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'Does cosmic radiation often cause cancer in humans?'Two things first.Far from settled, causes of cancer continue to be vigorously debated (1).Not radiation per se, rather Ionizing radiation - Wikipedia is considered damaging to tissues.With respect to the cancer risk from ionizing cosmic radiation, this answer briefly summarizesBroad outlines of the dispute between competing models.As an illustrative example, epidemiological data that suggest flight personnel, a unique population group routinely occupationally exposed to higher levels of ionizing cosmic radiation, may have a two-fold increased risk for melanoma though surprisingly, cosmic ionizing radiation may not be the relevant risk factor.Ionizing Radiation & Cancer Risk: Brief Consideration Of Competing ModelsThe relationship between dose and frequency of ionizing radiation on one hand and cancer on the other is neither straightforward nor settled, and is even a matter of considerable controversy and dispute.A mainstay through much of the 20th century, the LNT (Linear no-threshold model - Wikipedia) model presumes a strictly linear relationship between substance (radiation, potential toxin) dose and toxicity, higher the dose, higher the risk of damage, with no dose considered damage-free.Some trenchant, even downright cutting, analyses suggest (2, 3, 4, 5) that unquestioning acquiescence to the LNT model has been a travesty when defining cancer risk as well as for toxicology and public health policy in general.The article (5) by Edward Calabrese - Wikipedia in particular is a highly entertaining foray into the genesis of the LNT in the mid-20th century, how it was contrived as an attempt to explain the mechanism for evolution and how though it failed in that purpose early in its life, it got a second wind 'in service of and application for environmental risk assessment'.OTOH stands the concept of Hormesis - Wikipedia (from the Greek word meaning 'to stimulate'), which favors a biphasic response, where the possibility exists that sometimes lower doses might even confer health benefits while doses above a certain threshold would be increasingly damaging.The principle of hormesis holds that homeostatic feedback mechanisms in complex organisms allow for over-compensation in response to low doses of various stressors, a result of inevitable time lags that different tissues and organ systems take to communicate with each other (6).A modification of the hormesis model expands the idea further, ascribing beneficial effects to a hormetic zone with doses both below and above it considered toxic (see below figures that compare LNT, Threshold and Hormesis models from a guest post by Dr. William Sacks on the blog, 7, maintained by Barry Brook (scientist) - Wikipedia and a modified version of the hormesis model from 8).In the radiation field, the hormesis idea is called Radiation hormesis - Wikipedia (9), that contrary to the assumption of a strictly linear relationship between radiation dose and cancer potential, below a certain threshold, low radiation doses might reduce cancer incidence while doses above that threshold would increase it. Mechanisms by which low radiation doses might help stave off cancer include some largely mutually exclusive possibilities such asMore effective or appropriate activation of DNA and other repair enzymes.Potentially pre-cancerous cells more effectively triggered to commit suicide.Immune system activated more effectively or differently to be able to kill off pre-cancerous cells more efficiently.All that said, as far as I'm aware, consensus statements from major scientific organizations currently do not accept radiation hormesis (10).Ionizing Radiation & Cancer Risk: Brief Consideration Of Empirical Data On A High-Risk GroupGoing from theory to empirical data, unsurprisingly, higher the altitude, higher the level of cosmic radiation (11). Frequent fliers, particularly flight personnel, are thus an obvious target population to study the relation, if any, between the effect of dose and frequency of exposure to ionizing cosmic radiation and risk for cancer.As anticipated, many epidemiological studies on varying numbers of individuals (pilots, cockpit crew, flight attendants, other frequent fliers) and of varying quality have examined the link between cancers and flying (12). Problem is it's difficult if not impossible to separate out the role of occupational versus equally relevant confounding lifestyle factors, which could serve to either increase or decrease cancer risk.For one, Circadian rhythm - Wikipedia disturbance, an integral component of flying could by itself increase cancer risk.As epidemiological studies probe the deleterious effect of night shift work on health, circadian rhythm disturbance is becoming a well-known risk factor for cancer in its own stead (13). For example, a 2018 meta-analysis of 61 studies concluded (see below from 14).'confirmed the positive association between night shift work and the risks of several common cancers in women. We identified that cancer risk of women increased with accumulating years of night shift work, which might help establish and implement effective measures to protect female night shifters.’For another, flight personnel tend to be healthier compared to the general population with lower rates of hypertension, obesity and smoking, and higher levels of physical activity (15, 16). This decreases their cancer risk.While such confounding factors make it difficult to separate signal from noise, several Meta-analysis - Wikipedia have found increased risk for various skin cancers among flight personnel. A 2015 meta-analysis considered to be the largest thus far as well as among the most robust of such studies examined a total of 19 studies with a total of 266431 participants and concluded (see below from 11)'Pilots and cabin crew have approximately twice the incidence of melanoma compared with the general population. Further research on mechanisms and optimal occupational protection is needed.'More importantly, both this study (11) as well as a previous one (17) link increased melanoma risk not to ionizing radiation but rather to ultraviolet light, specifically to UVA. However, while UVA could go some way in helping explain higher risk for pilots, it does not do so for cabin crew. An accompanying editorial explains how ionizing cosmic radiation is unlikely to be relevant as well as how implicating UVA as the relevant risk factor also fails to fully explain (see below from 18).'Passengers and crewmembers are exposed to higher levels of radiation depending on cruising altitude, latitude, and solar activity.4 Pilots and flight crew receive an additional annual dose of 2 to 9 mSv [milli Sievert - Wikipedia], 5 which is significantly below the current exposure limit of 20 mSv per year according to the International Commission on Radiological Protection. 3 For comparison, a single chest x-ray provides roughly 0.02 mSv and a computed tomographic scan of the chest, abdomen, and pelvis provides approximately 8 mSv. The lifetime risk of dying of cancer among US adults is approximately 220 in 1000 and would be expected to increase modestly to approximately 223 in 1000 after a 20-year career as an airline crewmember (assuming 80 mSv of aggregate radiation exposure). 4 In addition to the fact that this modest dose of cosmic radiation should have little effect on cancer risk more generally,there is also no known relationship between even relatively high doses of ionizing (cosmic-type) radiation and melanoma. 5 Thus, it seems unlikely that cosmic radiation exposure is relevant in the observed increase in melanoma in this population...Episodic UV exposure is also associated with an increased risk of developing melanoma, whereas frequent low to moderate UV exposure is more associated with risk for nonmelanoma skin cancers. As discussed by Sanlorenzo et al, 3 a pilot’s exposure to UV-B (280-320 nm) radiation through the windshield is minimal because it is blocked by glass, but more than half of UV-A (320-380 nm) radiation penetrates glass. 3 The additional UV-A exposure for pilots offers a possible explanation for their increased incidence of melanoma but does not account for the increased risk for the cabincrew.'Bottom line, it appears flight personnel are at higher risk for melanoma while the exact reason(s) still remain unclear.Bibliography1. Tomasetti, Cristian, Lu Li, and Bert Vogelstein. "Stem cell divisions, somatic mutations, cancer etiology, and cancer prevention." Science 355.6331 (2017): 1330-1334. http://www.healthyliving.gr/wp-content/uploads/2017/03/Stem-cell-divisions-somatic-mutations-cancer-etiology-and-cancer-prevention.pdf2. Stebbing, A. R. D. "A mechanism for hormesis—a problem in the wrong discipline." Critical reviews in toxicology 33.3-4 (2003): 463-467.3. Doss, Mohan. "Correcting systemic deficiencies in our scientific infrastructure." Dose-Response 12.2 (2014): dose-response. http://journals.sagepub.com/doi/pdf/10.2203/dose-response.13-046.Doss4. Bus, James S. "“The dose makes the poison”: Key implications for mode of action (mechanistic) research in a 21st century toxicology paradigm." Current Opinion in Toxicology 3 (2017): 87-91.5. Calabrese, Edward J. "Obituary notice: LNT dead at 89 years, a life in the spotlight." Environmental research 155 (2017): 276-278. https://pdfs.semanticscholar.org/1171/9e98814235468eb3f175ed92ce46f5ff4a28.pdf6. Stebbing, A. R. "Growth hormesis: a by-product of control." Health Physics 52.5 (1987): 543-547.7. Lessons about nuclear energy from the Japanese quake and tsunami8. Lee, Duk-Hee, and David R. Jacobs. "Hormesis and public health: can glutathione depletion and mitochondrial dysfunction due to very low-dose chronic exposure to persistent organic pollutants be mitigated?." J Epidemiol Community Health (2014): jech-2014. http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.861.2740&rep=rep1&type=pdf9. Vaiserman, Alexander M. "Radiation hormesis: historical perspective and implications for low-dose cancer risk assessment." Dose-Response 8.2 (2010): dose-response. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2889502/pdf/drp-08-172.pdf10. Valentin, Jack. The 2007 recommendations of the international commission on radiological protection. Oxford: Elsevier, 2007. https://www.researchgate.net/profile/Hanno_Krieger/post/Why_is_1mSv_the_annual_dose_limit_for_the_general_public/attachment/59d62c7bc49f478072e9e04a/AS:273546683584517@1442230019192/download/ICRP+103+complete+ML12338A682.pdf.11. Sanlorenzo, Martina, et al. "The risk of melanoma in airline pilots and cabin crew: a meta-analysis." JAMA dermatology 151.1 (2015): 51-58. http://melanomacoalition.org/wp-content/research/2014-the-risk-of-melanoma-in-pilots-and-cabin-crew---a-meta-analysis.pdf12. Di Trolio, Rossella, et al. "Cosmic radiation and cancer: is there a link?." Future Oncology 11.7 (2015): 1123-1135.13. He, Chunla, et al. "Circadian disrupting exposures and breast cancer risk: a meta-analysis." International archives of occupational and environmental health 88.5 (2015): 533-547. https://pdfs.semanticscholar.org/47c6/fdbb6d40a54c86f4972d5a43b2faeee73211.pdf14. Yuan, Xia, et al. "Night Shift Work Increases the Risks of Multiple Primary Cancers in Women: A Systematic Review and Meta-analysis of 61 Articles." Cancer Epidemiology and Prevention Biomarkers 27.1 (2018): 25-40.15. Pizzi, Costanza, et al. "Lifestyle of UK commercial aircrews relative to air traffic controllers and the general population." Aviation, space, and environmental medicine 79.10 (2008): 964-974. Lifestyle of UK Commercial Aircrews Relative to Air Traffic Contr...: Ingenta Connect16. dos Santos Silva, Isabel, et al. "Cancer incidence in professional flight crew and air traffic control officers: disentangling the effect of occupational versus lifestyle exposures." International journal of cancer 132.2 (2013): 374-384. Cancer incidence in professional flight crew and air traffic control officers: Disentangling the effect of occupational versus lifestyle exposures17. Hammer, Gaël P., Maria Blettner, and Hajo Zeeb. "Epidemiological studies of cancer in aircrew." Radiation protection dosimetry 136.4 (2009): 232-239.18. Shantha, Erica, Chris Lewis, and Paul Nghiem. "Why do airline pilots and flight crews have an increased incidence of melanoma?." JAMA oncology 1.6 (2015): 829-830. https://pdfs.semanticscholar.org/74b0/fff507b22e1e943981497c5ccac02ff7d247.pdfThanks for the R2A, Paul Carter.

Caution: Long answer but worth reading…In general, flats are bought under two circumstancesUnder construction propertyReady to move-in propertyThe buying procedure is slightly different for under construction and ready to move-in property. Let me explain the procedure in a systematic way from under construction to ready to move-in.Under construction property:It's very important to verify the land document before we make a booking amount for under-construction property. Generally, booking amount ranges from 5–20%.Some unethical builders or sellers support document verification only after the booking amount paid. Kindly hold and never initiate transactions unless the documents are verified.General land verification goes as below1.RTC Extract: (Land record) RTC stands for Record of Rights, Tenancy, and Crop Information. RTC contains the details of,Survey numberLandowners detailsType of landArea of measurementWater rateSoil typeAgricultural, commercial, nonagricultural residential flood areaLand conversion detailsNature of possession of the LandLiabilitiesTenancyCrops grownExtract the RTC from Bhoomi Online service https://rtc.karnataka.gov.in/Service78/, it cost you Rs. 10/- to download an RTC extract.Please be note: It's advisable to extract few important documents directly from government server instead of depending on seller or builder. Chances that few unprofessional sellers or builders may tamper or duplicate the document. Do your own extract of important documents,An RTC looks like below image,2.Encumbrance certificate (for land): An encumbrance certificate is a certificate issued by the sub-register office of revenue department. An encumbrance certificate popularly knows as EC. An EC helps to verify,Mortgage liabilityCourt attachmentOwnershipProperty scheduleRegistration date and allotment numberMarket price and consideration priceDeed type (Acquired through sale deed, gift deed or inherited)History of registered transactions & ownershipsIf the land has been encumbered with court attachment, property has no marketing title and cannot entitle to sell.If the property has not encumbered, it has a clear marketing title to sell, buy, and build an apartment.The encumbrance certificate is usually issued in 2 forms: Form 15 or Form 16Form 15: is issued when the property has any encumbrance during the said period, Nature of encumbrance could be gift, partition, loan, lease, legality, and parties involved in dispute.Form 16: is issued when the property doesn’t have any encumbrance during the said period. Also, know as NIL ENCUMBRANCE CERTIFICATE (NEC). Having a clear marketing title to build.An encumbrance certificate looks like below image,An EC consist of 9 columns, refer the below image for the description of each columnYou can extract the EC from Kaveri Online Services https://kaverionline.karnataka.gov.in/ at the cost of Rs. 40/- per EC.3. Property Tax receipt: A property tax receipt, contain the details of,Tax payment (Amount and date of payment)Ownership detailsProperty scheduleApplication NumberWard numberKhata numberProperty tax receipt looks like below image.We can extract the property tax receipt from https://bbmptax.karnataka.gov.in/ at no cost. It's free to extract property tax. You need PID number or application number to extract tax paid receipts.4. Khata Certificate & extract: Khata is the recording of one's property in the books of the Government (here BBMP).When one registers Sale Deed in sub-register office, it is just an agreement between the seller and the buyer but when the Khata (of the property) is registered/transferred to one's name, it means the property is in the current owner's name in the government books.This also identifies the person/persons (on whose names the Khata is registered or transferred) Registered person(s) are primarily responsible for paying the tax.Khata certificate & extract contains the details of,Khata NumberOwnershipKhata transfer feeA Khata certificate & extract looks like below image,Page 1Page 2:Page 3:Khata can be extracted through Sakala online services Registration Page5. Landowner and builder agreement (if join venture): If the project is a joint venture between landowner and builder. It's important to go through the joint venture agreement to understand the responsibility of landowners and builders.The main intention of going through the joint venture agreement is to understand the feasibility & possibility of the partnership better the landowner and builder.If there is trouble in join venture, A project may halt for some duration of time till the issue get resolver among landowner and builder.A joint venture agreement must be a registered agreement.6.Building approval plan: Approval Plan from BIAPPA/BDA is necessary. Approval is provided based on the regulation of residential land, basic utilities, safety in place. Should not be an issue to construct a residential building here.7. Floor plan: Helps clearer visuals of the entire property. Buyers can use a floor plan alongside photos to understand the layout and space of the house. A clean floor plan shows the true size and potential of every roomAt the time of booking8. Agreement of SALE: It's important to execute an “agreement of sale” on or before making the booking amount to seller or builder. This is the promissory document that seller or builder is agreed to sell the property in future date, subject to terms & condition mentioned in sale agreement.Stamp duty: 0.1% of consideration value or market value, whichever is higher. Paying 0.1% stamp duty is important for loan documentation.Stamp duty can be paid in form of e-stamping or franking.At the time of project completion9. Completion Certificate: Completion certificate is issued by Municipal Corporation once the project is completed as per the approved layout plan.10. Occupancy Certificate: is also issued by Municipal Corporation after ensuring that basic amenities like Electricity Connection, Water Supply, Sewage Connection are provided as per the approved plan.At the time of Possession11. Sale Deed Registration: Once the project is complete in all respects and has received Completion and Occupancy Certificates from BBMP, the Builder shall transfer the property in your name by executing a Sale Deed that will be registered at the respective sub-register office.Sale Deed is the important document of ownership, it should be retained safe. In case, you have taken a home loan, original copy of Sale Deed may be retained by Bank till the loan repaymentTo boost the real estate sentiment in the State, the Karnataka government has announced a cut in the stamp duty rate on properties priced below Rs 20 lakh and between Rs. 21 -35 lakh.The announcement was made on 27th May 2020 during the COVID 19 pandemics.The rate cut is focusing on affordable housing. Rate remains same as before for premium housing that is valued more than Rs. 35 Lakh.The below table describes the latest stamp duty and registration charges,0.5% cess charge applicable across all the segments of affordable and premium housing.The stamp duty & registration charge calculation goes as belowExample 1: The purchase price is Rs. 20 Lakh,Stamp duty : 20,00,000*2% = Rs.40,000/- (DD on the name of respective sub-register office)Registration charge : 20,00,000*1% = Rs.20,000/- (DD on the name of respective sub-register office)Cess : 20,00,000*0.5% = Rs.10,000/- (DD on the name of respective sub-register office)Example 2: The purchase price is Rs. 35 Lakh,Stamp duty : 35,00,000*3% = Rs. 1,05,000/- (DD on the name of respective sub-register office)Registration charge : 35,00,000*1% = Rs.35,000/- (DD on the name of respective sub-register office)Cess : 35,00,000*0.5% = Rs.17500/- (DD on the name of respective sub-register office)Example 3: The purchase price is Rs. 80 Lakh,Stamp duty : 80,00,000*5% = Rs. 4,00,000/- (DD on the name of respective sub-register office)Registration charge : 80,00,000*1% = Rs.80,000/- (DD on the name of respective sub-register office)Cess : 80,00,000*0.5% = Rs.40000/- (DD on the name of respective sub-register office)Note: 0.1% of stamp duty in sale agreement, can be offset at the time of sale deed registration. Avoid double payment.You should carry following documents at the time of sale deed registration.Sale agreementProperty tax receiptKhata certificate & extractAdhara ( Preferably link your mobile number for digital signing - Its easy & convenient at the time of registration)12. Possession Letter: Once, Sale Deed is registered in your name, the builder will give you possession letter after handing over physical possession of the property.13. Allotment letter: Builder will provide the allotment letter for parking space.Below are the few points to be considered while buying a flat in Bangalore.Avoid choosing the property next to STP, recycling plant, garbage dumping spot, graveyard, high way, railway track, and polluting industry. Stay away from pollution for cause of your health & well being.Visit the project history of builder and check the quality of constructionFlat should have natural light and decent air circulation.Avoid 100% self-financing. Prefer bank loan, loan helps to control your cash flow. Bank supports for document verification besides offering loans.Avoid verbal agreement and verbal promises from seller. Keep all the possible terms & conditions in sale agreement till the sale deed executionAs you know real-estate market is not fixed. we need strong negotiation skills to bring down the price.Keep the booking amount as low as possible. Release rest of the amount only after you get confident about project progress. Avoid complete settlement in advance. Make the payment in installment as the project progress.Under-construction properties are paid based on the progress of the project. like on-booking. 10%, Basement 10%, 1st floor, 10%, 5th floor 10%, plastering, finishing and registration. Release the fund slowly as the project progress.Keep the record of payment. Avoid cash. Make payment through online, cheque or DDFranking of sale agreement is mandatory to opt for bank loan.Franking your agreement gives you better legal stand in case fail in delivery of possession, deal cancellation, delay possession by seller.If the agreement is signed by GPA holder, collect the registered GPA from seller for cross verification.Keep the eye on penalty clause in sale agreement. if delay in payment. Most seller demand at-least 18%.What is sale agreement says, if builder delay in delivering the possession.What is in sale agreement, if buyer cancels the deal? Most seller deducts at least Rs. 1.5 Lakh or 10% of booking amount as liquidated damage. The Balance amount will be initiated only after the schedule property sold to other prospective buyer. Refund process is time-consuming and losing bank interest for buyer. (Try to modify this clause on your favor)16.Most seller allows the property registration only after the complete payment that includes consideration price + parking charge + administrative charge if applicable + corpus fund if applicable + 3 years maintenance cost in advance + Utility implementation charges if applicable ( electric meter + bore-well +STP + water recycling + water softener etc..17. Most seller provides only bore well water facility. At later stage, if owners association decided to access Cauvery water connection, each flat owner may suppose to contribute around Rs. 45,000/- per flat for cauvery water connectivity.18. Buyer may spend another Rs. 10,000 for property tax application, khata transfer application, name change at electricity bill19. Additional cost applicable for modification. The modification should be informed well in advance at the time of slab construction. Seller will not permit buyer to do modification on his/her own or modification should be done with permission of builder.20. Most builders monopolies the interior contractor but you can take a call with price & quality competitive vendor after the sale deed is done.21. You may not able to choose your parking space. Parking space is allotted by the builder. You should be lucky if no water or STP pipe running just above your parking space or there might be occasional water dripping from pipe. which might spoil the place and vehicle due to constant dripping. (Keep note of this point and inform the seller about your preferred parking spot at the time of paying booking amount itself)22. Avoid parking space just above the underground water tank or STP. Such parking spot are very dangerous and not authorized to allot such space for parking23.Hidden charges:Most builders charge administrative fees of at least Rs. 50,000/-. I really don’t understand why most builders charge an administrative fees of Rs. 50,000/- when the buyer itself pays for all the paperwork of stamp duty and registration charge.Most builders charge the non-refundable corpus fund of at-least Rs. 50,000/-. apart from 1st 3 years of maintenance cost in advance. Maintenance cost roughly around Rs.3.5 per sq.ft.For example, if your flat size is 1000 Sq.ft. you need to pay Rs. 1,26,000/- as 3 years maintenance cost on or before registering the property24. Be aware of your taxation. If the consideration value is more than Rs. 50 lakh. Buyer should pay TDS. TDS is 1% of considerable value. Pay TDS on time to avoid late payment fee. Most sellers are least bothered to discuss taxation part. Take interest and clear your tax on-time.25. Get the property inspected by professional before you get the possession from seller. Make sure the tiles, kitchen granite, piping, wiring, switchboards, and doors are fitted well.No seepage, no wall cracked and decently painted. Seller may not care to address the issue once after the possession letter is signed by you.We provide the service of document verificationWe provide the service “sale agreement” drafting + execution + arranging seller & buyer signature + franking + home deliveredWe provide the service of sale deed drafting + execution + home delivered.To opt for our service, please whatsapp 9 7 4 2 4 7 9 0 2 0.Thank you for reading…

The American health care industry wastes $1T by some estimates, and possibly as much as 30% of health care spending by others. US health care expenditures are twice the OECD average – for instance, we spend twice what the UK does on health care (as a percentage of GDP) – and American health care costs are growing at 5% a year.Healthcare presents one of the greatest policy challenges for our country because profit incentives and care for the patient are often misaligned. It’s clear that the government is going to play some role in making sure the least well-off Americans have access to medicine, but we need healthcare policies that incentivize providers and payors to educate patients to make informed, data-driven choices. Only intelligent consumer choice will stimulate functioning, competitive markets in insurance, patient care, the pharmaceutical industry, and elsewhere. Today, pharmaceutical companies, health providers, electronic health record (EHR) systems, and other actors often have misaligned incentives and fail to enable more efficient solutions that do more for the patient per dollar - indeed, often the winners in these areas are those that unnecessarily charge more. Aligning incentives will spur top technology startups to develop innovative healthcare solutions, bring down costs, and deliver superior outcomes to American patients. Here are a few necessary reforms:Medical SchoolsExperts project a total physician shortfall of between 42,600 and 121,300 by 2030.* We need more medical schools fast, but the Liaison Committee on Medical Education accreditation process takes 8 years on average and most states require new medical schools to obtain a “certificate of need” before beginning construction. In addition, medical schools are required to sustain the high overhead of medical research rather than focusing exclusively on training doctors, and inflexible requirements prevent medical schools from experimenting with new curricula. Organic chemistry and other undergraduate prerequisites are completely irrelevant to becoming a good practicing doctor, and should be optional.High medical school costs force students to become high-earning specialists, e.g. plastic and orthopedic surgeons, when our country really needs more primary care physicians (PCPs). Primary care physicians, nurse practitioners, and physician’s assistants are far cheaper than specialists, but limited medical school and residency supply as well as occupational licensing concerns keep them out of the market. In addition, foreign doctors are almost always required to complete a full residency before being allowed to practice in the United States. Given a current skills gap of 30,000 doctors, adding 30,000 new PCPs, nurse practitioners, or physicians assistants could save $2.3B, $5.1B, or $6B in salary costs alone relative to the current mix of specialists and primary care doctors.In addition, primary care doctors achieve better health outcomes for patients than specialists by engaging in long-term counselling, tracking, and preventive care. Scholars estimate that replacing specialists with primary care physicians at a density of 1 per 10,000 population could save $931 per beneficiary a year. Adding a supply of 30,000 primary care physicians would save our country about $150-200B a year.*If implemented correctly, data-driven telemedicine can ameliorate demand for physicians somewhat. Doctors should be able to digitally prescribe most drugs, and data from increasingly sophisticated wearables will enable physicians to swiftly and efficiently diagnose patients.Reform PBMsIn 2017 the Centers for Medicare and Medicaid Services (CMS) spent $175B on prescription drugs alone, and there are currently shortages of vital drugs across the country. An oligopoly of Pharmacy Benefit Managers (PBMs) generates $200B a year in revenue by forcing drug manufacturers to pay rebates and other kickbacks in order for the PBM to place their drug on the “formulary”, or list of insurable drugs. Securing a place on the formulary is a matter of life and death for manufacturers, and by one estimate the current value of rebates and other price concessions from manufacturers to PBMs increased from $59B in 2012 to $127B in 2016.After speaking extensively with politicians on both sides, we were thrilled to see the Senate recently outlaw PBM “gag-orders” on pharmacies by a 98-2 vote. We are encouraged to see that Alex Azar’s Department of Health and Human Services (HHS) is planning to subject PBM rebates to anti-kickback law, but we would go further and require full price transparency on PBM contracts in the style of Colorado HB 1260. Although some rebate money flows to insurers, we estimate that reforming the space could save America on the order of $50B.End of Life Palliative CareAlthough discredited by hyperbolic language about “death panels”, counselling patients at end-of-life is both cost-effective and humane. 30% of Medicare expenditures are attributable to 5% of beneficiaries who die each year, and acute care in the final 30 days of life accounts for 78% of the costs incurred in the final year of life. While acute-care for the dying should obviously be available to those who want it, our country must shift to a model of counselling and palliative care at the end of life.Just having an end of life discussion with the cancer patient reduces medical costs by 35.7% on average, and given that there are roughly 600,000 cancer deaths in the United States a year, would have saved $687M a year for cancer patients in the last week of life alone! In addition accountable care organizations (ACOs) have saved $12,000 per patient during the final three months of life by implementing home-based palliative care. If extended to all cancer, end stage renal disease, and congestive heart failure patients this program could save the country $11.7B a year.We all agree that we must treat families of the dying with delicacy and compassion. But introducing a program by which families will share in Medicare/Medicaid savings from palliative care would help families and patients factor the overall social cost of end-of-life care into their decision calculus. We estimate that extending proven programs and testing different incentives structures could save our country $30-50B a year.FDA ReformClinical trials are an arduous multi-year process and have become drastically more costly in the last 30 years. Phase II and III efficacy trials cost roughly $400M per new drug, which severely limits the number of drugs that make it to the final stage of Food and Drug Administration (FDA) approval. A “progressive approval” approach would allow drugs to be repurposed for other uses and possibly sold after passing Phase I safety trials, which establish that a drug has a favorable risk balance and qualifies as value-based care. Drug companies could gradually establish efficacy by logging the effects the drug has on each person who opts to use it over the next several years.The extreme costs of clinical trials and FDA approval not only stymie drug development and the application of treatments to new indications, they effectively privilege Big Pharma over other innovators, inhibiting innovation and medical progress. A data-driven approach in which doctors and hospitals verify drug efficacy over time would allow the FDA to concentrate its resources on ensuring safety, particularly as the market for new drugs becomes sophisticated at assimilating information from the progressive approval process. While ramping up the number of drugs approved may not save our healthcare system money on net, a framework which encourages innovation will positively impact millions of lives by improving quality of care.Give Medicare Negotiating PowerTo pass the Affordable Care Act (ACA), the Obama Administration made a critical concession: Medicare would not be able to negotiate the price of drugs by controlling which drugs make it onto Medicare’s formulary. As a consequence, our federal government is a “price taker” that must blindly accept whatever prices drug companies demand, and the American government winds up subsidizing drug development costs for the rest of the world. Drug prices at home are extremely high, representing 10% of total healthcare expenditures, and about $144B of federal healthcare spending.In many other developed countries, governments use their monopsony or near-monopsony buying power to force pharmaceutical companies to sell drugs at much cheaper rates. For instance, Canada spends 70% of what the US spends on brand name drugs, the UK 40% of what we spend, and Denmark only 35%. If the US federal government used its considerably larger “countervailing power” to negotiate reduced drug prices – whether on a case by case basis or by pegging the value of a Quality Adjusted Life Year at a generous but fixed rate - savings could be in the range of $30-40B, possibly even as high as $90B a year.Pharmaceutical industry lobbyists (PhRMA) argue that high drug prices are necessary to stimulate R&D which generates many new life saving drugs every year. But in fact, median R&D spending on new cancer drugs – the most difficult to develop – is only around 40% of total revenue. In addition, most R&D is funded by American universities, and manufacturers of silver-bullet specialty drugs could continue to charge high prices to a federal payor. Giving government negotiating power isn’t a novel solution, but it’s one of the correct solutions to driving down drug costs for Americans.Tort LawThe threat of malpractice lawsuits forces doctors to engage in costly defensive medicine. Although the current administration has made some progress on tort reform (making arbitration legal for federal contractors and nursing homes), Congress must insist on Texas-style reforms including capped punitive and noneconomic damages from healthcare providers, eliminating contingency fees for speculative tort lawyers, reinforced federal preemption doctrine for food and drug products, and more. Unfortunately the trial lawyers lobby – one of the biggest political donors in the country – will fight reform at every step of the way.Some studies estimate that reducing physician malpractice fears to “somewhat concerned” about malpractice would decrease costs by 14%, saving the country $100B a year. Others argue that medical liability reform could save our country up to $210B a year. Congress must protect our doctors from being attacked by unscrupulous prosecutors in order to reduce the cost of healthcare for American citizens. We all agree that we must insist on protecting patients, but unchecked tort lawsuits just punish American patients and taxpayers with an unaffordable system.Data InteroperabilityThe ACA’s “meaningful use” requirements did little to make healthcare data accessible. As of 2015, only 6% of health care providers could share patient data with other clinicians who use an EHR system different from their own. Although 21st Century Cures Act made “information blocking” illegal, big EHR vendors routinely prevent their competitors from importing patient data by disclosing health records in garbled, incoherent formats. As a result, physicians are unable to make fully informed decisions about their patients.Judy Faulkner, CEO of EPIC, famously condescended then Vice-President Biden, “Why do you want your medical records? They’re a thousand pages of which you understand 10.” The answer is that only real, semantic interoperability which makes health data available to third parties via and open application programming interface (API) will allow an innovation ecosystem of apps, medical devices, and novel insurance plans to flourish. Granular, transparent healthcare data will allow entrepreneurs – whether college students or IBM executives – to invent new solutions from the bottom up and swiftly incorporate best practices into their businesses. In addition, direct service-to-service comparisons will allow consumers to make informed decisions about how to stay healthy, stimulating market competition for their dollars.We have been excited to see CMS’s Blue Button 2.0 API program formalize the Fast Healthcare Interoperability Resources (FHIR) standard for health records, which includes programmer resources, a complete API, and gives beneficiaries full control over their data – but EHR providers are refusing to use it. While any EHR system should ensure compliance with the Health Insurance Portability and Accountability Act (HIPAA) by storing protected health information on secure servers, we need to make interoperability truly mandatory.If patients could easily share their medical records with new providers and selectively reveal their data to health apps, fitness devices, diagnostic companies, insurers, and academic researchers, our entire healthcare industry would become hugely more affordable and effective. Reliable, real-time information about which treatments work, which failed, and what they cost will enable hospitals to identify and minimize cost centers as they strive to produce care more cheaply than federal benchmarks and share in the savings.Financing ReformOvertreatment and poor physician incentives may be the main driver of health care costs. Most hospital networks are local monopolies with limited incentives to innovate or save money. Replacing this broken system with value-based care models will immediately save over $100B in total, and should grow steadily over time to $200-300B as doctors harness digital technology interventions and other new techniques to make care cheaper and more effective. We break down a few potential sources of savings below:Bundled PaymentsThe Bundled Payment Care Initiative (“BPCI”) introduced in 2013 shows serious promise in making acute care clinical workflows more efficient, particularly in orthopedic care and oncology. Results continue to improve as providers adapt to the program.After adopting a bundled payment model, the NYU Medical center reduced costs to Medicare by 10% and reduced patient stays by 25% for total hip arthroplasty procedures, and a private practice joint arthroplasty generated 20% savings for CMS per episode while decreasing readmissions. The Congressional Budget Office estimates that a voluntary bundled payments system could save Medicare $6.6B a year. If CMS makes bundled payments mandatory for both Medicare and Medicaid, achieves health record interoperability, and allows the ecosystem to iterate on data-driven incentives, we expect savings to surpass $100B.Accountable Care OrganizationsACOs are widely seen as the Affordable Care Act’s main instrument to rein in health care spending, and ultimately we expect that bundled payments will be folded into a broader ACO model. To date ACOs have generated modest savings on average, but some, such as the Memorial-Hermann ACO, have generated 11% savings for Medicare. ACO contracts are more efficient if they involve two-sided risk (rewards for savings, penalties for overages), but studies have shown that even early versions of upside-risk only ACOs are associated with a 3% reduction in Medicare reimbursement. In addition, Medicare ACOs have improved quality measures across the board, despite their old, sickly populations.Provider networks are still adjusting to the ACO model, and returns will increase in the future. Projecting savings at 5-10% and assume that all Medicare beneficiaries are enrolled in ACO providers, ACOs would save Medicare $30-60B a year. If extended to Medicare and Medicaid, full ACO enrollment could generate between $56-112B a year.Preventive MedicineThe ACA now mandates coverage for all evidence-based prevention in non-grandfathered plans, so preventative screening and vaccinations have increased since the advent of Obamacare. However we need to drastically increase the scope of preventive medicine under the aegis of value-based care. Preventable chronic diseases are 7 of 10 top causes of death in the country, and account for 75% of health care costs. Half of American adults have chronic disease, and surprisingly, chronic illness among those younger than 65 years accounts for 67% of total medical spending. 70% of American adults are overweight, and 1 in 3 American kids and teens is overweight or obese. Prevalence of obesity has tripled since 1971.Some of the most cost-effective, successful preventive health interventions include childhood immunization, youth and adult tobacco counselling, alcoholism interventions, aspirin use for people with heart disease, and screenings for common cancers, STDs, and chronic conditions like hypertension. Evidence suggests that many other preventive health interventions are cost-neutral or increase long-term medical costs (because they extend lifespans). However critics often miss the fact that preventive health measures will extend the working careers of Americans, and pay for themselves in the long-run.In kidney care, for example, the federal government subsidizes extremely costly dialysis treatments for end stage renal disease patients but has not crafted incentives to perform preventative treatments before a patient advances to this critical, debilitating condition. Rather than fill the coffers of the corrupt duopoly that runs the dialysis industry, we should give providers incentives to halt the progression of kidney disease in its tracks. As a country we spend $42B on hemodialysis. Just getting prevention right here could save our system north of $10B a year.ConclusionFixing our sprawling, tangled healthcare system is one of our nation’s greatest policy challenges. In the coming years, America should move swiftly to embrace value-based care models which align market incentives to produce a wealth of patient data and an ecosystem of new information technologies geared at preventive treatment. At the same time, we must address specific areas where poor incentives have throttled the production and delivery of medical services. Replacing bureaucratic mandates with proven Western values of entrepreneurial innovation and educated individual decision-making will yield better patient experiences and results for Americans from every walk of life while saving our country $600-$900B annually – a transformative amount of money for the well-being of our nation.