This document discusses competition and regulation in Dutch health care markets. It provides context on reforms aimed at ensuring universal access, cost containment, and more market-based systems. Competition is seen as a means to deliver key policy objectives of accessibility, affordability, and quality. The regulatory framework in the Netherlands aims to promote effective competition while also coordinating the health system and motivating providers. Key regulators include the NZa for markets and the IGZ for quality. The system incorporates competitive elements like insurer choice and selective contracting while also regulating areas of potential market failure or abuse of dominance.
Unique Device Identification A Manufacturers ViewGS1 Nederland
This document discusses the challenges medical device manufacturers will face in implementing Unique Device Identification (UDI). It argues that a step-wise implementation timeline is needed as UDI regulations will require adding variable data to automatic identification and data capture (AIDC) markings on individual medical device packages and products. This will be technically challenging due to limited space for small AIDC carriers, requirements to print variable data inline during high-speed packaging, and ensuring the quality and scannability of AIDC markings on different packaging materials. The document advocates for reviewing results between implementation steps to adjust systems as needed before expanding UDI to additional device classes.
Home Run Distribution provides door-to-door advertising distribution services directly to consumers' homes, guaranteeing exposure, and allowing businesses to lock out competitors within exclusive territories; they print over 70 million hangers annually with a dedicated adult crew ensuring visual audits of every route; the document provides testimonials from satisfied clients that saw increased sales, memberships, and better results than other advertising methods.
This document discusses different types of digital devices and their core components. It outlines the basic parts that make up digital devices like computers including input, output, processing, memory, and storage. It also lists different examples of digital devices such as personal computers, workstations, game consoles, servers, clients, mainframes, supercomputers, handheld devices, media players, PDAs, smartphones, and microcontrollers.
This document discusses different types of digital devices and their core components. It outlines the basic parts that make up digital devices like computers including input, output, processing, memory, and storage. It also lists different examples of digital devices such as personal computers, workstations, game consoles, servers, clients, mainframes, supercomputers, handheld devices, media players, PDAs, smartphones, and microcontrollers.
Wie viele Studenten, habe ich einen Traum. Meiner ist es, ein Auslandspraktikum im Büro der Vereinten Nationen in Nairobi (UNON) zu absolvieren um mehr über die Welt zu erfahren und einen Beitrag dazu zu leisten, sie etwas besser zu machen. Leider kosten Träume häufig Geld und ohne das demokratische Stipendium werde ich meinen nicht verwirklichen können.
Mein Auslands-BAFöG-Antrag wurde abgelehnt, da ich mit dessen Hilfe schon ein Semester in Japan studiert habe um mir theoretisches Wissen über Entwicklungspolitik und Humanitäre Hilfe anzueignen - Leider ohne Rücksicht darauf, dass ich dies nun auch in die Praxis umsetzen will.
Ich werde den größten Teil meiner Ausgaben, die Lebensunterhaltskosten, durch meine Ersparnisse finanzieren. Mir fehlen jedoch die Mittel um für die Unterkunft, das Visum, die Versicherung und den Flug aufzukommen.
Ich bin höchst motiviert dazu, Teil einer Organisation zu werden, die für die Sicherung des Weltfriedens, die Einhaltung des Völkerrechts, den Schutz der Menschenrechte und die Förderung der internationalen Zusammenarbeit steht. Das Praktikum stellt für mich alles dar, worauf ich die letzten Monate und Jahre hingearbeitet habe. Es legt mir die ersten Bausteine, um eine spätere Karriere in der Internationalen Entwicklung einschlagen zu können und etwas meinen Heimatländern Indien und Deutschland zurückzugeben, die mich kontinuierlich in meinen akademischen und persönlichen Zielen unterstützt und gefördert haben.
Ich wäre unendlich dankbar, wenn auch Ihr mich dabei unterstützt und für mich abstimmt!
The document summarizes the colonial conflicts between France and England in North America from the 17th to 18th centuries over control of territory and trade routes. It discusses the founding of settlements by each empire along the St. Lawrence River and Mississippi River for economic and defensive purposes. As populations and tensions grew, clashes escalated into the French and Indian War, with key battles at Forts Duquesne and Quebec ultimately resulting in a British victory and their control of most former French lands east of the Mississippi per the Treaty of Paris in 1763.
This document provides an agenda for a lesson on the Supreme Court and the Bill of Rights. The lesson objectives are for students to identify the Supreme Court's powers, recognize important court cases, and teach classmates about a Supreme Court case while creating a political cartoon. The agenda includes a do now activity, review, taking notes on the Supreme Court, a Supreme Court case activity with presentations, and a political cartoon gallery for students to share their work. Assignments are the do now worksheet, Supreme Court case activity, and political cartoon gallery chart.
Este documento contiene una lista de palabras en inglés y español relacionadas con objetos cotidianos como tazas, perros, nubes, flores y museos. También incluye nacionalidades como México, Italia y Francia. El propósito es practicar el vocabulario básico en ambos idiomas.
Unique Device Identification A Manufacturers ViewGS1 Nederland
This document discusses the challenges medical device manufacturers will face in implementing Unique Device Identification (UDI). It argues that a step-wise implementation timeline is needed as UDI regulations will require adding variable data to automatic identification and data capture (AIDC) markings on individual medical device packages and products. This will be technically challenging due to limited space for small AIDC carriers, requirements to print variable data inline during high-speed packaging, and ensuring the quality and scannability of AIDC markings on different packaging materials. The document advocates for reviewing results between implementation steps to adjust systems as needed before expanding UDI to additional device classes.
Home Run Distribution provides door-to-door advertising distribution services directly to consumers' homes, guaranteeing exposure, and allowing businesses to lock out competitors within exclusive territories; they print over 70 million hangers annually with a dedicated adult crew ensuring visual audits of every route; the document provides testimonials from satisfied clients that saw increased sales, memberships, and better results than other advertising methods.
This document discusses different types of digital devices and their core components. It outlines the basic parts that make up digital devices like computers including input, output, processing, memory, and storage. It also lists different examples of digital devices such as personal computers, workstations, game consoles, servers, clients, mainframes, supercomputers, handheld devices, media players, PDAs, smartphones, and microcontrollers.
This document discusses different types of digital devices and their core components. It outlines the basic parts that make up digital devices like computers including input, output, processing, memory, and storage. It also lists different examples of digital devices such as personal computers, workstations, game consoles, servers, clients, mainframes, supercomputers, handheld devices, media players, PDAs, smartphones, and microcontrollers.
Wie viele Studenten, habe ich einen Traum. Meiner ist es, ein Auslandspraktikum im Büro der Vereinten Nationen in Nairobi (UNON) zu absolvieren um mehr über die Welt zu erfahren und einen Beitrag dazu zu leisten, sie etwas besser zu machen. Leider kosten Träume häufig Geld und ohne das demokratische Stipendium werde ich meinen nicht verwirklichen können.
Mein Auslands-BAFöG-Antrag wurde abgelehnt, da ich mit dessen Hilfe schon ein Semester in Japan studiert habe um mir theoretisches Wissen über Entwicklungspolitik und Humanitäre Hilfe anzueignen - Leider ohne Rücksicht darauf, dass ich dies nun auch in die Praxis umsetzen will.
Ich werde den größten Teil meiner Ausgaben, die Lebensunterhaltskosten, durch meine Ersparnisse finanzieren. Mir fehlen jedoch die Mittel um für die Unterkunft, das Visum, die Versicherung und den Flug aufzukommen.
Ich bin höchst motiviert dazu, Teil einer Organisation zu werden, die für die Sicherung des Weltfriedens, die Einhaltung des Völkerrechts, den Schutz der Menschenrechte und die Förderung der internationalen Zusammenarbeit steht. Das Praktikum stellt für mich alles dar, worauf ich die letzten Monate und Jahre hingearbeitet habe. Es legt mir die ersten Bausteine, um eine spätere Karriere in der Internationalen Entwicklung einschlagen zu können und etwas meinen Heimatländern Indien und Deutschland zurückzugeben, die mich kontinuierlich in meinen akademischen und persönlichen Zielen unterstützt und gefördert haben.
Ich wäre unendlich dankbar, wenn auch Ihr mich dabei unterstützt und für mich abstimmt!
The document summarizes the colonial conflicts between France and England in North America from the 17th to 18th centuries over control of territory and trade routes. It discusses the founding of settlements by each empire along the St. Lawrence River and Mississippi River for economic and defensive purposes. As populations and tensions grew, clashes escalated into the French and Indian War, with key battles at Forts Duquesne and Quebec ultimately resulting in a British victory and their control of most former French lands east of the Mississippi per the Treaty of Paris in 1763.
This document provides an agenda for a lesson on the Supreme Court and the Bill of Rights. The lesson objectives are for students to identify the Supreme Court's powers, recognize important court cases, and teach classmates about a Supreme Court case while creating a political cartoon. The agenda includes a do now activity, review, taking notes on the Supreme Court, a Supreme Court case activity with presentations, and a political cartoon gallery for students to share their work. Assignments are the do now worksheet, Supreme Court case activity, and political cartoon gallery chart.
Este documento contiene una lista de palabras en inglés y español relacionadas con objetos cotidianos como tazas, perros, nubes, flores y museos. También incluye nacionalidades como México, Italia y Francia. El propósito es practicar el vocabulario básico en ambos idiomas.
The document provides an overview of key concepts in biology including:
- Biology is the scientific study of life through processes like observation, hypothesis formation, experimentation, and analysis of data.
- The biosphere includes all living things and environments on Earth from land to oceans to the atmosphere. Biodiversity generally increases closer to the equator.
- All organisms share characteristics like being made of cells, needing energy, responding to stimuli, reproducing, and adapting. Evolution explains both unity and diversity of life through natural selection of adaptations over time.
- Understanding biology helps address issues like health, the environment, and new technologies like biotechnology which raises both promise and ethical questions. There are still many open questions left to
William R. D. Boyd III is a senior at Georgia Tech pursuing dual B.S. degrees in Physics and Computer Science with a 3.92 GPA. He has extensive research experience including projects at CERN and Georgia Tech. He is highly involved on campus through leadership positions and founding several organizations. He has received many honors and awards for his academic and research accomplishments.
This document provides the subject outline for the Marketing Research course offered during the summer term of 2012. The course will be taught on Tuesdays from 6-10 PM and will focus on the role and practice of marketing research. Students will learn about the marketing research process, including research design, data collection and analysis, and report preparation. Assessment will include a midterm exam, individual marketing research essay, and final exam. The essay requires students to demonstrate conceptual, application, and empirical skills related to a chosen topic. The goal is for students to understand and apply marketing research concepts to inform real-world marketing decisions.
Cells have a cell membrane that encloses the cytoplasm and organelles. The cytoplasm contains a cytoskeleton that maintains the cell's shape. There are two main types of cells - prokaryotic cells which lack membrane-bound structures, and eukaryotic cells which have organelles enclosed in membranes. Organelles such as the nucleus, mitochondria, chloroplasts, ribosomes, endoplasmic reticulum, Golgi bodies, vacuoles and lysosomes each have specific functions like processing energy and materials, transporting substances and recycling cellular wastes.
DoubleDragon Properties Corp is a real estate development company founded in 2003 by Edgar "Injap" Sia II. It aims to develop 1 million square meters of leasable space within 5 years, with 70% coming from 100 shopping malls branded as CityMalls. DoubleDragon has already secured over 45 sites for these malls and has begun construction on 25 malls, with 2 having opened already. The company went public in 2014 and has since seen its market capitalization surpass industry peers to become one of the largest listed companies in the Philippines, though its high price-to-earnings ratio suggests it may be overvalued.
Sarmad Rasheed is seeking a Junior Application Developer or IT Officer position. He has a Bachelor of Science in Computer Science degree and certifications in intermediate and matriculation level computer science. He has skills in programming languages like Java, JavaScript, HTML5, CSS3, and C++, as well as development tools like Ruby on Rails, Eclipse, Android Studio, and SQL. He has experience working as an intern in an IT department and experience developing mobile and web applications using Eclipse and Ruby on Rails. He is punctual, a quick learner, and has good communication skills in English, Urdu, and Punjabi.
Goldbach Group I Goldbach Seminar I Mobile Advertising – Trends 2015Goldbach Group AG
Die Präsentation zum Goldbach Seminar «Mobile Advertising – Trends 2015» vom 12.02.2015.
Gemäss comScore läuft bei den 100 grössten Websites der Welt 31% des Traffics über Mobile Devices. Dieser rasante Mobile Shift der Verbraucher stellt nicht nur die Medien vor zentrale Herausforderungen. Auch für etablierte Brands stellt sich die Frage, wie sie die Kundenbeziehung im mobilen Kanal stärken und in wirtschaftlichen Erfolg ummünzen können.
Deshalb beschäftigten wir uns am kommenden Goldbach Seminar mit dieser Veränderung der Mediennutzung. Dabei fokussierten wir uns auf aktuelle Möglichkeiten, welche mittels Second Screen und App-Marketing 2.0 das Engagement der Nutzer verstärken.
Personal public private social security saving accounts Matias Zelikowicz
This document discusses options for transitioning the U.S. Social Security system to a model of personal public-private social security saving accounts (PPPSSS). It outlines some of the key issues with the current Social Security system, such as its unsustainability given demographic trends. It then presents two policy alternatives: maintaining the status quo by raising taxes and cutting benefits, or transitioning to a PPPSSS model where half of Social Security taxes are invested in retirement accounts that offer principal protection, upside potential from market participation, and FDIC insurance. The document provides examples of how PPPSSS accounts would work using market-linked certificate of deposits tied to market indexes.
Peru has a population of 28.8 million people and a GDP of $109.1 billion in 2007. Its GDP per capita was $3,885.9 in 2007. Peru ranked 83rd out of 134 countries in the Global Competitiveness Index in 2008-2009, with an score of 3.9. Some of the most problematic factors for doing business in Peru included restrictive labor regulations, inefficient government bureaucracy, and inadequate infrastructure.
The document discusses the property and casualty insurance sector, noting that it offers good investment opportunities at current prices. While returns have historically been average, strategic choices can lead to sustained attractive returns in the low-to-mid teens for some companies. The sector has remained healthy through the financial crisis, with most insurers paying dividends without needing state aid. However, analysis of individual companies is needed to determine their true sustainable returns and competitive positions.
Lecture 1 - Knowledge, technological change and Innovation StudiesUNU.MERIT
This document outlines the schedule and content for a 10-lecture course on knowledge, technological change, and innovation studies. It includes the following key points:
- Lecture topics will cover sources of technological change, industry evolution, technology diffusion, sectoral patterns of innovation, and the world economy.
- Assignments include a debate and an empirical paper on R&D and industrial innovation.
- Course grades will be based on homework, exam, and class participation.
Venture capital investment in the US represents a small fraction of overall economic activity but has an outsized impact. In 2006:
1) Venture capital investment totaled $28.6 billion, representing just 0.2% of US GDP but supported 10.4 million US jobs and companies with $2.3 trillion in sales.
2) Venture-backed companies dominated certain sectors such as biotech, computers/peripherals, and software, providing over 50% of revenue and jobs in these industries.
3) For every $1 of venture capital invested between 1970-2001, there was $7.90 in US revenue generated in 2006, showing venture capital is a productive use
Longevity and Pensions: Protecting Company Pensions Against Longevity RiskAegon
Longevity and Pensions
This document discusses the risks increasing longevity poses to pension systems. It notes that while longer lives are desirable, pension systems have not adequately adjusted to reflect rising life expectancies. As a result, all three pillars of pensions - state, private company, and individual savings - face challenges. In particular, state pensions rely on younger workers to support retired generations, but population aging is reducing the ratio of workers to retirees. For company pensions, funding assumptions have historically underestimated longevity gains, leaving plans underfunded. The document explores solutions like hedging longevity risk through longevity swaps to better protect pension funding against rising lifespans.
Sustainability in its shortest definition is the capacity to endure. To endure one does not only need material goods, but also a mental and spiritual resilience and set of skills on how to cope. When the quality and quantity of our material goods and biophysical environment starts to change, when our fellow South Africans are sick and dying prematurely and when our economy does not deliver the needed health and wealth to all of us, our hope for a better future is severely tested. It is the integrity of our hope that could and should be playing a fundamental role in a possible transition towards sustainability.
In this talk ladies and gentleman, the question of South Africa’s sustainability is under scrutiny. I will first show you that from an ecological, from a human well-being, and even from an economic perspective there are several warning lights on the biophysical and material sustainability of this country. I will also show the remarkable optimism we have as South Africans and highlight the importance of hope. Third, and finally I will argue that we as humans have an ethical responsibility in the individual and collective choices we make. It is our attitudes and behaviours that sustain or destroy.
Martin de Wit addresses sustainability in South Africa. He summarizes that South Africa is ecologically, environmentally, and humanely unsustainable based on several indicators. However, recent data shows improvements in GDP, optimism, and belief that the country is heading in the right direction. De Wit argues sustainability requires hope, changes to material and lifestyle wedges, and behavioral changes to attitudes and consumption.
The document provides an overview of key concepts in biology including:
- Biology is the scientific study of life through processes like observation, hypothesis formation, experimentation, and analysis of data.
- The biosphere includes all living things and environments on Earth from land to oceans to the atmosphere. Biodiversity generally increases closer to the equator.
- All organisms share characteristics like being made of cells, needing energy, responding to stimuli, reproducing, and adapting. Evolution explains both unity and diversity of life through natural selection of adaptations over time.
- Understanding biology helps address issues like health, the environment, and new technologies like biotechnology which raises both promise and ethical questions. There are still many open questions left to
William R. D. Boyd III is a senior at Georgia Tech pursuing dual B.S. degrees in Physics and Computer Science with a 3.92 GPA. He has extensive research experience including projects at CERN and Georgia Tech. He is highly involved on campus through leadership positions and founding several organizations. He has received many honors and awards for his academic and research accomplishments.
This document provides the subject outline for the Marketing Research course offered during the summer term of 2012. The course will be taught on Tuesdays from 6-10 PM and will focus on the role and practice of marketing research. Students will learn about the marketing research process, including research design, data collection and analysis, and report preparation. Assessment will include a midterm exam, individual marketing research essay, and final exam. The essay requires students to demonstrate conceptual, application, and empirical skills related to a chosen topic. The goal is for students to understand and apply marketing research concepts to inform real-world marketing decisions.
Cells have a cell membrane that encloses the cytoplasm and organelles. The cytoplasm contains a cytoskeleton that maintains the cell's shape. There are two main types of cells - prokaryotic cells which lack membrane-bound structures, and eukaryotic cells which have organelles enclosed in membranes. Organelles such as the nucleus, mitochondria, chloroplasts, ribosomes, endoplasmic reticulum, Golgi bodies, vacuoles and lysosomes each have specific functions like processing energy and materials, transporting substances and recycling cellular wastes.
DoubleDragon Properties Corp is a real estate development company founded in 2003 by Edgar "Injap" Sia II. It aims to develop 1 million square meters of leasable space within 5 years, with 70% coming from 100 shopping malls branded as CityMalls. DoubleDragon has already secured over 45 sites for these malls and has begun construction on 25 malls, with 2 having opened already. The company went public in 2014 and has since seen its market capitalization surpass industry peers to become one of the largest listed companies in the Philippines, though its high price-to-earnings ratio suggests it may be overvalued.
Sarmad Rasheed is seeking a Junior Application Developer or IT Officer position. He has a Bachelor of Science in Computer Science degree and certifications in intermediate and matriculation level computer science. He has skills in programming languages like Java, JavaScript, HTML5, CSS3, and C++, as well as development tools like Ruby on Rails, Eclipse, Android Studio, and SQL. He has experience working as an intern in an IT department and experience developing mobile and web applications using Eclipse and Ruby on Rails. He is punctual, a quick learner, and has good communication skills in English, Urdu, and Punjabi.
Goldbach Group I Goldbach Seminar I Mobile Advertising – Trends 2015Goldbach Group AG
Die Präsentation zum Goldbach Seminar «Mobile Advertising – Trends 2015» vom 12.02.2015.
Gemäss comScore läuft bei den 100 grössten Websites der Welt 31% des Traffics über Mobile Devices. Dieser rasante Mobile Shift der Verbraucher stellt nicht nur die Medien vor zentrale Herausforderungen. Auch für etablierte Brands stellt sich die Frage, wie sie die Kundenbeziehung im mobilen Kanal stärken und in wirtschaftlichen Erfolg ummünzen können.
Deshalb beschäftigten wir uns am kommenden Goldbach Seminar mit dieser Veränderung der Mediennutzung. Dabei fokussierten wir uns auf aktuelle Möglichkeiten, welche mittels Second Screen und App-Marketing 2.0 das Engagement der Nutzer verstärken.
Personal public private social security saving accounts Matias Zelikowicz
This document discusses options for transitioning the U.S. Social Security system to a model of personal public-private social security saving accounts (PPPSSS). It outlines some of the key issues with the current Social Security system, such as its unsustainability given demographic trends. It then presents two policy alternatives: maintaining the status quo by raising taxes and cutting benefits, or transitioning to a PPPSSS model where half of Social Security taxes are invested in retirement accounts that offer principal protection, upside potential from market participation, and FDIC insurance. The document provides examples of how PPPSSS accounts would work using market-linked certificate of deposits tied to market indexes.
Peru has a population of 28.8 million people and a GDP of $109.1 billion in 2007. Its GDP per capita was $3,885.9 in 2007. Peru ranked 83rd out of 134 countries in the Global Competitiveness Index in 2008-2009, with an score of 3.9. Some of the most problematic factors for doing business in Peru included restrictive labor regulations, inefficient government bureaucracy, and inadequate infrastructure.
The document discusses the property and casualty insurance sector, noting that it offers good investment opportunities at current prices. While returns have historically been average, strategic choices can lead to sustained attractive returns in the low-to-mid teens for some companies. The sector has remained healthy through the financial crisis, with most insurers paying dividends without needing state aid. However, analysis of individual companies is needed to determine their true sustainable returns and competitive positions.
Lecture 1 - Knowledge, technological change and Innovation StudiesUNU.MERIT
This document outlines the schedule and content for a 10-lecture course on knowledge, technological change, and innovation studies. It includes the following key points:
- Lecture topics will cover sources of technological change, industry evolution, technology diffusion, sectoral patterns of innovation, and the world economy.
- Assignments include a debate and an empirical paper on R&D and industrial innovation.
- Course grades will be based on homework, exam, and class participation.
Venture capital investment in the US represents a small fraction of overall economic activity but has an outsized impact. In 2006:
1) Venture capital investment totaled $28.6 billion, representing just 0.2% of US GDP but supported 10.4 million US jobs and companies with $2.3 trillion in sales.
2) Venture-backed companies dominated certain sectors such as biotech, computers/peripherals, and software, providing over 50% of revenue and jobs in these industries.
3) For every $1 of venture capital invested between 1970-2001, there was $7.90 in US revenue generated in 2006, showing venture capital is a productive use
Longevity and Pensions: Protecting Company Pensions Against Longevity RiskAegon
Longevity and Pensions
This document discusses the risks increasing longevity poses to pension systems. It notes that while longer lives are desirable, pension systems have not adequately adjusted to reflect rising life expectancies. As a result, all three pillars of pensions - state, private company, and individual savings - face challenges. In particular, state pensions rely on younger workers to support retired generations, but population aging is reducing the ratio of workers to retirees. For company pensions, funding assumptions have historically underestimated longevity gains, leaving plans underfunded. The document explores solutions like hedging longevity risk through longevity swaps to better protect pension funding against rising lifespans.
Sustainability in its shortest definition is the capacity to endure. To endure one does not only need material goods, but also a mental and spiritual resilience and set of skills on how to cope. When the quality and quantity of our material goods and biophysical environment starts to change, when our fellow South Africans are sick and dying prematurely and when our economy does not deliver the needed health and wealth to all of us, our hope for a better future is severely tested. It is the integrity of our hope that could and should be playing a fundamental role in a possible transition towards sustainability.
In this talk ladies and gentleman, the question of South Africa’s sustainability is under scrutiny. I will first show you that from an ecological, from a human well-being, and even from an economic perspective there are several warning lights on the biophysical and material sustainability of this country. I will also show the remarkable optimism we have as South Africans and highlight the importance of hope. Third, and finally I will argue that we as humans have an ethical responsibility in the individual and collective choices we make. It is our attitudes and behaviours that sustain or destroy.
Martin de Wit addresses sustainability in South Africa. He summarizes that South Africa is ecologically, environmentally, and humanely unsustainable based on several indicators. However, recent data shows improvements in GDP, optimism, and belief that the country is heading in the right direction. De Wit argues sustainability requires hope, changes to material and lifestyle wedges, and behavioral changes to attitudes and consumption.
This document analyzes medical malpractice insurance rates over the past 30 years. It finds that:
1) Payouts by medical malpractice insurers have directly tracked medical inflation rates over the past 30 years, with costs being stable and virtually flat since the mid-1980s.
2) Insurance premiums charged to doctors do not correspond to changes in payouts. Rather, premiums rise and fall with the strength of the economy and insurers' ability to earn returns through investments.
3) The insurance industry undergoes economic cycles where it aggressively competes for premiums in soft markets but sharply increases rates and reduces coverage in hard markets, creating an appearance of liability "crises" to justify
home depot Bank of America 38th Annual Investment Conferencefinance2
Carol Tomé and Mark Holifield presented at the Bank of America 38th Annual Investment Conference. The presentation discussed (1) Home Depot's progress on five priorities including implementing store standards and supply chain improvements, (2) the evolution of Home Depot's capital efficiency strategy through investing in priorities and rationalizing non-core assets, and (3) expected benefits from supply chain improvements including gross margin expansion and $1.5 billion additional cash from reducing inventory turns.
This presentation exhibits the journey of Pakistan economy. The historical performance is exhibited and explained through contemporary theories of economics
This document provides an overview of the life insurance industry in India. It discusses the history and development of life insurance in India from its origins in 1818 to the present regulatory environment. Key events include the establishment of the Life Insurance Corporation of India in 1956, which had a monopoly for many years, and reforms in the 2000s that opened the industry to private companies and established the Insurance Regulatory and Development Authority (IRDA) to oversee the industry. The document also examines the contributions and growth potential of the life insurance sector for the Indian economy.
The document discusses America's retirement savings challenge and proposes Workplace Savings 3.0 as a solution. It summarizes that as (1) Americans are living longer while traditional sources of lifetime income are declining, (2) current 401(k) plans have hit ceilings on participation and savings rates, and (3) the Pension Protection Act helped but the 2008 market shock exposed risks. It then proposes that Workplace Savings 3.0 would build on the PPA with stronger protection against volatility, built-in lifetime income options, guidance for all participants, and legal safe harbors for employers.
Pakistan's economy has experienced slowing growth over the long run due to a lack of structural reforms and incentives for sustained investment. While remittances and debt inflows have contributed to meeting external financing needs, they have also contributed to "Dutch disease" effects. Going forward, Pakistan will need to implement structural reforms in key sectors like energy and taxation to improve its fiscal position and reliance on external financing. Engaging the Pakistani diaspora through knowledge transfer and targeted investment in high-multiplier sectors could help counter Dutch disease effects from remittances and promote more sustainable development.
Local Economic Development in the urban contextNachman Shelef
Local Economic Development in the Urban Context discusses the evolution of LED thinking and strategies. Current LED views focus on (1) building economic capacity and improving the future quality of life for all, and (2) collaborative partnerships between public, business, and non-governmental sectors to create better economic growth conditions. Cities have natural economic advantages due to agglomeration effects, and good urban planning can enhance these advantages through compact, mixed-use development centered around pedestrian access. LED strategies should leverage cities' role as economic engines by focusing on urban regeneration and quality of life improvements.
The document appears to be a report on the potential of the life insurance industry in Surat market. It includes an introduction, objectives, limitations, methodology and data collection sections. The objectives are to understand the life insurance industry, analyze Kotak Life Insurance's brand awareness and customer preferences, conduct a market survey to understand the potential in Surat, and make recommendations based on findings. Limitations discussed include lack of awareness, perceptions of insurance, competition in the industry, and more. The methodology section outlines a descriptive research approach using primary and secondary data collection methods.
Here are the key steps I took for data collection for my project:
Primary Data Collection:
1. Questionnaire: I designed and administered a questionnaire to collect primary data from respondents in Surat. The questionnaire gathered information on demographics, awareness and perception of life insurance, current insurance ownership, needs and preferences.
2. Interviews: I conducted in-depth interviews with 20 individuals from different age groups, occupations and income levels to get qualitative insights into their views and decision making process related to life insurance.
Secondary Data Collection:
1. Company Reports: I referred to annual reports and presentations of Kotak Life Insurance to understand their business, products, market share etc.
2. Industry Reports:
The document discusses health care reform in the United States. It notes that US health care costs are the highest in the world at over $3.5 trillion annually. Approximately 47 million Americans are uninsured and health outcomes in the US lag behind other developed nations. The Patient Protection and Affordable Care Act of 2010 aimed to address these problems through insurance reforms, expanded coverage of the uninsured, and delivery system reforms to improve quality and efficiency.
1) Foreign aid plays an important role in Pakistan's economy, accounting for a significant portion of capital inflows and government revenues. However, aid levels have declined sharply in recent years.
2) Pakistan faces major security challenges from conflicts in neighboring Afghanistan that have imposed huge economic costs on Pakistan in the form of damaged infrastructure and disrupted economic activity.
3) Effective use of foreign aid could help Pakistan address both its economic and security issues by funding development priorities like power, transportation and education, which also have indirect security benefits by promoting stability and counteracting extremism. However, reforms are needed to improve aid effectiveness.
Economic tools and the choice of energy options with specific reference to Re...Martin de Wit
Economic tools can help analyze the costs and benefits of renewable energy options over time, but have limitations. Storage solutions are needed to overcome the intermittency of renewables. Transitions to new energy systems take decades as new technologies diffuse. External environmental costs are not fully captured in traditional economic analysis of energy options. Policy mixes that include regulations, incentives and disincentives can promote transitions to more sustainable energy systems.
Taltioni on kansallinen yksityisen ja julkisen sektorin yhteinen palvelualusta. Taltioni sisältää kansalaisen itsensä omistamat ja hallinnoimat terveys- ja hyvinvointitiedot.
Palveluntuottajalle asetettavien hyväksymiskriteerien ja sääntökirjan merkitysPalveluseteli-hanke
Kunta päättää mitä palveluja voidaan hankkia palvelusetelillä. Se päättää myös palvelun sisällöstä ja laadusta ja luo siten kriteerit palvelun tuottajien hyväksymiselle. Palvelun tuottajien hyväksymiskriteerit muodostavat asiakirjan, jota kutsutaan sääntökirjaksi
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These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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Hollannin terveydenhoitomarkkinat
1. Competition and Regulation
Dutch Health Care Markets
Finnish delegation
Amsterdam, November 6, 2009
dr. Rein Halbersma
Economic Expert, unit for Economic Analysis
3. Reform and public policy objectives
• Cutler (2002): successive waves of healthcare reform aiming at
• Ensuring universal access to medical care
• Centralised regulation-based cost containment by various rationing
mechanisms
• Decentralised market- and incentive-based systems
• Promoting effective competition is not a goal in itself,
but is seen as the best way to deliver the key public policy objectives of:
• Accessibility
• Affordability
• Quality
4. expenses health care and life expectancy in the Netherlands
82 14
12
80
10
78
8
levensverwachting
76
uitgaven als %BNP
6
74
4
72
2
70 0
1953
1956
1959
1962
1965
1968
1971
1974
1977
1980
1983
1986
1989
1992
1995
1998
2001
2004
Bron: CBS en OECD Health Data
5. An overview of the framework
Competition Auctions Regulation State provision
Decentralization Hierarchy
Motivation Coordination
Transaction costs
Market failures Government failures
(market power, externalities, information (information problems, incentive problems,
problems, hold up etc) regulatory uncertainty etc)
5
6. General economic objectives
Coordination
Ensure that the right services are produced at the right
time and place.
(includes financial risk, quality and access)
Motivation
Ensure that the parties have individual incentives to make
coordinated decisions.
Transaction costs
Ensure that coordination and motivation are provided at
the lowest possible cost
(production, search, transportation, contracting,...)
6
7. Scorecard for health care delivery systems
Hierarchy Private Private Self insurance
(public integrated insurers/provider insurers/provider (health
model) (no mandatory (mandatory savings
insurance) insurance) accounts)
Coordination of risk
++ - + --
Motivating health
- ++ ++ +
care providers
public contracting selective contracting Selective contracting
yardstick competition competition policy competition policy
Freedom of choice
++ - - ++
Adverse
++ -- + +
selection/access
Moral hazard
-- - - ++
Rationing Rationing Rationing
Gate keeping Gate keeping Gate keeping
Co-payments Co-payments Co-payments
Transaction cost
Health care Providers/Third party Providers/Third party Patient
providers/government payer/patient payer/patient
7
9. The Dutch Healthcare Authority
Legal tasks of the NZa
• NZa established by the Healthcare Market Design Act (2006)
• Roughly three complementary tasks
• regulating providers and insurers
• mitigating dominant market positions
• initiating market-based reforms where feasible
Organizational structure of the NZa
• Exezcutive Board
• supported by legal & communication staff
• Cure and Care departments
• budget and price regulation
• Supervisory department
• market power assessment
• Research & Development department
• design, advocacy and implementation of reforms
9
10. Mission of the NZa
“The NZa creates and monitors properly functioning healthcare
markets. The interests of the consumers are central in the
performance of these tasks. Efficiency, both in the short and long
term, market transparency, freedom of choice, access to
healthcare and quality are guaranteed. This gives the consumer
the best value for his or her healthcare euros.”
10
11. The Dutch regulatory landscape: competition and quality
The NZa
• ex ante regulation of dominant market positions
• advisory role in merger control
• transparency role in quality control
The NMa (Netherlands Competition Authority)
• ex post regulation of dominant market positions
• decisive role in merger control
• enforcing cartel prohibitions
The IGZ (Healthcare Inspection Agency)
• standard setting and enforcement role in quality control
11
12. The Dutch regulatory landscape: health insurers
The NZa
• ex ante: misleading policies, marketing, consumer targeting
• ex post: legality of reimbursements
The DNB (Dutch Central bank)
• compliance with solvency requirements (Basel II)
The AFM (Authority Financial Markets)
• supervises behaviour of financial institutions
The CBP (Data Protection Authority)
• ensures privacy of patient and client records
12
13. The regulatory toolbox (I)
Regulatory environment for the NZa
• absence of EU level framework (contrast: telecom, energy)
• legal tools endowed by the Healthcare Market Design Act
1. power to impose general obligations (all market parties)
2. power to impose specific obligations on individual parties
General obligations
• law contains no specific criteria for application
• policy objectives: universal access, affordability, quality
• promoting effective competition as a means to this end
• examples:
• transparency requirements (quality, marketing)
• terms of agreements (response time, exclusivitiy)
• price regulation (e.g. general price cap)
13
14. The regulatory toolbox (II)
Specific obligations for individual market parties
• key criterion: Significant Market Power (SMP) = dominance
• relevant market definition on case by case basis
• dominance analysis: market share, structure, effects
• proportional ex ante obligations
• transparency and non-discrimination
• obligation to deal and reference offer
• cost accounting principles and price regulation
• proposed priorization for application of SMP
• exclusion over exploitation
• selling power over buying power
• predatory prices and discrimination:
• only intervene if clearcut foreclosure effects
14
15. Creating effective competition
Systematic effort to deregulate primary care
• 2005: experiment with physiotherapists
• 2007: NZa consulted its deregulation framework
• 2008: proposal to deregulate psychologists, dieticians
• 2010: experiment with dental care
For secondary care, barriers of entry obstruct effective competition
• highly regulated labor markets
• restricted capacity at universities
• 2008: overhaul of capacity planning of specialists
• restricted access to capital markets
• for-profit goal is forbidden, hence equity is scarce
• 2009: proposal to experiment with for-profit goal
15
17. Overview of the health care system in the Netherlands
Supplementary Health Insurance (voluntary)
Third Compartment
Mandatory Health Insurance
(compulsory for the entire population)
Second Compartment
National Health Insurance for Exceptional Medical Expenses
(compulsory for the entire population)
First Compartment
18. Health care financing in the Netherlands in the second
compartment
• Public insurance for exceptional medical expenses
• mandatory for all citizens
• home care, nursing homes, care for the handicapped
• 20 G€ annually (1.25 k€ per capita)
• Private basic insurance
• mandatory for all citizens
• general practicioner, hospital care, pharmaceutical care
• 2008: also mental care (moved from public insurance)
• 32 G€ annually (2 k€ per capita)
• Private supplementary insurance
• dental, paramedic (physiotherapy) and cosmetic care
• Total expenditures: 12.4% of GDP (including daycare, public health etc.)
• annual increase of 7.7% since 1998
18
19. The idea behind competitive health care markets
Health care providers
Insurers can selectively contract hospitals
Negotiations between
insurers and hospital
Insurers
Consumers choose between competing insurers
19
20. Economic characteristics of competition
• Consumers have free choice of health insurance company,
• no risk selection, no lock-in
• incentives for prevention?
• Competition between health insurance companies leads to
downward pressure on costs:
• Selective contracting with health care providers
• Directing consumers toward more efficient choices
• Utilization review by insurers:
• Crosschecking need for treatment received
• Best practice benchmarking
20
21. Characteristics of the Dutch health insurance market
• New 2005/2006 legal framework provides for:
• Mandatory health insurance for all Dutch citizens
• Uniform comprehensive benefits package
• Obligation for all health insurers to provide services to all
consumers without:
• risk selection
• premium differentiation
• Funding regime:
• 50% of the premium is a nominal premium (differentiated per
insurer not per consumer) and collected by insurers
• 50% of the premium is income dependent and collected by the
state (this part of the premium is redistributed to insurers based
on a risk adjustment system)
21
22. Risk adjustment system
• Remove financial incentives for risk selection
• Compensates insurers for predictable losses
• Insurers will make an effort to efficiency instead of risk selection
• Fair competition among insurers
• Ex-ante risk adjustment
• Age, sex, source of income (e.g. salary, subsidy)
• Region (classification of postcode areas based on socio-economic,
demographic and healthcare related characteristics of the postcode area)
• Recent outpatient drug consumption (chronic diseases)
• Diagnose (was the patient treated in hospital last year, and does this
predict further high cost treatments/ drugs?)
• Ex-post risk adjustment
• Correction of the ex-ante adjustment. Necessary e.g. because of the
changes in case mix from one year to the next, general cost increase,
unexpected high costs
• Net yearly risk per enrolled consumer 35 Euro
22
23. Insurer supervision: selective contracting
Health Insurance Act
• In theory, health insurers
• do not have to contract every provider, BUT
• do have to contract SUFFICIENT amount of care
• can differentiate payments per provider
• can differentiate deductibles for consumer, depending on the
chosen provider
• In practice:
• every health insurer contracts every provider
• payments are differentiated, BUT
• there is no differentiation in deductibles
• Explanation:
• quality differences between providers not transparent
• consumers value choice more than lower deductible
• we expect this to be a long-run equilibrium
23
29. Some conclusions on the insurance market
• The average premium 2006 (1.028 Euro) is below expected premium
(1.106 Euro). The average premium 2007 is 1.103 Euro and 2008
1.049.
• Premiums are difficult to compare as a consequence of adjustments
in 2007 (share of the government) and 2008 (law change for
deductibles).
• 18% of the enrollees switched in 2006 (year of policy change).
Switching in 2007 and 2007 is below 5%
• Elderly people and enrollees with a bad health switch significantly
less.
• Collective contracts are important. Price reductions up to 7,5%.
• 93% of enrollees buy a supplementary insurance.
29
31. Conditions for competition
• Stable system of invoicing:
• Clear product description.
• Administration performs well.
• Supply side conditions:
• Lower barriers to entry.
• Risk on investment and bankruptcy rules.
• Profit possible.
• Liberalization of contracts between doctors and hospitals.
• Demand side conditions:
• Selective contracting and steering of enrollees.
• Risk adjustment is adjusted to new institutional design.
31
32. 2005: introduction of competition
Revenue of major diagnoses in the competitive
segment
Other Hip replacement
Incontinentence 26% 20%
operation
5% Diabetes Mellitus
Tonsillectomy 12%
6%
Knee 145 products (27
Groin rupture replacement
Cataract diagnoses) of elective
8% 12%
11%
outpatient care
Competitive segment is 8% of total hospital revenue
32
33. Increase of the B-segment in 2008 and 2009
2008
• Chronic heart diseases
• Pregnancy (pregnancy, delivery, after birth control and miscarriage)
• Knee operations (meniscus and cruciate ligament leasie)
• Some cancer treatments (breast and prostate)
• Umbilical hernia
• Sterilization (men and women)
2009
• Treatments in ophthalmology, surgery, orthopedics, urology, gynecology,
neurosurgery, dermatology, internal medicine, cardiology and
anesthesiology.
Competitive segment 2008 and 2009 are an
estimated 20% and 31% of total hospital revenue,
respectively.
33
34. Recent increase in hospital concentration
Voor fusietoezicht Na fusietoezicht
115
110
105
100
95
90
85
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Average HHI hospitals in local market: 2,350
Average HHI insurers in corresponding market: 5,300 34
36. Price development in the B-segment and A-segment
Percentage price increase/decrease (nominal prices)
2.5
2
1.5
A-segment
B-Slice 2005
1
0.5
0
2005-2006 2006-2007 2007-2008 2008-2009
• The price increase in the A-segment is approx. lower than the price
increase in the B-Slice 2005.
• In 2008-2009, the price increase in the B-slice 2008 was 0.7%.
• Overall, the price development in the competitive sector is more
favorable than the price development in the regulated sector.
37. Price development in the B-segment
Price B-Slice 2005 B-Slice 2008 B-Slice 2009
Development
`05-`06 `06-`07 `07-`08 `08-`09 `08 `08-`09 `09
Nominal 0.0% 2.1% 1.1% 0.8% - 0.7%
Real -1.2% 0.5% -1.4% -0.2% - -0,3%
Mark-up on cost - - - - 2.0% - -0.3%
• For each B-Slice, there is mostly a decline in the real prices.
• In 2008 (2009), we can only calculate the mark-up of B-Slice 2008
(2009) on the estimated cost.
• The estimated cost is already corrected for inflation.
40. ‘Functional Budget’ Model (1)
• Cost
- Operational Cost
- Interest and depreciation
B-C= change in reserves
• Budget = max allowed Revenue set by NZa
B-R=change in tariff for
nursing days
• (actual) Revenue earned through billing of
- Tariff for treatments
- Tariff for nursing days
41. ‘Functional Budget’ Model (2)
Component ‘price’ Share in Budget
2004
Fixed Cost per capita 8(10)
Semi-Fixed Cost per bed and per doctor 24 (23)
Variable cost inpatient visits 43 (37)
outpatient visits
nursing days
Location Cost Depreciation/ 16 (16)
interest
43. How is the AWBZ market organized?
The AWBZ market is divided into:
• EXTRAMURAL CARE: Health care services delivered outside a
medical institution (hospital, nursing home, psychiatric clinics, etc).
• INTRAMURAL CARE: Health care services delivered in a medical
institution.
In the extramural care there are two different actors:
• PGB clients: These people have a voucher at disposal and they
can organize their care provision themselves. They are free to
receive services from providers that are not contracted by the care
office.
• In kind clients: These people receive services from a provider who
has entered into a contract with the care office.
44. Structure of the extramural AWBZ market
• The Netherlands is divided in 32 regions; each region has a care office
which goals are to:
• Purchase care for their in kind clients. A change in legislation in
2003 made it possible to selectively contract care providers (for all
the functions of the extramural care).
• Inform clients about the contents of a care service that is provided.
• They are accountable for spending financial means for the AWBZ.
• They have a regional budget, which caps the expenditure
• Prices of providers are regulated; maximum tariffs are set by the NZa.
• Providers of care and care offices negotiate on prices. Some services
have a price which is equal to the maximum tariff, but some price
variability is also observed.
46. Some results from research on the homecare market
1. Positive and significant effect of market share on contracted prices
2. Decreasing relative contracted prices over time.
3. Significant differences in the relative contracted prices across regions
4. No support to the argument of superior quality of large providers (based on
subjective data)
47. Analysis NZa of problems in the current regulation
• Indication: independent indication, but delegation of indication determination to
providers and no clear standard
• No incentives for buying agencies to buy the right health care. No proper health
insurance market.
• No transparency for consumers, waiting lists, low perception of quality and low
efficiency
47
48. Yardstick competition
Yardstick competition is a
dynamically updated price-cap,
that follows the development of the
average unit costs.
Firms have a strong incentive to
improve their unit costs, hence the
average will drop over time.
When the market consists of
regionally fragmented
monopolies (or oligopolies), a
yardstick based on national
average costs can create effective
competition.
Yardstick competition is applied to
Dutch energy companies.
49. What is needed for yardstick competition
Yardstick competition needs
homogenous products that can
be accurately measured.
Dutch hospitals have 30.000
products (“DBCs”) that are
classified by diagnosis and
treatment.
In 2006, the NZa proposed
yardstick competition for
Dutch hospitals, that consists of a
price-cap on the average price
per product, adjusted for their
patient mix.
Owing to bad data registration, this
plan has been cancelled.
50. Long term perspective: Market definition
1. Distinction between the market for basic care and the market for complex and
highly specialized care
2. Within the market for complex care, a number of submarkets exist.
3. Housing and care are separate markets, except when living is an integral part of
the provision of care (e.g. 24 hour supervision in mental health care).
50
51. Long term perspective
• Market for basic care
• No price regulation necessary, if the purchasing is carried out by risk
taking insurers (risk adjustment should be possible)
• Combination with normal health insurance, to solve externalities
• Government monitors market behaviour and quality.
• Market for complex/specialistic care
• Risk adjustment is not possible. Therefore a competitive health
insurance market cannot be established.
• Price regulation is necessary, due to monopolized markets.
51
52. Transition proposals by NZa
Long term model Short term model
Basic Care Extramural Care
Liberalization, possibly
Liberalization with reverse auctions
Purchased by local
communities and
health insurers (if Intramural Care
risk adjustment is
possible)
Yardstick competition
/benchmarking
Complex care
Yardstick competition/
benchmarking
54. Recent increase in hospital concentration
Voor fusietoezicht Na fusietoezicht
115
110
105
100
95
90
85
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
54
55. Background
• Concerns and discussion about mergers in healthcare
• Mergers have to be assessed by NMa and NZa
• Mergers have negative and positive welfare effects (in case of
horizontal merger):
• Reduction of competitive constraints
• Easier coordination (e.g. keeping prices higher)
• Larger size
• Different input and output mix (potentially)
• Merger assessment process
• Predicting the market developments with and without the merger
• Weighing the positive and negative effects against each other
• This project: focus on positive effects
• Idea: measure the potential efficiency gains
56. How do we define markets for antitrust purposes?
• The smallest area or group of products for which there are no close
substitutes outside the group
• The market established using this criterion determines the measure of
market concentration
• Pre-merger and post-merger competitive effects rest upon this definition
• SSNIP Test (EU Merger Guidelines)
• Area or group of products in which a hypothetical monopolist, could
impose a “small but significant and non-transitory increase in price,”
(SSNIP) holding constant the terms of sale for all products produced
elsewhere
Presumption of anticompetitive effects if there is a large
increase in concentration in this area
57. Product market versus geographic market (I)
What is a Product Market?
• Group of products with few outside substitutes
• Smallest sensible segment with Dutch data: Medical specialty
• Total of 24 (e.g. cardiology, neurology)
• Similar to ICD coding of “Major Diagnostic Category”
• Other segmentations:
• Specialties with same complexity/volume (Varkevisser)
• Care type with the same resource requirements (e.g.
primary/secondary tertiary)
• Inpatient versus outpatient
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58. Product market versus geographic market (II)
What is a Geographic market?
• Geographic area with few outside substitutes outside the area
• Smallest sensible area: zip code
• Look for smallest group of zip codes that make up market
• Supplement markets with additional areas, defining “active
competitors” as hospitals with significant market (>1%) share in
that zip code area
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59. Patient flow versus patient choice (I)
Patient flow methods
• Assumption: Existing travel pattern is indication of future
preference
• Elzinga-Hogarty method: find zip code area where:
• Few outflows from the area (imports of care) indicates demand self-
sufficiency
• Few inflows to the area (exports of care) indicates supply self-
sufficiency
• Intuitive and easy to compute (and often used in court)
• Problems with EH-method:
• What is “few”? (usually 10% to 25%)
• Sensitive to starting point, expansion method
• Elzinga’s testimony in US court:
• method not suitable for hospital mergers
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60. Patient flow versus patient choice (II)
Patient choice methods
• Analyze choice conditional on characteristics (distance)
• When characteristics change, choice will change
• Can directly simulate effect of merger on prices
• Methods based on patient choice
• Critical Loss (can also be used with patient flow analysis)
• Uses willingness to travel as proxy for willingness to pay
• BUT: needs to be validated using consumer surveys
• Option Demand
• Uses hospital profits as proxy for willingness to pay
• BUT: for-profit not allowed in the Netherlands
• Logit Competition Index (LOCI)
• Computes price equilibrium for Bertrand competition
• BUT: neglects structure of the insurance market
• NZa has recently implemented all these methods
• Each method has challengeable assumptions, BUT
• Predictions are strongly correlated for all 3 patient choice methods
• This robustness should help in court
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62. System Model
Management
(Effort/Ability)
PROCESS
PROCESS
Resources Products
(Inputs) (Outputs)
Exogenous factors
(Non-discretionary resources or products)
63. Scale (Size)
Output
F∗(y1+y2)
D
y1+y2
A+B
y2 C
B
y1 A
O x1 x2 E∗(x1+x2) x1+x2 Input
64. Scope (Harmony)
Nurses
B
A borrows nurses
and lends doctors
L(y) = resources
necessary to produce
given output
A
O Doctors
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