales para ampliar los ejercicios nacionales de cuentas de salud y asegurar que estén normalizados, sean comparables y se institucionalicen. Las acciones nacionales para realizar un seguimiento de los gastos en salud no solo han enriquecido los resultados colectivos, sino que se han convertido en un componente importante del liderazgo mundial, al fundamentar las políticas en todo el mundo. Más de 100 países han creado cuentas de salud de conformidad con la norma mundial, y han logrado una mejor comprensión del gasto en salud y de los flujos financieros. Estos resultados son clave para vigilar los avances relativos a las iniciativas nacionales y mundiales, como los Objetivos de Desarrollo Sostenible y la cobertura universal de salud. Todavía quedan retos por delante, como la institucionalización y la calidad de los resultados. También se necesita responsabilidad social para mejorar las fuentes de datos, y aumentar la producción y eluso de las cuentas de salud.

Budget Impact Analysis of Treatment Flow Optimization in Epilepsy Patients: Estimating Potential Impacts with Increased Referral Rate to Specialized Care.

Objectives: We developed a Markov model to simulate a treatment flow of epilepsy patients who refer to specialized care from non-specialized care, and to surgery from specialized care for estimation of patient distributions and expenditures caused by increasing the referral rate for specialized care.Methods: This budget impact analysis of treatment flow optimization in epilepsy patients was performed as a long-term simulation using the Markov model by comparing the current treatment flow and the optimized treatment flow. In the model, we simulated the prognosis of new onset 5-year-old epilepsy patients (assuming to represent epilepsy occurring between 0 and 10 years of age) treated over a lifetime period. Direct costs of pharmacotherapies, management fees and surgeries are included in the analysis to evaluate the annual budget impact in Japan.Results: In the current treatment flow, the number of refractory patients treated with four drugs by non-specialized care were estimated as 8766 and yielded JPY5.8 billion annually. However, in the optimized treatment flow, the number of patients treated with four drugs by non-specialized care significantly decreased and who continued the monotherapy increased. The costs for the four-drug therapy by non-specialized care were eliminated. Hence cost-saving of JPY9.5 billion (-5% of the current treatment flow) in total national expenditures would be expected.Conclusion: This study highlights that any policy decision-making for referral optimization to specialized care in appropriate epilepsy patients would be feasible with a cost-savings or very few budget impacts. However, important information in the decision-making such as transition probability to the next therapy or excuse for sensitive limitations is not available currently. Therefore, further research with reliable data such as big data analysis or a national survey with real-world treatment patterns is needed.

Budget Impact Analysis of Treatment Flow Optimization in Epilepsy Patients: Estimating Potential Impacts with Increased Referral Rate to Specialized Care

Objectives: We developed a Markov model to simulate a treatment flow of epilepsy patients who refer to specialized care from non-specialized care, and to surgery from specialized care for estimation of patient distributions and expenditures caused by increasing the referral rate for specialized care. Methods: This budget impact analysis of treatment flow optimization in epilepsy patients was performed as a long-term simulation using the Markov model by comparing the current treatment flow and the optimized treatment flow. In the model, we simulated the prognosis of new onset 5-year-old epilepsy patients (assuming to represent epilepsy occurring between 0 and 10 years of age) treated over a lifetime period. Direct costs of pharmacotherapies, management fees and surgeries are included in the analysis to evaluate the annual budget impact in Japan. Results: In the current treatment flow, the number of refractory patients treated with four drugs by non-specialized care were estimated as 8766 and yielded JPY5.8 billion annually. However, in the optimized treatment flow, the number of patients treated with four drugs by non-specialized care significantly decreased and who continued the monotherapy increased. The costs for the four-drug therapy by non-specialized care were eliminated. Hence cost-saving of JPY9.5 billion (-5% of the current treatment flow) in total national expenditures would be expected. Conclusion: This study highlights that any policy decision-making for referral optimization to specialized care in appropriate epilepsy patients would be feasible with a cost-savings or very few budget impacts. However, important information in the decision-making such as transition probability to the next therapy or excuse for sensitive limitations is not available currently. Therefore, further research with reliable data such as big data analysis or a national survey with real-world treatment patterns is needed.

The financial burden of rib fractures: National estimates 2007 to 2016

BackgroundThe aim of this study is to define the cost of rib fracture hospitalization by single, multiple, and flail type using a nationally representative sample. MethodsThe national inpatient sample (NIS) was used to identify patients with a primary diagnosis of rib fracture hospitalization 2007-2016. International Classification of Diseases, Ninth Revision (ICD-9) and Tenth Revision (ICD-10) codes were used to characterize patients as having single, multiple, or flail chest rib fractures. Patients with only trauma related diagnosis groups (DRG) at the time discharge were included in the final sample. The cost of hospitalization was obtained by converting reported charges into cost using the all-payer inpatient cost-to-charge ratio (CCR) for all hospitals in the NIS data. The log of cost was modeled using multivariate linear regression. The rib fracture type was the primary predictor in the model. ResultsThere were 373,053 rib fracture admissions during 2007-2016. The average cost per hospitalization was $10,169 (95%Confidence Interval [CI]: 9,942–10,395), which translated into a national expenditure of $3.64 billion over 10 years. The cost of rib fracture hospitalization increased from $209 million in 2007 to $469 million in 2016. Compared to single rib fracture patients, the cost of hospitalization for multiple rib fractures and flail chest was 3% (p = 0.001) and 5% (p=0.02) higher, respectively. Higher injury severity score, total number of body regions injured and longer length of stay were associated with higher rib fracture hospitalization cost. ConclusionsRib fractures affect ~22,000-45,000 people per year in the United States. The cost of rib fractures is over $469 million per year and is increasing over time. Multiple rib fractures and flail chest rib fractures are associated with increased cost. Pathways to improve care in patients with rib fractures should consider the cost of treatment.

National Defence Expenditure and Its Implications on Economic Development in Nigeria

The issue of security is presently a critical challenge for the Nigeria State: biggest democracy in Africa as reports of killings are plastered on a daily basis on both print and social media. This is unpalatable for a developing country like Nigeria that has its eyes set on improving the lot of its citizens and becoming a force to reckon with in the global economy. It is on this backdrop that this study set sail to examine the association between national defence expenditure and economic development in Nigeria. The study adopted Ex-post facto research design as the variables- Misery Index, CDEX and RDEX: cannot be manipulated as they are annual time series data sourced from the World Development Indicator and the Central Bank of Nigeria annual report from a period of 38 years covering from 1981 to 2018, which were in turn analyzed using the error correction model (ECM) method of estimation. The result of the Johansen cointegration test revealed that government capital spending on defence, recurrent spending on defence, foreign direct investment and misery index have common trends in the long run. The outcome of the normalized cointegration disclosed a negative and significant relationship between government capital spending on defence and misery index, while a positive and significant long run relationship exists between government recurrent spending on defence and misery index. The short run analysis pointed to a positive and significant relationship between previous year’s misery index and current year’s misery index. The study thus recommended that government defence spending be reassessed to make it development oriented and proper monitoring of defence spending be carried out.

The macroeconomics of abortion:A scoping review and analysis of the costs and outcomes.

Although abortion is a common gynecological procedure around the globe, we lack synthesis of the known macroeconomic costs and outcomes of abortion care and abortion policies. This scoping review synthesizes the literature on the impact of abortion-related care and abortion policies on economic outcomes at the macroeconomic level (that is, for societies and nation states). Searches were conducted in eight electronic databases. We conducted the searches and application of inclusion/exclusion criteria using the PRISMA extension for Scoping Reviews. For inclusion, studies must have examined one of the following macroeconomic outcomes: costs, impacts, benefits, and/or value of abortion care or abortion policies. Quantitative and qualitative data were extracted for descriptive statistics and thematic analysis. Of the 189 data extractions with macroeconomic evidence, costs at the national level are the most frequently reported economic outcome (n = 97), followed by impacts (n = 66), and benefits/value (n = 26). Findings show that post-abortion care services can constitute a substantial portion of national expenditures on health. Public sector coverage of abortion costs is sparse, and individuals bear most of the costs. Evidence also indicates that liberalizing abortion laws can have positive spillover effects for women's educational attainment and labor supply, and that access to abortion services contributes to improvements in children's human capital. However, the political economy around abortion legislation remains complicated and controversial. Given the highly charged political nature of abortion around the global and the preponderance of rhetoric that can cloud reality in policy dialogues, it is imperative that social science researchers build the evidence base on the macroeconomic outcomes of abortion services and regulations.

Endocrine prevention of breast cancer

Breast cancer (BC) is the most common non-cutaneous malignancy among women worldwide and is a significant cause of morbidity, mortality, and national health care expenditure. Unfortunately, with few exceptions like alcohol consumption, obesity, and physical activity, most BC risk factors are unmodifiable. Antiestrogen endocrine therapy, commonly known as BC chemoprevention, is an effective method of BC prevention. In multiple randomized trials, two selective estrogen receptor modulators — tamoxifen and raloxifene, and two aromatase inhibitors — exemestane and anastrozole have reduced BC incidence by 50%–65% in high-risk women. An estimated 15% of the US women between 35 and 79 years of age may qualify as high risk for BC, yet a small percentage of these women will ever have a formal BC risk assessment or a discussion of endocrine prevention options. The etiology of underutilization of endocrine prevention of BC is multifactorial — infrequent use of BC risk assessment tools in the primary care settings, insufficient knowledge of BC risk assessment tools and antiestrogen agents among primary care providers, concerns of side effects, inadequate time for counseling during primary care visit, and lack of predictive biomarkers may play significant roles. Many small studies incorporating risk assessment tools and decision-making aids showed minimal success in enhancing endocrine prevention. One critical factor for underutilization of endocrine prevention is low uptake of endocrine prevention by high-risk women even when appropriately recommended. Furthermore, adherence to BC endocrine prevention is unsatisfactorily low. Despite the current infrequent usage, endocrine prevention has the potential to reduce the public health burden of BC significantly. Innovative approaches like finding new agents, alternative dosing and schedule of currently available agents, transdermal medication delivery, increased public and professional awareness, and policymakers' commitments may bring the desired changes.

Determinants of Poverty in Mexico: A Quantile Regression Analysis

Most studies on the determinants of poverty do not consider that the relative importance of each of these determinants can vary depending on the degree of poverty suffered by each group of poor people. For Mexico’s case, the studies carried out so far do not contemplate this approach, even though there is wide variation in the degree of poverty among the different groups of the poor. Investigating these differences is important to design better policies for fighting poverty, which consider how each variable that explains poverty affects each group of people who suffer from poverty differently. This article examines the determinants of poverty for Mexican households. Using data from the Mexican National Household Income and Expenditure Survey (ENIGH) 2018, the study estimates a probit model and a quantile regression model to examine the extent to which the determinants of poverty vary across the poverty spectrum. The results from the probit model indicate that households with more than one member, having a female head, or speaker of an indigenous language are more likely to be poor. The results obtained in the quantile regressions indicate that there are significant differences with the results of the simple ordinary least squares model, especially for households in extreme poverty but also for the other income categories analyzed for several of the explanatory variables used in the models. Households in the categories extremely poor and deeply poor are most affected if they are in the southern region or if the household head speaks an indigenous language or is an elderly person. It is observed that achieving a higher educational level is an effective way to increase income across the poverty spectrum.

An Analysis on Forecasting Inflation Rate in the Philippines: A Recurrent Neural Network Method Approach

Inflation rate is the proceeding rise within the common level of costs of products and services in an economy over a certain span of time. In 2018, the Philippines has the highest inflation rate among the 10 South East Asian countries. The objective of this research is to forecast the inflation rate of the Philippines for the next five years (2019-2023). Also, the researchers compared the results obtained from the Multiple Linear Regression and Recurrent Neural Network (RNN) performed in MATLAB to determine which of these two models will be the better model in forecasting inflation rate. In this study, the researchers observed the behavior of the Inflation Rate(y) and its economic factors such as Import (x1), Export (x2), Money Supply (x3), Gross Domestic Product (x4), Gross National Product (x5), Expenditure (x6) and Exchange Rate (x7). Using Multiple Linear Regression, this study determined that the significant predictors are Money Supply (x3) and Expenditures (x6). By evaluating the forecast efficiency of the two methods, the researchers concluded that Multilayered Recurrent Neural Network outperforms Multiple Linear Regression in predicting inflation rate of the Philippines. This paper can be useful to the Philippine Government on their decisions about monetary policy making since forecasting the inflation rate has a huge importance and impact in conducting monetary policy.

Examining the connection among national tourism expenditure and economic growth in Algeria

Tourism is one of the most important sectors for several researchers and decision makers, due to its influence on the world economic growth in the twenty-first century, making it as a source of competition between countries to a global industry for its effective strategic role in the development of countries. In this paper, we used two variables natural logarithm of per capita gross domestic product (GDP) and natural logarithm of per capita international and national tourism expenditure (ITE) to study the relationship between the tourism sector and economic growth in Algeria over the period of 1995–2017. We established with the unit root test with and without breakpoint that the variables are stationary in the first difference and there is a structural break in (ITE) and (GDP). Thus, with the presence of a breakpoint, we employed the methodology of Gregory–Hansen to avoid such issue, but we found that there was no evidence of cointegration with breakpoint, so then we used the vector autoregressive model (VAR). The model showed that the tourism sector has a positive and insignificant coefficient on the economic growth, while the economic growth factor has a positive and significant on the tourism sector. In the short run, there was a one-way causality from GDP to ITE at the level of 1%, confirming the economic-driven tourism growth hypothesis. Also, we found with Breitung and Candelon causality that there was same causality at the level of 10%.

Reducing administrative costs in US health care: Assessing single payer and its alternatives.

Excess administrative costs in the US health care system are routinely referenced as a justification for comprehensive reform. While there is agreement that these costs are too high, there is little understanding of what generates administrative costs and what policy options might mitigate them. Literature review and national utilization and expenditure data. We developed a simulation model of physician billing and insurance-related (BIR) costs to estimate how certain policy reforms would generate savings. Our model is based on structural elements of the payment process in the United States and considers each provider's number of health plan contracts, the number of features in each health plan, the clinical and nonclinical processes required to submit a bill for payment, and the compliance costs associated with medical billing. For several types of visits, we estimated fixed and variable costs of the billing process. We used the model to estimate the BIR costs at a national level under a variety of policy scenarios, including variations of a single payer "Medicare-for-All" model that extends fee-for-service Medicare to the entire population and policy efforts to reduce administrative costs in a multi-payer model. We conducted sensitivity analyses of a wide variety of model parameters. Our model estimates that national BIR costs are reduced between 33% and 53% in Medicare-for-All style single-payer models and between 27% and 63% in various multi-payer models. Under a wide range of assumptions and sensitivity analyses, standardizing contracts generates larger savings with less variance than savings from single-payer strategies. Although moving toward a single-payer system will reduce BIR costs, certain reforms to payer-provider contracts could generate at least as many administrative cost savings without radically reforming the entire health system. BIR costs can be meaningfully reduced without abandoning a multi-payer system.