The French way of cancer treatment | Anya Schiffrin

An account of cancer care in France.

When my dad began to get worse, the home visits started. Nurses came three times a day to give him insulin and check his blood. The doctor made house calls several times a week until my father died on December 1.

The final days were harrowing. The grief was overwhelming. Not speaking French did make everything more difficult. But one good thing was that French healthcare was not just first rate — it was humane. We didn’t have to worry about navigating a complicated maze of insurance and co-payments and doing battle with billing departments.

Every time I sit on hold now with the billing department of my New York doctors and insurance company, I think back to all the things French healthcare got right. The simplicity of that system meant that all our energy could be spent on one thing: caring for my father.

That time was priceless.

The French way of cancer treatment | Anya Schiffrin

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Colonoscopies Explain Why U.S. Leads the World in Health Expenditures - NYTimes.com

By ELISABETH ROSENTHAL | Published: June 1, 2013

MERRICK, N.Y. — Deirdre Yapalater’s recent colonoscopy at a surgical center near her home here on Long Island went smoothly: she was whisked from pre-op to an operating room where a gastroenterologist, assisted by an anesthesiologist and a nurse, performed the routine cancer screening procedure in less than an hour. The test, which found nothing worrisome, racked up what is likely her most expensive medical bill of the year: $6,385.
That is fairly typical: in Keene, N.H., Matt Meyer’s colonoscopy was billed at $7,563.56. Maggie Christ of Chappaqua, N.Y., received $9,142.84 in bills for the procedure. In Durham, N.C., the charges for Curtiss Devereux came to $19,438, which included a polyp removal. While their insurers negotiated down the price, the final tab for each test was more than $3,500.
“Could that be right?” said Ms. Yapalater, stunned by charges on the statement on her dining room table. Although her insurer covered the procedure and she paid nothing, her health care costs still bite: Her premium payments jumped 10 percent last year, and rising co-payments and deductibles are straining the finances of her middle-class family, with its mission-style house in the suburbs and two S.U.V.’s parked outside. “You keep thinking it’s free,” she said. “We call it free, but of course it’s not.”
In many other developed countries, a basic colonoscopy costs just a few hundred dollars and certainly well under $1,000. That chasm in price helps explain why the United States is far and away the world leader in medical spending, even though numerous studies have concluded that Americans do not get better care.
Whether directly from their wallets or through insurance policies, Americans pay more for almost every interaction with the medical system. They are typically prescribed more expensive procedures and tests than people in other countries, no matter if those nations operate a private or national health system. A list of drug, scan and procedure prices compiled by the International Federation of Health Plans, a global network of health insurers, found that the United States came out the most costly in all 21 categories — and often by a huge margin.
Americans pay, on average, about four times as much for a hip replacement as patients in Switzerland or France and more than three times as much for a Caesarean section as those in New Zealand or Britain. The average price for Nasonex, a common nasal spray for allergies, is $108 in the United States compared with $21 in Spain. The costs of hospital stays here are about triple those in other developed countries, even though they last no longer, according to a recent report by the Commonwealth Fund, a foundation that studies health policy.

Colonoscopies Explain Why U.S. Leads the World in Health Expenditures - NYTimes.com

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Everything you ever wanted to know about Canadian health care in one post

Everything you ever wanted to know about Canadian health care in one post

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High health care costs: It’s all in the pricing - The Washington Post

High health care costs: It’s all in the pricing - The Washington Post: Ezra Klein

...the International Federation of Health Plans — a global insurance trade association that includes more than 100 insurers in 25 countries — released more direct evidence. It surveyed its members on the prices paid for 23 medical services and products in different countries, asking after everything from a routine doctor’s visit to a dose of Lipitor to coronary bypass surgery. And in 22 of 23 cases, Americans are paying higher prices than residents of other developed countries. Usually, we’re paying quite a bit more. The exception is cataract surgery, which appears to be costlier in Switzerland, though cheaper everywhere else.

The PDF of the PowerPoint (of the trailer of the film...) from IFHP is here.

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25 Best Global Healthcare Rankings

Interesting web site with all these links on International comparative health care. 

25 Best Global Healthcare Rankings: Healthcare Infographics

These interesting infographics help you visualize various healthcare rankings, and can help you see just where your country of residence sits.

1. Global Health-Care Snapshot: Presents a ranking of countries by how much they spend as a percent of GDP. Includes comparisons of costs in 1980 and in 2006 so that you can see where health care costs have grown the most. Includes helpful information on how people are insured in developed countries, and tabs that illustrate life expectancy and infant mortality.
2. Health Care Expenditures: An International Comparison: This infographic ranks different expenditures on healthcare by country. Expenditures considered include nursing homes, administration, medications, hospitals and more. An interesting way to break down healthcare costs.
3. U.S. Healthcare Quality: Get a look at how countries are ranked in terms of health care quality. This infographic looks at different factors related to quality, and ranks different countries.

There are lots more...
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To Fix Health Care, Help the Poor - NYTimes.com

To Fix Health Care, Help the Poor - NYTimes.com:

IT’S common knowledge that the United States spends more than any other country on health care but still ranks in the bottom half of industrialized countries in outcomes like life expectancy and infant mortality. Why are these other countries beating us if we spend so much more? The truth is that we may not be spending more — it all depends on what you count.

In our comparative study of 30 industrialized countries, published earlier this year in the journal BMJ Quality and Safety, we broadened the scope of traditional health care industry analyses to include spending on social services, like rent subsidies, employment-training programs, unemployment benefits, old-age pensions, family support and other services that can extend and improve life.

We studied 10 years’ worth of data and found that if you counted the combined investment in health care and social services, the United States no longer spent the most money — far from it. In 2005, for example, the United States devoted only 29 percent of gross domestic product to health and social services combined, while countries like Sweden, France, the Netherlands, Belgium and Denmark dedicated 33 percent to 38 percent of their G.D.P. to the combination. We came in 10th.

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NHS or US healthcare? | Poll | Comment is free | guardian.co.uk

NHS or US healthcare? | Poll | Comment is free | guardian.co.uk:

Which system would you rather be treated under?

89.9% ---- The NHS, every time

10.1% ---- I'd prefer to avoid the waiting lists and go stateside

 The website TownHall did a piece on a UK-NHS "horror story" and so I comment bombed them with posts on US anecdotes, international health care, and so on. It is amazing what a bubble these people live in. Read the comments and be prepared to bemoan the US educational system and our media environment. All of their prejudices are clearly pulled right out of Fox, IBD, WSJ, and the rest. Heaven forbid actual research.

I also found this poll from a few years ago that I thought was useful.




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JustLists' 30 Significant Medical Achievements and Their Country of Origin

30 Significant Medical Achievements and Their Country of Origin :

"Much debate occurs today about whether a country’s chosen health system impedes or encourages discovery and invention in the medical field. The fact is… innovation occurs wherever fertile and creative minds are trying to address real human need. Here is a list of a few significant discoveries/inventions:"

This is just too good a list not to share! Have fun showing it to your friends and frenemies!

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Evidence Based Medicine and Reform

This week has been very disappointing, with the USPSTF breast cancer screening guidelines coming out and recieving such an intemperate analysis by virtually everyone with access to a microphone or a camera.

Here is a very thoughtful analysis for those who are interested, but I'm really writing this because of what it says about us as Americans and our love-hate relationship with science.

So, researchers at USPSTF have made an evaluation and recommendations that fly in the face of "common sense." Common sense in America being that more is always better, whether it be testing or surgery or whatever. You can't be overtested, there are no downsides to excessive intervention. Except when there are. I will not go into the downsides of overtesting and overdiagnosing, but it really bothers me that we look to science to advance medicine, to make breakthroughs, to guide treatment and yet, we get a recommendation that falls outside of what we "know" to be true, we flip our collective gaskets.

Apparently, sensing opportunity, Glen Beck had on Bernadine Healy, whom I remember becasue she was in a position of responsibilityin Medicine (she was the Director of NIH from 1991-93), and she apparently doesn't care much for scientific thinking. She trotted out the old saw about prostate cancer survival being better here in America than in the UK because, obviously, the British hate their citizenry.

I have this debunking on the blog here, and it is basically that screening finds things that don't need treatment, but treating all of these cases as if they are life threatening makes our numbers look good. For a better estimate of how the US really does in saving people for dying from preventable causes, go here to see we have the distinction of being 19th out of 19.

But hearing about Ms. Healy being on glen beck reminded me that I had a letter published in US News (that's what the editor told me, though I never actually could find the link - ah, well), after she wrote an article praising anecdote above evidence based medicine. HCRenewal has an analysis here, and here is my letter:

To the Editor:

Healy castigates the practice of evidence based medicine in her polemic as if it were anathema to medical science, and, more particularly, to the individual physician's practice of medicine. Hippocrates knew that "Experience is delusory." "Experience," or anecdote, is sometimes helpful in medicine, but often harmful, because we physicians often internalize our experience into hard rules about treating patients. This often leads us down dangerous paths.

Evidence based medicine is long overdue counterweight to this kind of medical practice. EBM, when evidence is available, makes us think hard about our practices: Are we doing this because that's the way we've always done it, or because we have scientific research to back up our decisions? Sadly, it is too often the former, because the evidence is just not there or has not yet been synthesized into a useful form, or, most commonly, not yet reached the physicians "in the trenches." EBM is not discarding or devaluing physician judgment," as Healy argues, it is rather an attempt to make our judgment more rational.

I find it astonishing that Healy trumpets the jury awarding damages against a physician who did not order a PSA test based upon the best evidence available to him. Every physician should howl in protest at this outcome. Using this standard, we should all have monthly full body high speed CT scans and massive blood testing to search for every possible disorder that comes to the mind of the physician or the patient. But we do not practice this way because it is, yes, I'll say it, stupid!

Evidence based medicine is not a "straightjacket", but a means to an end: providing the best care based on the best scientific evidence we have.

So are we a scientifically based medical community and society, or are we thinking irrationally and letting fear mongers lead us over a cliff?

Don't answer that.

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T.R. Reid: Can We Really Fix U.S. Health Care?

From the Commonwealth Club of California Podcast is here.

Friday, September 18, 2009, 12:34:52 PM


T.R. Reid, Correspondent, The Washington Post; Commentator, National Public Radio; Author, The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care

For 100 years, U.S. presidents have unsuccessfully strived to provide universal health coverage. When LBJ created Medicare in 1965, he thought the program would gradually be extended – to people over 60, then 55, then 45, etc., so that everybody would have government health insurance by 2000. Decades later, the Clinton plan failed. George W. Bush created Medicare Part D. Barack Obama says we have the best chance ever this year to fix our health-care system. Is he right? Reid weighs in and reveals what we can learn from health-care models across the globe.

This program was recorded in front of a live audience at The Commonwealth Club in San Francisco on September 14, 2009.

A very good listen. Excellent tid bits about health promotion in Britain, insights into the minds of Canadians and more!

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America’s Health Care is … Fairly Average - Pew Research Center

Daily Number: America’s Health Care is … Fairly Average - Pew Research Center

res ipsa loquitor...

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The Health Care System Under French National Health Insurance: Lessons for Health Reform in the United States -- Rodwin 93 (1): 31 -- American Journal of Public Health

The Health Care System Under French National Health Insurance: Lessons for Health Reform in the United States -- Rodwin 93 (1): 31 -- American Journal of Public Health:

Keepin' it real. Every system comes with trade-offs...

THE FRENCH HEALTH CARE system has achieved sudden notoriety since it was ranked No. 1 by the World Health Organization in 2000.1 Although the methodology used by this assessment has been criticized in the Journal and elsewhere,2–5 indicators of overall satisfaction and health status support the view that France’s health care system, while not the best according to these criteria, is impressive and deserves attention by anyone interested in rekindling health care reform in the United States (Table 1). French politicians have defended their health system as an ideal synthesis of solidarity and liberalism (a term understood in much of Europe to mean market-based economic systems), lying between Britain’s 'nationalized' health service, where there is too much rationing, and the United States’ 'competitive' system, where too many people have no health insurance. This view, however, is tempered by more sober analysts who argue that excessive centralization of decisionmaking and chronic deficits incurred by French national health insurance (NHI) require significant reform.

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TR Reid Busts International Health Care Myths

This was in my Pittsburgh Post-Gazette, but also in other papers as well. TR Reid, of PBS "Sick Around the World" has done the leg work and homework to become perhaps the most knowledgable journalist in the world on internation health care.

As Americans search for the cure to what ails our health-care system, we've overlooked an invaluable source of ideas and solutions: the rest of the world. All the other industrialized democracies have faced problems like ours, yet they've found ways to cover everybody -- and still spend far less than we do.

I've traveled the world from Oslo to Osaka to see how other developed democracies provide health care. Instead of dismissing these models as 'socialist,' we could adapt their solutions to fix our problems. To do that, we first have to dispel a few myths about health care abroad:

Myth 1: It's all socialized medicine out there.
Not so.

Read on about myths 2-5:

MYTH 2: Overseas, care is rationed through limited choices or long lines.
MYTH 3: Foreign health-care systems are inefficient, bloated bureaucracies.
MYTH 4: Cost controls stifle innovation.
MYTH 5: Health insurance has to be cruel.

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Do we do better in the US on prostate cancer?

Four Pinocchios for Recidivist Rudy - Fact Checker:

This is not about Rudy Giuliani, he's irreleveant, but this is about the mythology that remains in the World of Fox about poor outcomes elsewhere. Somebody brought this one up recently (prostate Ca) so I put this here for future reference.

"Let's begin by deconstructing the original Giuliani claim, featured in a campaign ad in New Hampshire. It rests on a crude statistical calculation by his medical adviser, David Gratzer, on the basis of a 2000 study by a pair of health experts from Johns Hopkins university. According to Gratzer, '49 Britons per 100,000 were diagnosed with prostate cancer, and 28 per 100,000 died of it. This means that 57 percent of Britons diagnosed with prostate cancer died of it; and consequently, that just 43 percent survived.'

There are several problems with this line of reasoning, according to health experts.

In order to make statistically valid comparisons in epidemiology, it is necessary to track the same population. Because prostate cancer is a slow-developing tumor, it is probable that the Britons who died of prostate cancer in 2000 contracted the disease 15 years earlier. They represent an entirely different cohort of cancer sufferers than those who were diagnosed with the disease in 2000. The number of Britons diagnosed with the disease is itself a subset of the number of Britons with the disease.

'You would get an F in epidemiology at Johns Hopkins if you did that calculation,' said Johns Hopkins professor Gerard Anderson, whose 2000 study 'Multinational Comparisons of Health Systems Data' has been cited by Gratzer as a source for his statistics. 'Numerators and denominators have to be the same population.'

Five-year prostate cancer survival rates are higher in the United States than in Britain but, according to Howard Parnes of the National Cancer Institute, this is largely a statistical illusion. Americans are screened for the disease earlier and more systematically than Britons. If you are detected with prostate cancer symptoms at age 58 in year one of a disease that takes fifteen years to kill you, your chances of surviving another five years (until the age of 63) are obviously much higher than if your cancer is detected in year eleven, at the age of 68. Both Anderson and Parnes say that it is impossible, on the basis of the available data, to conclude that Americans have a significantly better chance of surviving prostate cancer than Britons.

Whether or not early screening actually reduces mortality from prostate cancer is the subject of much controversy among researchers, both in the United States and Europe. According to Otis Brawley, chief medical officer for the American Cancer Society, "at least 50 percent of men diagnosed with prostate cancer don't need to be treated. The problem is that we can't figure out which men need treatment, and which don't."

In an attempt to figure out if screening for prostate cancer does indeed save lives, the National Cancer Institute has been following 70,000 men since 1992, but has yet to a firm conclusion, Brawley said. Half of the men in the sample are being screened and the other half are not being screened. An August 2007 NCI report said it was still unclear whether "earlier detection and consequent earlier treatment" led to "any change in the natural history and outcome of the disease." Screening can lead to "over-treatment" which can in turn result in undesirable side effects such as erectile dysfunction and incontinence.

"This is getting completely ridiculous," e-mailed Giuliani spokesman Jason Miller. "You are still not getting it. The point the mayor has made is that privatized medicine is better than socialized medicine. If you can find one person who said they'd rather be treated for prostate cancer in the UK instead of the US, we'd like to meet them."

UPDATE WEDNESDAY 4:30 P.M.: Reader Jim Crowder asked an interesting question this morning, in response to Dr. Brawley's statement that at least 50 per cent of men diagnosed with prostate cancer "don't need to be treated." Crowder asked, "OK, If I am in the 1/2 group that would benefit by earlier treatment, wouldn't I rather be in the US and receive it? In fact I have received treatment."

I [Fact Checker] asked Dr Brawley to respond. Here is what he says:

We know that at least half of the screened and detected do not need treatment and any treatment they get can only give them side effects of treatment, including a 0.5% to 1% chance of death from treatment.We do not know that we benefit the other half who have a disease that is destined to disrupt their life by causing symptoms and in many death. Indeed some of our clinical treatment studies are designed to figure out whether we cure those who need to be cured.

Connecticut versus Washinginton State comparisons show that men in Washington State have a much higher risk of prostate cancer diagnosis and treatment and side effects of treatment, but have the same risk of death as men in Connecticut. In several papers, [including] one by me, this has been attributed to the higher rates of screening in Washington compared to Connecticut. Both have had the same decline in mortality rates.

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Health at a glance: OECD indicators 2005 - Google Book Search

Health at a glance: OECD indicators 2005 - Google Book Search

I was looking to find the prevelance of Nurse Practitioners elsewhere in the world and found the entire OECD "Health at a glance 2005"

Very interesting.

Who has the highest paid specialists? The Netherlands.

Where do PCPs and specialists get paid the same? Portugal.

Most MRIs? Japan. CTs? Japan.

And who pays the most? Oh, you know this one!

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Senate Finance Committee Hearing on Expanding Health Care Coverage

"Roundtable Discussion on “Expanding Health Care Coverage”
May 5 , 2009, at 10:00 a.m., in 106 Dirksen Senate Office Building

Over at the PNHP Blog, Don McCanne points out that the voices for single payer are being stifled and excluded because of the view of most in the Congress that it is a politically unviable proposition, though he "respects" their views.

Even more problematic was an exchange later in the hearings between Sen. Pat Roberts and Scott Serota, CEO of the Blue Cross and Blue Shield Association.

Sen. Roberts told the tale of how a group of surgeons and anesthesiologists surrounded him after his knee surgery and told him and said they'd all quit if we went to a national health plan or even, I believe, to a public option and their reimbursements were to be decreased.

I don't have the transcript, but he went on to say something along the lines of how there was no way to control costs in a national health system and then asked Serota what he thought.

Of course, Serota explained in that patrician way of so many how there was no way in the world to produce high quality and lower costs than we have in the US now with private insurance.

Now, if Sen. Baucus doesn't want single payer advocates around because he doesn't think it is politically viable, that is one thing. But what he doesn't seem to realize is that having a knowledgeable single payer advocate and someone knowledgeable about international comparative health care in the room would have resulted in the particular line of BS that Roberts and Serota were peddling to be swatted down without breaking a sweat.

That is why it is so critical to have a broader range of views at the table. There was no one there willing to point out the obvious: Reducing future surgeons' income from $500 K to $400 K, for example, will not bring the world to a halt. Essentially every country in the world controls costs and maintains quality at massive savings compared to the disastrously inefficient US private insurance industry.

But there was no one at the table willing to tell them that.

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OECD Waiting Times Study Executive Summary

I realized that while I have a link to this study elsewhere, it is rather a pain to get to the information because the document is in pdf.

Now, this is from 2003, and so the UK/NHS data is now happily out of date. And leaders in Canada have seen the results in the UK and are pushing to end the bloc financing of hospitals that helped so much in the UK. But anyway, here is the summary:

• Waiting times for elective surgery are a significant health policy concern in approximately half of all OECD countries.
• This report is devoted to [analyzing waiting times]. An interesting feature of OECD countries is that while some countries report significant waiting, others do not.
• Waiting times are a serious health policy issue in the 12 countries involved in this project (Australia, Canada, Denmark, Finland, Ireland, Italy, Netherlands, New Zealand, Norway, Spain, Sweden, and the United Kingdom).
• Waiting times are not recorded administratively in a second group of countries (Austria, Belgium, France, Germany, Japan, Luxembourg, Switzerland, and the United States) but are anecdotally (informally) reported to be low.
  
• This paper contains a comparative analysis of these two groups of countries and addresses what factors may explain the absence of waiting times in the second group. It suggests that there is a clear negative association between waiting times and capacity, either measured in terms of number of beds or number of practising physicians. Analogously, a higher level of health spending is also systematically associated with lower waiting times, all other things equal.
  
• Among the group of countries with waiting times, it is the availability of doctors that has the most significant negative association with waiting times. Econometric estimates suggest that a marginal increase of 0.1 practising physicians and specialists (per 1 000 population) is associated respectively with a marginal reduction of mean waiting times of 8.3 and 6.4 days (at the sample mean) and a marginal reduction of median waiting times of 7.6 and 8.9 days, across all procedures included in the study.
  
• Analogously, an increase in total health expenditure per capita of $100 is associated with a reduction of mean waiting times of 6.6 days and of median waiting times of 6.1 days.
  
• In the comparison between countries with and without waiting times, low availability of acute care beds is significantly associated with the presence of waiting times. Also, evidence from this and other studies suggests that fee-for-service remuneration for specialists, as opposed to salaried remuneration, is negatively associated with the presence of waiting times. Fee-for-service systems may induce specialists to increase productivity and may also discourage the formation of visible queues because of competitive pressures. In addition, evidence from this and other studies suggests that activity-based funding for hospitals may also help reduce waiting times.

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Kaiser Family Foundation Health Policy Tutorials and Compendia

Tutorials:

KaiserEDU's tutorials are multimedia presentations on health policy issues, research methodology or the workings of government.

Here are a few to get started (I haven't yet, but put them here for reference and eventual use!)

Health policy experts provide overviews of current topics in health policy. Watch and download slides from these and other tutorials:
The Public and Health Care Reform
A Primer on Tax Subsides for Health Care
Expanding Health Coverage to the Uninsured

They also have Compendiums:

These modules include background summaries along with links to academic literature, policy research and data sets on current health policy issues, such as:
U.S. Health Care Costs
Health Information Technology
Addressing the Nursing Shortage
The Uninsured
International Health Systems

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Candian Medical Association Looks to Europe to Improve Health System

Letter to members kicks off CMA debate:

The Canadian Medical Association is looking at European health systems for ways to improve.

The CMA won't launch its online consultation about transforming Canada's health care system until April 6, but if the initial response to President Robert Ouellet's March 6 letter announcing the endeavour is any indication, the consultation website should be a busy place.

Within five days of emailing the letter to members and posting it on cma.ca, the CMA had received 149 emails, many containing lengthy comments.

In his letter, entitled Status quo, or transformation?, Ouellet suggested that if Canada wants 'a sustainable, universal health care system, we have to transform the one we have.' It was first emailed to 45,000 members and posted on cma.ca, and then sent by regular mail to a further 25,000 members.

The link the the letter is at their website, and a few choice comments are there, and here:

• "I kindly disagree with you. The problems in our system will not be solved by privatizing the most lucrative parts of it. Canadian doctors want to practise medicine, not run businesses."
• "I was delighted with your comments. The constant arguments that any changes in our system will make us like the US have been misleading and frustrating."
• "It is about time care and money be patient based. Bring on the new system you suggest - it cannot come soon enough for me."
• "I'm baffled how we are like sheep and accept the wait times in our country when other countries far surpass our achievements."

It's funny, isn't it? Canada has the sense to look past the end of its collective nose for solutions, while we continue to try to tweak our system as it continues on its glide-path into the mountain.

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RAND | (Technical) Reports | Possibility or Utopia?: Consumer Choice in Health Care: A Literature Review

RAND (Technical) Reports Possibility or Utopia?: Consumer Choice in Health Care: A Literature Review:

This literature review examines consumer choice in health insurance plans against the background of the German health system in order to inform the questions: What are models of consumer choice and their effects?, and: If consumers want lower cost health care, what instruments can insurers use to provide it and what are the likely effects of those instruments? The review looked at experiences in other industrialized countries, especially the United States, for consumer choice options such as co-payments, reimbursement/bonuses, and deductibles, as well as organizational designs such as gatekeeper systems and selective contracting. In addition to cost-containment measures, the review also examined what was known about effects on health status, satisfaction, fairness and the macro-economic situation. The review describes the health economics theory of consumer choice, the methodology for the literature review, the German health system, and studies on consumer choice of insurers and providers, and reflects on their relevance on the German system. This literature review examines consumer choice in health insurance plans against the background of the German health system in order to inform the questions: What are models of consumer choice and their effects?, and: If consumers want lower cost health care, what instruments can insurers use to provide it and what are the likely effects of those instruments? The review looked at experiences in other industrialized countries, especially the United States, for consumer choice options such as co-payments, reimbursement/bonuses, and deductibles, as well as organizational designs such as gatekeeper systems and selective contracting.

The full document is here.

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