Reduction In Payments Research Articles

The Relationship between Taxation, Accounting and Legal Forms

Abstract Legal frameworks have an enormous influence on the concrete choice of legal form, especially in (multinational) groups of companies. For example, tax regulations and accounting standards directly influence the legal enterprise’s structure, including the shareholding structures. However, the tax burden must not be understood as a static or a fixed quantity determined in advance. This is because the design or choice of companies’ legal form can also be used as a tool to gain competitive advantages and optimise the tax burden or after-tax profit. Accordingly, the tax-optimising choice of legal form can be used as an instrument for tax planning and internal financing (reduction of tax payments and optimisation of the group tax rate). Therefore, for groups of companies and multinationals, the question that arises is how and within what limits can they make effective use of the cross-border tax rate differential, particularly through structuring their legal form. However, using cross-border tax advantages may be prevented by the controlled foreign corporation (CFC) taxation, called the Anti Tax Avoidance Directive (ATAD), which was introduced in all EU member states from 1 January 2019 onwards due to European law: Art. 7, 8 of Directive 2016/1164 to combat tax avoidance practices. In multinational companies, there is a tension between the tax-optimising choice of legal form, including the structuring of shareholdings, and CFC taxation. It is important to identify the CFC taxation requirements according to ATAD or the respective member state of residence and to avoid these requirements when structuring individual circumstances or investments. An important finding here is that the factual prerequisites for CFC taxation under ATAD are not aligned with the accounting rules, especially controlling interest and control participation. Finally, from an overall perspective, tax-optimised corporate groups’ structure or the legal architecture is not a static variable but an evolving system composed of tax-optimised sub-systems or subgroup structures. This connection between the choice of legal form, shareholding structure and the legal system, tax planning, and tax optimisation in multinational companies is analysed and evaluated based on the Austrian CFC taxation (Sec. 10a CITA) and the German CFC taxation (Sec. 7 FTTA). Furthermore, the implications for companies and society, and the legislator, are highlighted. The article also deals with the relationship between law and tax planning.

The prevalence of stress and burnout in UK emergency ambulance service workers and its impact on their mental health and well-being.

Aims:To assess the prevalence of burnout among emergency ambulance service workers in one ambulance station; to determine if there are any variances based on socio-demographic information such as gender, clinical grade and length of service; to examine the distinctions between personal, work-related and patient-related burnout; to identify current workplace interventions to reduce stress and burnout that will improve mental health and well-being.Methods:Mixed methods – the Copenhagen Burnout Inventory (CBI) was utilised, measuring burnout across three domains (personal, work-related and patient-related) alongside collecting demographic information such as gender, role, full-time or part-time employment and length of service. A free-text space was available to provide opinions on causes of burnout and on how current practice can be improved; these were analysed via thematic analysis.Results:Seventy-eight staff members completed the questionnaire. These were: 16 emergency care assistants, 15 technicians and 47 paramedics. Thirty-eight (48.7%) staff members experienced personal burnout, 42 (53.8%) experienced work-related burnout and 29 (37.1%) experienced patient-related burnout. It was found that those most at risk of burnout were full-time male employees with more than 10 years’ experience and employed within a paramedic position. Six themes were identified through thematic analysis: unnecessary callouts, shift patterns, support options, management, sickness absence and job demands.Conclusion:Findings suggest that burnout is prevalent within the ambulance service environment and can result in long-term sickness absences and declining mental health. This requires further investigation into causation alongside consideration of preventative measures and interventions to improve ambulance service staff well-being while increasing staff resilience to prevent burnout. Support for managers in recognising symptoms of burnout is also imperative because providing them with the training to recognise a mental health issue, interpret it and promptly treat it can mean the difference between sickness absences, future PTSD, unwell staff presenting at work and staff feeling valued and supported by management. The introduction of mandatory counselling and well-being sessions was also recommended by participants to improve staff mental health and well-being and reduce instances of work-related burnout, while providing financial advantages to the ambulance service with a reduction in additional overtime and sickness payments.

Trends in out of pocket payments and catastrophic health expenditure in the Kyrgyz Republic post \u201cManas Taalimi\u201d and \u201cDen Sooluk\u201d health reforms, 2012\u20132018

BackgroundOver the years, the Kyrgyz Republic has implemented health reforms that target health financing with the aim of removing financial barriers to healthcare including out-of-pocket health payments (OOPPs). This study examines the trends in OOPPs, and the incidence of catastrophic health expenditure (CHE) post the “Manas Taalimi” and “Den Sooluk” health reforms.MethodsWe used data from the Kyrgyzstan Integrated Household Surveys (2012–2018). Population-weighted descriptive statistics were used to examine the trends in OOPPs and CHE at three thresholds; 10 percent of total household consumption expenditure (Cata10), 25 percent of total household consumption expenditure (Cata25) and 40 percent of total household non-food consumption expenditure (Cata40). Panel and cross-sectional logistic regression with marginal effects were used to examine the predictors of Cata10 and Cata40.FindingsBetween 2012 and 2018, OOPPs increased by about US $6 and inpatient costs placed the highest cost burden on users (US $13.6), followed by self-treatment (US $10.7), and outpatient costs (US $9). Medication continues to predominantly drive inpatient, outpatient, and self-treatment OOPPs. About 0.378 to 2.084 million people (6 – 33 percent) of the population incurred catastrophic health expenditure at the three thresholds between 2012 and 2018. Residing in households headed by a widowed or single head, or residing in rural regions, increases the likelihood of incurring catastrophic health expenditure.ConclusionsThe initial gains in the reduction of OOPPs and catastrophic health expenditure appear to gradually erode since costs continue to increase after an initial decline and catastrophic health expenditure continues to rise unabated. This implies that households are increasingly incurring economic hardship from seeking healthcare. Considering that this could result to forgone expenditure on essential items including food and education, efforts should target the sustainability of these health reforms to maintain and grow the reduction of catastrophic health payments and its dire consequences.

Cost-effective mortgage modification program to reduce mortgage defaults

What is the most cost-effective mortgage modification program to reduce mortgage defaults? To shed light on this question and evaluate the Home Affordable Modication Program (HAMP) initiated in 2009, we present a quantitative model where home-buying households can take out a mortgage loan whose price is endogenously determined to reflect the mortgage contract terms—maturity, per-period payment, and amortization scheme—as well as the default risk. We conduct an experiment in which (i) a series of house price shocks are plugged into the model economy to generate the housing market crash, mirroring the recent financial crisis, and (ii) three alternative government-funded mortgage modification programs, each associated with a change in maturity, per-period payment, or amortization scheme, are introduced and compared. We find that the amortization reschedule is the most cost-effective way of implementing a modification program, followed by the payment reduction and the term extension.

Assessing the Returns to Land and Greenhouse Gas Savings from Producing Energy Crops on Conservation Reserve Program Land.

Using land already enrolled in the Conservation Reserve Program (CRP) in the eastern region of the U.S. for producing energy crops for bioenergy while reducing land rental payments offers the potential for lowering the program costs, increasing returns to CRP landowners, and displacing greenhouse gas (GHG) emissions from fossil fuels. We develop an integrated modeling approach to analyze the combination of biomass prices and CRP land rental payment reductions that can incentivize energy crop production on CRP land and its potential to increase soil carbon stocks and displace fossil fuel emissions. We find that conversion of 3.4 million ha in the CRP can be economically viable at a minimum biomass price of $75 Mg-1 with full CRP land rental payment or at $100 Mg-1 with 75% of this land rental payment; this conversion can result in savings of 0.52 and 1.25 billion Mg CO2-eq in life-cycle emissions through the displacement of energy-equivalent fossil fuels and coal-based electricity, respectively, and an additional 0.11 billion Mg CO2-eq soil carbon sequestration relative to the status quo, with CRP left unharvested over the 2016-2030 period. The soil carbon debt due to the transition from unharvested CRP land to energy crops is short-lived and more than offset by the reduction in fossil fuel emissions. The net discounted benefits from producing energy crops on CRP land through a reduced need for government payments to maintain existing enrollment, higher returns to CRP landowners, and the value of the reduction in GHG emissions could be as high as $16-$30 billion by using them for cellulosic biofuels to displace gasoline and $35-$68 billion by displacing coal-based electricity over the 2016-2030 period if biomass prices are $75-$125 Mg-1 and land rental payments are reduced by 25%.

ОЦІНКА ПЛАТІЖНОГО БАЛАНСУ УКРАЇНИ

The article highlights the features of the formation and assessment of the balance of payments in Ukraine. The balance of payments of Ukraine is a functional macroeconomic model that reflects all transactions that are carried out between the subjects of the national economy and the subjects of the economies of other countries of the world. This model allows you to develop and implement a sound foreign economic policy of Ukraine, analyze the state of commodity and financial markets, conduct scientific research of economic processes in the state, etc. Ukraine is actively implementing the methodology of balance of payments formation according to the recommendations of the International Monetary Fund. Ukraine's balance of payments by main components is grouped into two accounts: "capital and financial transactions" and "current transactions": capital transactions cover all transactions related to the receipt or payment of capital transfers and the acquisition or sale of property rights and non-financial assets; current transactions include all transactions between residents and non-residents on real values, as well as transactions on the free provision or receipt of valuables for current use. Like any other "balance of payments" consists of receipts and payments. It is active (surplus) when revenues are greater than payments and passive (deficit) when payments are greater than revenues. Based on the assessment of the balance of payments of Ukraine for 2020, certain conclusions can be drawn: stable external demand for food softened the drop in exports of goods from Ukraine during the COVID-19 pandemic, and the increase in prices contributed to its growth at the end of 2020; despite a slight recovery in domestic demand in the IV quarters of 2020, imports of goods to Ukraine by the results of 2020 decreased significantly; the current account surplus in Ukraine in 2020 was provided by a significant positive balance of trade in services and a record surplus of the primary income account; capital outflow from Ukraine on the financial account stopped at the end of 2020 due to the optimism of investors; despite the crisis and significant payments on external debt, Ukraine's gross reserves increased in 2020, and the financial crisis once again confirmed the importance of both international support and a balanced macroeconomic policy. The current account surplus in Ukraine in 2020 reached one of the largest levels in the history of Ukraine, it was formed due to a significant decrease in imports of goods and services, a reduction in payments on primary income and the relative stability of exports of goods and remittances. The article proposes recommendations for improving approaches to the formation of the balance of payments in Ukraine using certain methods when regulating the balance of payments of the state.

Trends and projections of universal health coverage indicators in Iraq, 2000-2030: A national and subnational study.

Iraq has had limited access to healthcare services due to successive conflicts and political turmoil. Since 2018, Iraq has embarked on a new reconstruction process which includes a goal of 100% immunisation against certain diseases in 2030. We aimed to undertake a comprehensive assessment of Iraq's progress towards universal health coverage (UHC) targets that could contribute to Iraq's policy and strategies. We estimated the coverage of UHC indicators from six nationally representative population-based household surveys in Iraq during 2000-2018. We employed 14 health service indicators and two financial risk protection indicators in our UHC progress assessment. We used a Bayesian hierarchical regression model to estimate the trend and projection of health service indicators. Improved water sources, adequate sanitation, institutional delivery, skilled birth attendants, and BCG reached the 80% targets in 2018, and are projected to maintain their status in 2030at national and subnational levels. Family planning needs satisfied, acute respiratory infection treatment for pneumonia, and oral rehydration therapy will be much less than 80% in 2030. 12% of Iraqi households incurred catastrophic health expenditures in 2012, which was a fourfold increase from 2007. Some governorates faced ten- to twentyfold increases in catastrophic health expenditures, for example, from 0.8% to 15.9% in Diala. Approximately 3% of non-poor households became poor due to out-of-pocket (OOP) payments in 2012. Without proactive strengthening of the healthcare systems, achieving UHC in Iraq by 2030 would be a challenge. Worsened trends were observed in both conflict-affected and underdeveloped areas in health service coverage and financial risk protection. Recovery of GDP spending on health and pre-pooled financing mechanisms should be introduced for OOP payment reduction. Prioritising nationwide primary healthcare services and regulating public-private role-allotment in the health sector are crucial in improving low coverage indicators and decreasing disparities among governorates.

Challenges of the program to reduce the amount of hospitalized patients in the Iran health system: a qualitative study

Background: The health transformation plan was put into action in Iran, in 2014, with 8 service packages. This plan was not implemented as a pilot and therefore, various problems and barriers have since emerged. Objectives: The current study investigated the challenges of out of pocket in the health system of Iran. Methods: This applied study was conducted qualitatively with a semi-structured interview on 30 of the policy makers and planners of the in Iran health system in 2020, using the purposeful sampling method. The obtained data were entered into MAXQDA10 software, and analyzed through content analysis approach. Results: From data analysis, 5 themes: Weakness in the structure of health expenditure management, Weakness in the structure of policy and planning, effectiveness and low efficiency of the health system,Weakness in the opportunities facing the Ministry of Health, consequences of the program were categorized in 12 concept and 79 sub-themes and challenges were extracted. Conclusion: By identifying the opportunities and challenges of out-of-pocket (OOP) payment, the results of this study could provide a suitable framework for monitoring and evaluation of the payment reduction program in the Iran health system and a good way for policy makers and planners in different stages of the program

Challenges of the Out-of-Pocket Payment Program in the Health System of Iran: A Qualitative Study

Background: The health transformation plan was implemented in Iran with eight service packages in 2014. However, it has faced various problems and barriers since no pilot programs were launched. Objectives: The present study aimed to investigate the challenges of the out of pocket payment in the health system of Iran. Methods: The required data for this applied qualitative study were collected through semi-structured interviews with 30 policymakers and planners of the health system of Iran in 2020. It must be noted that the participants were selected using the purposeful sampling method. The obtained data were entered into MAXQDA software (version 10) and analyzed through the content analysis approach. Results: The data analysis resulted in five themes: 1) weakness in the structure of health expenditure management, 2) weakness in the structure of policy and plan development, 3) low effectiveness and efficiency of the health system, 4) lack of opportunities to identify the challenges facing the Ministry of Health, 5) consequences of the program. They were categorized into 12 concepts and 79 sub-themes, and the challenges were extracted from them. Conclusion: By identification of the opportunities and challenges of the out-of-pocket payment, the results of this study can provide a suitable framework for observation and evaluation of the payment reduction program in the health system of Iran. Moreover, the findings offer good suggestions for policymakers and planners in different stages of the program.

Custom-made health-care: an experimental investigation

BackgroundPhysicians’ financial interests might conflict with the best service to patients. It is essential to gain a thorough understanding of the effect of remuneration systems on physician behaviour.MethodsWe conducted a controlled laboratory experiment using a within-subject design to investigate physician behaviour underpayment heterogeneity. Each physician provided medical care to patients whose treatments were paid for under fee-for-service (FFS) or capitation (CAP).ResultsWe observed that physicians customized their care in response to the payment system. FFS patients received considerably more medical care than did CAP patients with the same illness and treatment preference. Physicians over-served FFS patients and under-served CAP patients. After a CAP payment reduction, we observed neither a quantity reduction under CAP nor a spillover in FFS patients’ treatment.ConclusionsThe results suggest that, in our experimental model, fee regulation can be used to some extent to control physician spending since we did not identify a behavioural response to the CAP payment cut. Physicians did not recoup lost income by altering treatment behaviour toward CAP and/or FFS patients. Experimental economics is an excellent tool for ensuring the welfare of all those involved in the health system. Further research should investigate payment incentives as a means of developing health care teams that are more efficient.

The development of ferrous metallurgy is an effective way to restore the Syrian economy

The Middle East is a victim of civilian contacts. Under the current conditions, the question arises of rationalizing the investment strategy of the post-war development of the countries of the region that have managed to overcome this crisis. In the article this problem is considered on the example of Syria. A rational way of multiplicative stimulation of the development of the country’s economy is proposed, based on the approach of J. M. Keynes. This approach consists in choosing the most favorable conditions for investment. According to the results of research at this point (industry) was ferrous metallurgy. At the initial stage of the post-war reconstruction of the republic, it can come out with a locomotive. The optimal configuration and place for the construction of a production metallurgical cluster that provides the market with the most popular types of metal products: 1 million tons per year of hot-rolled sheet (1-12.5 mm), 150 thousand tons of galvanized sheet per year (0.2-2, 5 mm), 200 thousand tons per year of shaped steel (2-8 mm), 50 thousand tons per year of galvanized shaped steel (0.7-3 mm). The functioning of the cluster will provide Syria with sheets and fittings, will contribute to the development of engineering and other sectors of the economy, will lead to an increase in the country’s GDP by 4.5% and a reduction in government debt payments by $ 532.5 million per year.

PROBLEMS OF ENVIRONMENTAL ENTREPRENEURSHIP IN UKRAINE IN THE CONTEXT OF GLOBALIZATION PROCESSES

Introduction. According to its semantics, the market economy strives for a harmoniously balanced development. Ecological entrepreneurship in the conditions of harmonious balanced development is impossible without the use of small and almost waste-free technologies. The problem of utilization and processing of waste is one of the main problems of modern civilization of the technocratic type. And the ecological enterprise promotes the decision of the given problems concerning economic expediency and profitability of utilization, depletion and recycling of a waste. Based on this, the main purpose of research is to determine the importance of domestic environmental entrepreneurship in the context of globalization processes. The main objectives of the article are to determine the reserves that will provide stimulating conditions for the development of environmental entrepreneurship in the context of globalization. Results. The tendency of intensification of globalization processes cannot but affect the economic, ecological and social processes in the state in the conditions of openness of the national economy. According to the experience of developed countries, ecological entrepreneurship is a powerful locomotive for the development of national economies. In Ukraine, one of the consequences of the planned economy is the high energy, material and resource efficiency of production technologies. The ecological factor is organically connected with the effective use of common labor resources. which in particular finds a manifestation in the reduction of the number of absences from work, and thus the reduction of payments for hospital leaves, which contributes to the achievement of the economy. The real transition to efficient environmental entrepreneurship is impossible without paid nature management, which is based on the calculation and use of natural resource rent, building an effective system of environmental payments for environmental pollution create a basis for economic and legal relations of environmental responsibility. We believe that innovative components are a necessary and mandatory part of environmental entrepreneurship. Effective waste management involves converting them into useful goods that are in demand among consumers. Conclusions. It is necessary to approach the solution of problems of integrated management by rational nature management, proceeding from concrete regional possibilities. In this case, the environmental enterprise will organically complement the state's efforts in this direction. With the general direction of possible ways of solving this problem, in practice the regional and sectoral levels of transition to the principles of harmonious balanced development come to the fore. It is necessary to approach the solution of problems of integrated management by rational nature management, proceeding from concrete regional possibilities. In this case, the environmental enterprise will organically complement the state's efforts in this direction. Key words: entrepreneurship, ecological, nature management, effect, branch, technologies.

P73. Clinical review of spine surgery patient safety indicators avoids CMS payment reductions

BACKGROUND CONTEXT The Hospital Acquired Conditions Reduction Program provides a financial incentive to reduce Patient Safety Indicators (PSI), defined as potentially preventable hospital-related events associated with harmful outcomes for patients. PSI are identified by ICD coding. However, ICD coding does not always reflect the true medical course of the patient. PURPOSE To determine if addition of a clinician to the review process results in a reduction of incorrectly generated PSI. STUDY DESIGN/SETTING Retrospective chart review. PATIENT SAMPLE Patients who had spine surgery at a single institution from 2015 to 2019. OUTCOME MEASURES N/A METHODS All PSI generated at our institution were collected over a 57-month period. The number and type of spine-related PSI were compared before and after the implementation a clinical reviewer to identify incorrectly generated PSI. The financial impact of this intervention was also calculated. RESULTS From 2015 to 2019, a total of 1,290 PSI were reported with 140 (11%) attributable to spine surgery. Prior to implementation of a clinical reviewer, 112 PSI were reported over 40 months (2.8 PSI/month). Following implementation, 28 PSI were reported over 17 months, a statistically significant decrease by 1.2 PSI/month (p<0.000). In addition, 10 different PSI types were reported prior to, compared to six after implementation. This resulted in our organization avoiding a 1% CMS cost reduction, ranging from $3 to 4 million. CONCLUSIONS Implementation of a review process with clinician collaboration to ensure ICD-10 coding accurately reflects the medical course for a patient may lead to more precise PSI reporting, with substantial cost-savings for hospitals. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. The Hospital Acquired Conditions Reduction Program provides a financial incentive to reduce Patient Safety Indicators (PSI), defined as potentially preventable hospital-related events associated with harmful outcomes for patients. PSI are identified by ICD coding. However, ICD coding does not always reflect the true medical course of the patient. To determine if addition of a clinician to the review process results in a reduction of incorrectly generated PSI. Retrospective chart review. Patients who had spine surgery at a single institution from 2015 to 2019. N/A All PSI generated at our institution were collected over a 57-month period. The number and type of spine-related PSI were compared before and after the implementation a clinical reviewer to identify incorrectly generated PSI. The financial impact of this intervention was also calculated. From 2015 to 2019, a total of 1,290 PSI were reported with 140 (11%) attributable to spine surgery. Prior to implementation of a clinical reviewer, 112 PSI were reported over 40 months (2.8 PSI/month). Following implementation, 28 PSI were reported over 17 months, a statistically significant decrease by 1.2 PSI/month (p<0.000). In addition, 10 different PSI types were reported prior to, compared to six after implementation. This resulted in our organization avoiding a 1% CMS cost reduction, ranging from $3 to 4 million. Implementation of a review process with clinician collaboration to ensure ICD-10 coding accurately reflects the medical course for a patient may lead to more precise PSI reporting, with substantial cost-savings for hospitals.

Psychologists object to proposed payment reductions for 2021

Following a proposed rule by the Centers for Medicare &amp; Medicaid Services (CMS) that would see a marked reduction in payments in 2021 to psychologists providing services to Medicare patients, the American Psychological Association (APA) is planning to ask the CMS to preserve and increase payment for psychological services.

Pricing in commercial dental insurance and provider markets.

ObjectiveTo examine the impact of commercial dental insurer and provider concentration on dentist reimbursement.Data SourcesWe utilized provider data from the American Dental Association, reimbursement data from IBM Watson MarketScan® Commercial Research Databases, submitted billed charges from FAIR Health®, dental insurance market concentration data from FAIR Health®, and county‐level demographic and economic data from the Area Health Resources File and the Council for Community and Economic Research.Study DesignWe used the Herfindahl‐Hirschman Index to separately measure commercial dental insurance concentration and dentist concentration. We studied the effect of provider and insurance concentration on dentist reimbursement. Using two‐stage least squares, we accounted for potential endogeneity in dental insurer and provider concentration.Principal FindingsAcross the dental procedures we examined, a 10 percent increase in dental insurance concentration is associated with a 1.95 percent (P‐value = .033) reduction in gross payments to dentists. Conversely, a 10 percent increase in dentist concentration is associated with a more modest 0.71 percent (P‐value = .024) increase in gross payments. A 10 percent increase in dental insurance concentration is associated with a 1.16 percentage point (P‐value = .016) decline in the allowed‐to‐list price ratio, while a 10 percent increase in dentist concentration is associated with a 0.56 percentage point (P‐value = .001) increase in the allowed‐to‐list price ratio. Similar patterns were found across dental procedure subcategories.ConclusionsDental provider markets are substantially less concentrated than insurance markets, which may limit the ability of dentists to garner higher reimbursement.

Learning and the "Early Joiner" Effect for Medical Conditions in Medicare's Bundled Payments for Care Improvement Program: Retrospective Cohort Study.

Studies of medical conditions in the Bundled Payments for Care Improvement (BPCI) initiative did not show reductions in Medicare payments for the majority of conditions, but this could mask heterogeneity. To determine whether earlier enrollment and/or longer participation in BPCI were associated with performance. We divided BPCI hospitals into wave 1 (joined 10/1/13, 1/1/14, or 4/1/14), wave 2 (joined 7/1/14, 10/1/14, 1/1/15, or 4/1/15), and wave 3 (joined 7/1/15, 10/1/15, or 1/1/16) and compared changes in Medicare payments for acute myocardial infarction, heart failure, pneumonia, sepsis, and chronic obstructive pulmonary disease between BPCI and matched controls in 6-month increments. US hospitals. Medicare payments. There were 120 hospital-condition pairs in wave 1, 264 in wave 2, and 300 in wave 3. Wave 1 hospitals had similar savings to controls early in the program (0-6 mo difference in differences -$10, P=0.976; 6-12 mo +$295, P=0.441; 12-18 mo -$540, P=0.218; 18-24 mo -$485, P=0.259) but had greater savings than controls at 24-30 months (difference in differences -$663, P=0.035). Wave 2 (0-6 mo +$193, P=0.524; 6-12 mo -$183, P=0.489; 12-18 mo -$162, P=0.618) and wave 3 hospitals (0-6 mo +$79, P=0.753; 6-12 mo -$32, P=0.876) did not achieve significant savings at any time interval. There were no differential changes in patient outcomes over time. Hospitals that joined BPCI earliest began to achieve savings at roughly 2 years of participation. These findings have implications for this and other alternative payment models.

Mortgage Design in an Equilibrium Model of the Housing Market

ABSTRACTHow can mortgages be redesigned to reduce macrovolatility and default? We address this question using a quantitative equilibrium life‐cycle model. Designs with countercyclical payments outperform fixed payments. Among those, designs that front‐load payment reductions in recessions outperform those that spread relief over the full term. Front‐loading alleviates liquidity constraints when they bind most, reducing default and stimulating housing demand. To illustrate, a fixed‐rate mortgage (FRM) with an option to convert to adjustable‐rate mortgage, which front‐loads payment reductions relative to an FRM with an option to refinance underwater, reduces price and consumption declines six times as much and default three times as much.

ESRD QIP Payment Reductions Are Associated with Mortality, Utilization, and Cost

Research ObjectiveCMS launched the ESRD Quality Incentive Program (QIP) in 2010. The ESRD QIP adjusts Medicare payments to dialysis facilities based on their performance on a set of quality measures. The measures are revised in most years. We assessed whether the magnitude of ESRD QIP payment reductions was associated with several important patient outcomes that are not an intrinsic part of the QIP measure set.Study DesignWe compared mortality, utilization of health care services, and Medicare payments per patient‐year during 2015‐2017 for dialysis facilities in each ESRD QIP payment reduction category (0%, 0.5%, 1.0%, 1.5%, and 2.0%) corresponding to their QIP performance for the same year. The data sources include Medicare claims and enrollment files. Results were expressed as unadjusted averages and as modeled measures of association that adjusted for important patient factors (age, sex, race, ethnicity, diabetes, duration of ESRD, and dual eligibility).Population StudiedThe patient cohort consisted of Medicare fee‐for‐service beneficiaries receiving chronic dialysis for ESRD on the first day of each year. Patients were attributed to the first facility that provided treatment during the year.Principal FindingsMost patients were treated in facilities that did not receive an ESRD QIP payment reduction (Table). There was a stepwise increase in mortality, hospitalization, hospital days, and Medicare payments per year in facilities with successively larger payment reductions. The increase in Medicare payments was largely for inpatient services. All findings were statistically significant in adjusted regression models (shown in the Table for mortality and total payment).ConclusionsMortality, utilization, and Medicare payments were substantially higher for patients treated in facilities whose contemporaneous performance on ESRD QIP measures resulted in a payment reduction. Moreover, these outcome measures increased stepwise with the magnitude of facility payment reductions. The findings are consistent with the hypothesis that the ESRD QIP measures and scoring system capture meaningful determinants of health care quality and value.Implications for Policy or PracticeThe findings support the validity of ESRD QIP. The findings offer an approach to ongoing monitoring and validation of QIP measures.Primary Funding SourceThe study was funded by the Centers for Medicare and Medicaid Services.

MEDICARE

Research ObjectiveLower extremity joint replacements (LEJR) are among the most common and expensive inpatient surgeries for Medicare beneficiaries. The Comprehensive Care for Joint Replacement (CJR) Model of 2016 is a bundled‐payment initiative for LEJR that was mandated for hospitals in 67 Metropolitan Statistical Areas (MSA) covering the episode of acute and postacute care (PAC). It provides financial incentives for participating hospitals to improve outcomes and reduce episode cost of care. Approximately 30% of LEJR beneficiaries receive institutional PAC (ie, care in skilled nursing facility [SNF], inpatient rehabilitation center, or long‐term hospital) after an inpatient stay. This study aims to determine the impact of CJR on (1) institutional PAC use, readmission rate, and SNF care outcomes for patients discharged to SNFs (the most common type of institutional PAC); and (2) existing gaps in these measures between Medicare‐only and dual‐eligible (Medicare beneficiaries who are also eligible for Medicaid) patients.Study DesignWe conducted difference‐in‐difference models with MSA sampling weights using Medicare claims and assessment files, and hospital and PAC facility datasets from 2013 to 2017. We compared patient outcomes in hospitals of 75 initially randomly assigned MSAs (participation in CJR mandated) and outcomes of hospitals in 120 control areas. In analyses on all LEJR patients, the outcomes included institutional PAC utilization rate, all‐cause 30‐/90‐day readmission rates, and total payments for readmissions. In analyses on patients discharged to SNF, outcomes included SNF five‐star ratings, rate of successful community discharge, rate of transition to long‐stayers, SNF length of stay (LOS), and SNF total spending. All models adjusted for important patient, facility, and market characteristics.Population Studied457,472 patients from 763 CJR‐hospitals and 597,764 patients from 924 control hospitals during 2013‐2017.Principal FindingsCJR was associated with a 2.35‐percentage‐point (P &lt; .001) decrease in institutional PAC utilization, and a 1.74‐percentage‐point (P = .001) and a 1.97‐percentage‐point (P &lt; .001) decline in 30‐day and 90‐day readmission rates, respectively. The corresponding reductions in total payments for readmissions were $629.89 (P = .003) and $676.74 (P = 0.006), respectively. Among patients discharged to SNF, the CJR policy was associated with a 4.58‐percentage point (P = .002) higher rate of discharge to 4‐ or 5‐star SNFs, 0.76 days of reduction (P = .001) in SNF LOS, and $481.82 (P = .019) less SNF care spending. Compared to Medicare‐only patients, dual‐eligible beneficiaries with partial benefits had $1911.53 (P = .017) lower in total payments for 30‐day readmission and had $2545.08 (P = .040) lower in aggregate spending for 90‐day readmission in the treatment hospitals, under the CJR. No significant relationships were found between CJR and other SNF outcomes, or between CJR and disparities in other outcomes examined in this study between Medicare‐only and dual‐eligible LEJR patients.ConclusionsThe mandatory CJR bundled payments reform led to reduced use of institutional PAC and readmission rates, but had no effect on important SNF outcomes, such as successful discharge to community, for LEJR patients initially discharged to SNF. Furthermore, the CJR had no effect on disparities in postdischarge outcomes associated with Medicaid insurance.Implications for Policy or PracticeFuture Medicare alternative payment models and revisions to the mandatory CJR and other voluntary initiatives could incorporate incentives for improved SNF outcomes and equality of care.Primary Funding SourceNational Institutes of Health.

Trade liberalization and trade inflows: A study of Nigeria’s economy using ARDL model approach

In Nigeria, despite the success of implementation of trade liberalization measures, and the persistent signs of economic recovery as seen from reduction in external debt and debt service payments, some macroeconomic pointers still showed poor performance of the overall economy and it is against this backdrop, that this study investigated effect of trade liberalization and trade inflows in Nigeria covering the period 1981-2018 with the help of the ARDL model of estimation. Based on the issues covered in the literature review, empirical investigations were carried out on the effect of trade liberalization and trade inflows in the Nigeria. Results showed that trade openness (TOP) had a negative relationship with economic growth in both the current year and in the long run. Similarly, import volume index (IMPVID) had a negative relationship with real gross domestic product (RGDP) for the current year and in the long run, while export volume index (EXPVID) had a positive impact on RGDP but was insignificant in the previous year’s lags. The result from the ARDL Bounds Test for co-integration test indicated evidence of long run relationship among the variables of interest while trade openness and RGDP had a non-directional causality between them. Based on these findings, the study recommended that government should encourage import liberalization through reduction in tariff rates, gradual removal of non-tariff barriers (NTB), outright banning of certain goods which will ensure that domestic imports, following trade liberalization, are directed mainly on intermediate and capital goods.