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New medical technologies are a leading driver of U.S. health care spending. This article identifies promising policy options to change which medical technologies are created, with two related policy goals: (1) Reduce total health care spending with the smallest possible loss of health benefits, and (2) ensure that new medical products that increase spending are accompanied by health benefits that are worth the spending increases. The analysis synthesized information from peer-reviewed and other literature, a panel of technical advisors convened for the project, and 50 one-on-one expert interviews. The authors also conducted case studies of eight medical products. The following features of the U.S. health care environment tend to increase spending without also conferring major health benefits: lack of basic scientific knowledge about some disease processes, costs and risks of U.S. Food and Drug Administration (FDA) approval, limited rewards for medical products that could lower spending, treatment creep, and the medical arms race. The authors identified ten policy options that would help advance the two policy goals. Five would do so by reducing the costs and/or risks of invention and obtaining FDA approval: (1) Enable more creativity in funding basic science, (2) offer prizes for inventions, (3) buy out patents, (4) establish a public-interest investment fund, and (5) expedite FDA reviews and approvals. The other five options would do so by increasing market rewards for products: (1) Reform Medicare payment policies, (2) reform Medicare coverage policies, (3) coordinate FDA approval and Centers for Medicare & Medicaid Services coverage processes, (4) increase demand for technologies that decrease spending, and (5) produce more and more-timely technology assessments.

Limiting the growth of health care costs while improving population health is perhaps the most important and difficult challenge facing U.S. health policymakers. The role of innovation in advancing these social goals is controversial, with many seeing innovation as a major cause of cost growth and many others viewing innovation as crucial for improving the quality of care and health outcomes. The authors argue that mitigating the tension between improving health and controlling costs requires more-nuanced perspectives on innovation. More specifically, they argue that policymakers should carefully distinguish between innovative activities that are worth their social costs and activities that are not worth their social costs and try to encourage the former and discourage the latter. The article considers innovation in drugs, devices, and methods of delivering health care, with particular attention to delivery.

An efficient method for enantioselective synthesis of highly functionalized pyrans (up to 98% ee) through Ru-catalyzed asymmetric ring-opening metathesis/cross-metathesis is described. Reactions are promoted by a recyclable chiral Ru-chloride or a new chiral Ru-iodide complex; the latter catalyst is less efficient but gives rise to significantly higher levels of enantioselectivity. Catalytic reactions can be performed in undistilled solvent and with a wide range of substrates, including those that contain secondary and tertiary alcohols. Representative regioselective functionalizations that highlight the utility of the catalytic method are also presented.

The discovery and development of a new class of Ru-based catalysts for olefin metathesis is described. These catalysts, particularly those that do not bear a phosphine ligand, have been demonstrated to promote unique levels of reactivity in a variety of olefin metathesis reactions. The design and development of supported and chiral optically pure variants of this class of Ru catalysts for use in enantioselective metathesis are discussed as well. All catalysts are air stable, reusable, and can be employed with unpurified solvents.

Background: The cost of acute ischemic events in persons with established atherosclerotic conditions is unknown., Methods: The direct medical costs attributable to secondary acute myocardial infarction (AMI) or ischemic stroke among persons with established atherosclerotic conditions were estimated from 1995-1998 data on 1,143 patients enrolled in US managed care plans., Results: The average 180-day costs attributable to secondary AMI or stroke were estimated as USD 19,056 in the AMI cohort having a private insurance (commercial; n = 344), USD 16,845 in the AMI cohort having government insurance (Medicare, age >/=65 years; n = 200), USD 10,267 for stroke commercial (n = 108), USD 16,280 for stroke Medicare (n = 113), USD 15,224 for peripheral arterial disease commercial (n = 170), and USD 15,182 for peripheral arterial disease Medicare (n = 208)., Conclusion: These estimates can be used to study the cost-effectiveness of interventions proven to reduce these secondary events., (Copyright 2004 S. Karger AG, Basel)

Design, synthesis, characterization, and catalytic activity of six enantiomerically pure Ru-based metathesis catalysts are disclosed (3a-3f). The new chiral catalysts were prepared through steric and electronic alterations of the parent catalyst system (3). The present studies indicate that the effect of structural modifications of chiral complex 3 does not always correspond to those of the related achiral complexes. The present findings illustrate that modified Ru complexes (3e and 3f) deliver reactivity levels that are more than 2 orders of magnitude higher than 3. Reactivity and physical data are provided that shed light on the origin of activity differences. Some members of the new generation of chiral Ru catalysts promote asymmetric ring-opening (AROM) and ring-closing (ARCM) metatheses that cannot be effected by the first generation chiral catalyst (3).

Objective: To evaluate the cost-effectiveness of increasing lengths of brief postpartum hospitalizations., Methods: A cost-effectiveness model extrapolating from secondary data was used. Social costs in 2000 US dollars were estimated using several sources, including a randomized controlled trial, a retrospective study, and survey data. Life-years saved from reduced infant mortality were estimated from administrative data from Washington State. A total of 113147 singleton newborns who were born in nonmilitary hospitals in Washington State in 1989 or 1990 and had postpartum stays short enough to be affected by length of stay legislation were studied. The cost-effectiveness of increases in postpartum lengths of stay similar to those that would occur if all mothers and singleton newborns used at least the time allotted to them under the federal length of stay legislation was measured., Results: Estimated lower-bound cost per newborn life-year saved was 19 800 dollars (95% confidence interval: 11600-61300 dollars) when only neonatal deaths were considered. The corresponding upper-bound estimate was 94800 dollars (95% confidence interval: 55200-286800 dollars ). The results were very sensitive to assumptions about the discount rate for future life-years and the time from birth during which averted deaths are considered (neonatal deaths, postneonatal infant deaths, or all infant deaths)., Conclusions: At hospitals that do not experience additional capacity costs as a result of increased lengths of stay, lengthening short postpartum stays seems to be more cost-effective than many common health interventions and well below cost-effectiveness thresholds suggested by the literature. Even at hospitals that experience additional capacity costs, the cost-effectiveness of lengthening short postpartum stays seems to be roughly equal to the benchmark of 100000 dollars per quality-adjusted life-year suggested by the literature.

Background: Cochlear implants are expensive, yet often cost-effective. However, among hundreds of thousands of potential US candidates, only about 3000 received implants in 1999. To analyze whether insurance reimbursement levels may contribute to low access rates., Design: Surveys were performed during 1999 and 2000 of physicians and audiologists at clinics providing cochlear implant services, selected hospitals where surgery is performed, and state Medicaid agencies. Secondary data were obtained on Medicare payment rates and hourly incomes of otolaryngologists and audiologists., Participants: One hundred thirty-one physicians (response rate 67.9%), 111 audiologists (74.0%), 60 hospitals (73.2%), and 44 Medicaid agencies (86.3%)., Outcome Measures: Reimbursement rates for selected Current Procedural Terminology codes and for cochlear implant systems (devices); time required to perform services; additional time not reimbursed; and device purchase prices., Results: Medicare and Medicaid payment rates often fail to cover costs of aural rehabilitation. Medicare sometimes and Medicaid often fails to cover surgeon costs. Sometimes private insurance does not cover hospitals' device costs. Under Medicare, in 1999 hospitals lost more than $10 000 per device for inpatient surgery and about $5000 per device for each outpatient surgery. Device reimbursement in 2002 for outpatient surgery under Medicare is about $3773 higher than in 1999. Medicaid device payment policies vary greatly and fail to cover costs in at least 18 states, accounting for 44% of national Medicaid enrollment., Conclusions: Efforts to expand access to cochlear implants may be impeded by financial incentives. Facilitating access for Medicare and Medicaid patients could require changes in payment policies.

The synthesis and structure of a new chiral bidentate imidazolinylidene ligand and a derived chiral Ru-based carbene are disclosed. The Ru complex is stereogenic at the metal center; it can be prepared in >98% diastereoselectivity and purified by silica gel chromatography with undistilled solvents. The air-stable Ru complex efficiently catalyzes ring-closing and ring-opening metathesis and is recyclable. The chiral complex is highly effective (0.5-10 mol % loading) in promoting enantioselective ring-opening/cross metathesis reactions (up to >98% ee). These enantioselective transformations can be effected in air, with unpurified solvent and with substrates that would only polymerize with Mo-based catalysts.

Background and Purpose: Few data exist for large managed care populations on the occurrence of subsequent acute ischemic events in persons with established atherosclerotic vascular disease. We estimated the occurrence of secondary stroke, acute myocardial infarction (AMI), and vascular deaths among 2 large, managed care samples., Methods: With the use of International Classification of Diseases, Ninth Revision, Clinical Modification codes, patients aged > or =40 years and with stroke, AMI, or peripheral arterial disease (PAD) were identified from administrative data of UnitedHealthcare plans during 1995-1998. Stroke, AMI, and PAD cohorts were identified within a commercial insurance sample and a Medicare sample. Cumulative occurrences of subsequent stroke, AMI, or vascular death were estimated by survival analysis., Results: In the stroke commercial cohort (n=1631; mean age, 62.1 years), cumulative occurrence of subsequent events was 4.2%, 6.5%, 9.8%, and 11.8% at 0.5, 1, 2, and 3 years, respectively; cumulative secondary event occurrence in the AMI commercial cohort (n=6458; mean age, 56.0 years) was 3.5%, 4.8%, 7.3%, and 8.5% and in the PAD commercial cohort (n=5813; mean age, 59.2 years) was 1.5%, 2.8%, 4.8%, and 6.5%, respectively. Cumulative secondary event occurrences were even higher in stroke (n=1518; mean age, 79.5 years), AMI (n=2197; mean age, 76.2 years), and PAD (n=5033; mean age, 76.6 years) cohorts of the Medicare sample: 18.1%, 17.0%, and 8.7%, respectively, at 3 years. More than 75% of each stroke cohort's secondary events were strokes; more than 75% of each AMI cohort's secondary events were AMIs. Of the PAD cohorts' secondary events, 27% to 39% were strokes, 48% to 57% were AMIs, and 13% to 16% were vascular deaths., Conclusions: Among these managed care enrollees with existing atherosclerotic vascular disease, subsequent ischemic events represent a significant symptomatic disease burden. Given these findings, it is very important to determine whether secondary prevention strategies are being effectively used to manage patients with diagnosed atherosclerosis.

Glass-bound Ru-based catalysts! Ru-containing glass pellets efficiently promote olefin metathesis reactions and are easily employed in syntheses of compound libraries. These robust catalysts are active in air and commercially available solvents, can be recycled up to 16 times, and removed from reaction mixtures with a simple pair of tweezers (minimal solvent waste)., (Copyright © 2001 WILEY-VCH Verlag GmbH, Weinheim, Fed. Rep. of Germany.)