infonet-economy

Zielsetzung: Auf der einen Seite erwarten die Öffentlichkeit und der Gesetzgeber[1] von den Schweizer Krankenversicherern, dass sie die Leistungserbringer[2] nach ihrer Wirtschaftlichkeit unterscheiden können. Auf der anderen Seite wird es mit dem steigenden Wettbewerbsdruck für den einzelnen Versicherer immer überlebensnotwendiger, die Wirtschaftlichkeitsbeurteilung möglichst gut zu beherrschen. Aus diesem Grund wurde der vorliegende Ärzteindex entwickelt.

Methodik: Der Ärzteindex beruht auf Individualdaten aus jeweils drei Behandlungsjahren, mit denen Arzt-Patienten-Beziehungen beschrieben werden. Mithilfe einer linearen, multiplen Regression wird aus diesen Arzt-Patienten-Beziehungen ein Modell erstellt, welches die Erwarteten-Kosten von Patienten bei ihren Ärzten berechnet. Durch die Division der Effektiven-Kosten der Patienten eines Arztes mit den Erwarteten-Kosten kann die relative Wirtschaftlichkeit des Arztes bestimmt werden. Die Stärke des Ärzteindexes liegt darin, dass er durch die verwendeten Individualdaten die spezifische Morbidität der Patienten eines jeden Arztes berücksichtigt.

Ergebnisse: Bisher wurde der Ärzteindex erfolgreich für drei Fachrichtungen von Ärzten entwickelt. Für die Allgemeinmediziner erreicht er einen Erklärungsgehalt (Korrigiertes R 2) von 67 %, bei den allgemein inneren Medizinern einen Erklärungsgehalt von 69 % und bei den Pädiatern 32 %. Unseres Wissens gibt es heute kein anderes Modell für die Schweiz, welches die Wirtschaftlichkeit von Ärzten besser erklären kann.

Schlussfolgerung: Die vorliegende Arbeit zeigt, dass es statistisch möglich ist, eine differenzierte, morbiditätsorientierte und damit auch faire Beurteilung unterschiedlicher Behandlungsstile von Ärzten vorzunehmen. Es ist das einzige Modell in der Schweiz, welches Pharmaceutical Cost Groups, d. h., Gruppen von chronisch kranken Personen, die aufgrund des Medikamentenbezugs identifiziert werden können, in die Bewertung einfließen lässt. Mit dem Modell ist die Hoffnung verbunden, dass es zu einer Versachlichung der Diskussion zwischen Ärzten und Krankenversicherern beiträgt.

In order to promote the diffusion of insurance contracts with managed care characteristics among Swiss citizens the Federal Council suggests that Parliament defines networks of integrated care (with budgetary responsibility) as part of the federal law on social health insurance. At this stage Parliament is still searching for an appropriate solution.

Social relations between humans critically depend on our affective experiences of others. Oxytocin enhances prosocial behavior, but its effect on humans’ affective experience of others is not known. We tested whether oxytocin influences affective ratings, and underlying
brain activity, of faces that have been aversively conditioned. Using a standard conditioning procedure, we induced differential negative affective ratings in faces exposed to an aversive conditioning compared with nonconditioning manipulation. This differential negative
evaluative effect was abolished by treatment with oxytocin, an effect associated with an attenuation of activity in anterior medial temporal and anterior cingulate cortices. In amygdala and fusiform gyrus, this modulation was stronger for faces with direct gaze, relative to
averted gaze, consistent with a relative specificity for socially relevant cues. The data suggest that oxytocin modulates the expression of evaluative conditioning for socially relevant faces via influences on amygdala and fusiform gyrus, an effect that may explain its prosocial
effects.

Understanding how organisms deal with probabilistic stimulus-reward associations has been ad-vanced by a convergence between reinforcement learning models and primate physiology, which demonstrated that the brain encodes a reward prediction error signal. However, organisms must also predict the level of risk associated with reward forecasts, monitor the errors in those risk predictions, and update these in light of new information. Risk prediction serves a dual purpose: (1) to guide choice in risk-sensitive organisms and (2) to modulate learning of uncertain rewards. To date, it is not known whether or how the brain accomplishes risk prediction. Using functional imaging during a simple gambling task in which we constantly changed risk, we show that an early-onset activation in the human insula correlates significantly with risk prediction error and that its time course is consistent with a role in rapid updating. Additionally, we show that activa-tion previously associated with general uncertainty emerges with a delay consistent with a role in risk prediction. The activations correlating with risk prediction and risk prediction errors are the analogy for risk of activations correlating with reward prediction and reward prediction errors for reward expectation. As such, our findings indicate that our understanding of the neural basis of reward anticipation under uncertainty needs to be expanded to include risk prediction.

To monitor the environment for social threat humans must build affective evaluations of others. These evaluations are malleable and to a high degree shaped by responses engendered by specific social encounters. The precise neuronal mechanism by which these evaluations are constructed is poorly understood. We tested a hypothesis that conjoint activity in amygdala and fusiform gyrus would correlate with acquisition of social stimulus value. We tested this using a reinforcement learning algorithm,
Q-learning, that assigned values to faces as a function of a history of pairing, or not pairing, with aversive shocks. Behaviourally, we observed a correlation between conditioning induced changes in skin conductance response (SCR) and subjective ratings for likeability of faces. Activity in both amygdala and fusiform gyrus (FG) correlated with the output of the reinforcement learning
algorithm parameterized by these ratings. In amygdala, this effect was greater for averted than direct gaze faces. Furthermore, learning-related activity change in these regions correlated with SCR and subjective ratings. We conclude that amygdala and fusiform encode affective value in a manner that closely approximates a standard computational solution to learning.

The analysis of the competitive environment – monopoly, oligopoly or many competitors –in which international organizations act, has been neglected in scholarly
research. Both this external and the internal type of competition in international organizations are rather weak and performance is far from ideal. To strengthen both
types of competition, several tentative proposals are advanced. They range from the introduction of an international competition agency, the use of prediction markets, matching contributions, to the employment of elements of direct democracy via randomly elected trustees. These proposals are put forward to stimulate discussion
and to advance new ideas about the design of international organizations.