Pharmacy Benefit Managers (PBM) induce drug manufacturers to offer rebates to insurers and employers by denying coverage through formulary exclusions, impeding physician prescription through prior authorization, and reducing patient drug use through cost sharing. As they tighten these access obstacles, PBMs reduce the net prices received by the manufacturers.

We argue that the effectiveness of Rwandan governments, both at implementing the 1994 genocide and inducing the current growth miracle, illustrates that the state has high capacity. Yet this capacity is not captured by conventional Weberian concepts, with their focus on taxation and formal bureaucracy. Rather, the capacity of Rwanda's state relies on its ability to leverage dense social networks which connect it to society. The origins of these networks lie in the construction of the historical state which expanded by merging with local lineages and kinship groups. Using data on the historical expansion of the Rwandan state as a proxy for the strength of state–society social networks we show they are uncorrelated with measures of Weberian state capacity. In a fieldwork exercise, we show that rule compliance today is positively correlated with our proxy, but uncorrelated with Weberian state capacity.

We develop a theory of the accumulation of state capacity as the outcome of a political competition between elites and (civil) society. State capacity is accumulated by elites, and it is productive as well as useful in controlling society. However, society can fight back and accumulate its own capacity, facilitating collective action. The theory leads to three distinct equilibria depending on initial conditions. One type, a weak state, emerges when society is strong relative to the elite. Another, a despotic state, originates where the elite is initially relatively powerful. A third type, an inclusive state, emerges when the elite and society are more evenly matched. The theory has several important implications; first, variation in state capacity does not require large structural differences; second, inclusive states have the highest levels of state capacity in the long run; third, the effects of shocks or external threats like wars are conditional on the balance of power between elites and society.

Many economic analyses, including those that address the COVID-19 pandemic, focus on the value of averting deaths and do not include the value of averting nonfatal illnesses. Yet, incorporating the value of averting nonfatal cases may change conclusions about the desirability of the policy. While per case values may be small, the number of nonfatal cases is often large, far outstripping the number of fatal cases. The value of averting nonfatal cases is also increasingly important in evaluating COVID-19 policy options as vaccine- and infection-related immunity and treatments reduce the case-fatality rate. Unfortunately, little valuation research is available that explicitly addresses COVID-19 morbidity. We describe and implement an approach for approximating the value of averting nonfatal illnesses or injuries and apply it to COVID-19 in the USA. We estimate gains from averting COVID-19 morbidity of about 0.01 quality-adjusted life year (QALY) per mild case averted, 0.02 QALY per severe case, and 3.15 QALYs per critical case. These gains translate into monetary values of about $5300 per mild case, $11,000 per severe case, and $1.8 million per critical case. While these estimates are imprecise, they suggest the magnitude of the effects.

Six field experiments were conducted to investigate any interaction between pyroxasulfone and flumioxazin on soybean tolerance and control of multiple-herbicide-resistant (MHR) waterhemp in soybean during 2016 and 2017 in Ontario, Canada. There was a synergistic increase in soybean injury with the co-application of pyroxasulfone and flumioxazin at all rates evaluated at 2 wk after emergence (WAE), the two highest rates evaluated (134/106 and 268/211 g ai ha–1) at 4 WAE, and the highest rate (268/211 g ai ha–1) evaluated at 8 WAE. Soybean injury with all pyroxasulfone and flumioxazin treatments was transient and had no adverse effect on soybean grain yield. Pyroxasulfone applied preemergence at 45, 89, 134, and 268 g ai ha–1 controlled MHR waterhemp up to 72%, 89%, 92%, and 95%, respectively. Flumioxazin applied preemergence at 35, 70, 106, and 211 g ai ha–1 controlled MHR waterhemp up to 78%, 90%, 93%, and 96%, respectively. Pyroxasulfone/flumioxazin applied preemergence at 45/35, 89/70, 134/106, and 268/211 g ai ha–1 controlled MHR waterhemp up to 92%, 96%, 98%, and 100%, respectively. There were no significant antagonistic or synergistic interactions for the control of MHR waterhemp with pyroxasulfone/flumioxazin at rates evaluated except at 268/211 g ai ha–1, which provided a synergistic increase in MHR waterhemp control at 4 WAE. The MHR waterhemp biomass and density reductions followed a trend similar trend to visible control. Pyroxasulfone/flumioxazin at 268/211 g ai ha–1 caused a synergistic response in biomass reduction (9% difference). Based on these results, there is an additive increase in MHR waterhemp control and potential for a synergistic increase in soybean injury with the co-application of pyroxasulfone plus flumioxazin.

From 2014 to 2020, we compiled radiocarbon ages from the lower 48 states, creating a database of more than 100,000 archaeological, geological, and paleontological ages that will be freely available to researchers through the Canadian Archaeological Radiocarbon Database. Here, we discuss the process used to compile ages, general characteristics of the database, and lessons learned from this exercise in “big data” compilation.

Two studies were conducted to ascertain the biologically effective dose (BED) of flumioxazin and pyroxasulfone for multiple herbicide–resistant (MHR) waterhemp [Amaranthus tuberculatus (Moq.) Sauer] control in soybean [Glycine max (L.) Merr.] in southwestern Ontario, Canada, during 2016 and 2017. In the flumioxazin study, the predicted flumioxazin doses for 50%, 80%, and 90% MHR A. tuberculatus control were 19, 37, and 59 g ai ha−1 at 2 wk after application (WAA) and 31, 83, and 151 g ai ha−1, respectively, at 12 WAA. The predicted flumioxazin doses to cause 5% and 10% soybean injury were 129 and 404 g ai ha−1, respectively, at 2 wk after emergence (WAE), and the predicted flumioxazin doses to obtain 50%, 80%, and 95% of the weed-free control plot’s yield were determined to be 3, 14, and 65 g ai ha−1, respectively. In the pyroxasulfone study, the predicted pyroxasulfone doses that provided 50%, 80%, and 90% MHR A. tuberculatus visible control were 25, 50, and 88 g ai ha−1 at 2 WAA and 41, 109, and 274 g ai ha−1 at 12 WAA, respectively. The dose of pyroxasulfone predicted for 80% reduction in MHR A. tuberculatus density was 117 g ai ha−1, and the doses of pyroxasulfone predicted for 80% and 90% reduction in A. tuberculatus biomass were 204 and 382 g ai ha−1, respectively. The predicted doses of pyroxasulfone that caused 5% and 10% injury in soybean at 2 WAE were 585 and 698 g ai ha−1, respectively. The predicted doses of pyroxasulfone required to obtain 50%, 80%, and 95% yield relative to the weed-free plots were 6, 24, and 112 g ai ha−1, respectively. Flumioxazin and pyroxasulfone applied preemergence at the appropriate doses provided early-season MHR A. tuberculatus control in soybean.

The income elasticity of the value per statistical life (VSL) is an important parameter for policy analysis. Mortality risk reductions often dominate the quantified benefits of environmental and other policies, and estimates of their value are frequently transferred across countries with significantly different income levels. U.S. regulatory agencies typically assume that a 1.0 percent change in real income over time will lead to a 0.4 to 0.6 percent change in the VSL. While elasticities within this range are supported by substantial research, they appear nonsensical if applied to populations with significantly smaller incomes. When transferring values between high and lower income countries, analysts often instead assume an elasticity of 1.0, but the resulting VSL estimates appear large in comparison to income. Elasticities greater than 1.0 are supported by research on the relationship between long-term economic growth and the VSL, by cross-country comparisons, and by new research that estimates the VSL by income quantile. Caution is needed when applying these higher elasticities, however, because the resulting VSLs appear smaller than expected future earnings or consumption in some cases, contrary to theory. In addition to indicating the need for more research, this comparison suggests that, in the interim, VSL estimates should be bounded below by estimates of future income or consumption.

Existing theories of democratic reversals emphasize that elites mount actions like coups when democracy is particularly threatening to their interests. However, existing theory has been largely silent on the role of elite social networks, which interact with economic incentives and may facilitate antidemocratic collective action. We develop a model where coups generate rents for elites and show that the effort an elite puts into a coup is increasing in their network centrality. We empirically explore the model using an original dataset of Haitian elite networks that we linked to firm-level data. We show that central families were more likely to be accused of participating in the 1991 coup against the democratic Aristide government. We then find that the retail prices of staple goods that are imported by such elites differentially increase during subsequent periods of nondemocracy. Our results suggest that elite social structure is an important factor in democratic reversals.

In April 2019, the U.S. Fish and Wildlife Service (USFWS) released its recovery plan for the jaguar Panthera onca after several decades of discussion, litigation and controversy about the status of the species in the USA. The USFWS estimated that potential habitat, south of the Interstate-10 highway in Arizona and New Mexico, had a carrying capacity of c. six jaguars, and so focused its recovery programme on areas south of the USA–Mexico border. Here we present a systematic review of the modelling and assessment efforts over the last 25 years, with a focus on areas north of Interstate-10 in Arizona and New Mexico, outside the recovery unit considered by the USFWS. Despite differences in data inputs, methods, and analytical extent, the nine previous studies found support for potential suitable jaguar habitat in the central mountain ranges of Arizona and New Mexico. Applying slightly modified versions of the USFWS model and recalculating an Arizona-focused model over both states provided additional confirmation. Extending the area of consideration also substantially raised the carrying capacity of habitats in Arizona and New Mexico, from six to 90 or 151 adult jaguars, using the modified USFWS models. This review demonstrates the crucial ways in which choosing the extent of analysis influences the conclusions of a conservation plan. More importantly, it opens a new opportunity for jaguar conservation in North America that could help address threats from habitat losses, climate change and border infrastructure.

It is a cliché of self-help advice that there are no problems, only opportunities. The rationale and actions of the BSHS in creating its Global Digital History of Science Festival may be a rare genuine confirmation of this mantra. The global COVID-19 pandemic of 2020 meant that the society's usual annual conference – like everyone else's – had to be cancelled. Once the society decided to go digital, we had a hundred days to organize and deliver our first online festival. In the hope that this will help, inspire and warn colleagues around the world who are also trying to move online, we here detail the considerations, conversations and thinking behind the organizing team's decisions.

Can multicellular life be distinguished from single cellular life on an exoplanet? We hypothesize that abundant upright photosynthetic multicellular life (trees) will cast shadows at high sun angles that will distinguish them from single cellular life and test this using Earth as an exoplanet. We first test the concept using unmanned aerial vehicles at a replica moon-landing site near Flagstaff, Arizona and show trees have both a distinctive reflectance signature (red edge) and geometric signature (shadows at high sun angles) that can distinguish them from replica moon craters. Next, we calculate reflectance signatures for Earth at several phase angles with POLDER (Polarization and Directionality of Earth's reflectance) satellite directional reflectance measurements and then reduce Earth to a single pixel. We compare Earth to other planetary bodies (Mars, the Moon, Venus and Uranus) and hypothesize that Earth's directional reflectance will be between strongly backscattering rocky bodies with no weathering (like Mars and the Moon) and cloudy bodies with more isotropic scattering (like Venus and Uranus). Our modelling results put Earth in line with strongly backscattering Mars, while our empirical results put Earth in line with more isotropic scattering Venus. We identify potential weaknesses in both the modelled and empirical results and suggest additional steps to determine whether this technique could distinguish upright multicellular life on exoplanets.

Distinguished Oral

Background: Shared Healthcare Intervention to Eliminate Life-threatening Dissemination of MDROs in Orange County, California (SHIELD OC) was a CDC-funded regional decolonization intervention from April 2017 through July 2019 involving 38 hospitals, nursing homes (NHs), and long-term acute-care hospitals (LTACHs) to reduce MDROs. Decolonization in NH and LTACHs consisted of universal antiseptic bathing with chlorhexidine (CHG) for routine bathing and showering plus nasal iodophor decolonization (Monday through Friday, twice daily every other week). Hospitals used universal CHG in ICUs and provided daily CHG and nasal iodophor to patients in contact precautions. We sought to evaluate whether decolonization reduced hospitalization and associated healthcare costs due to infections among residents of NHs participating in SHIELD compared to nonparticipating NHs. Methods: Medicaid insurer data covering NH residents in Orange County were used to calculate hospitalization rates due to a primary diagnosis of infection (counts per member quarter), hospital bed days/member-quarter, and expenditures/member quarter from the fourth quarter of 2015 to the second quarter of 2019. We used a time-series design and a segmented regression analysis to evaluate changes attributable to the SHIELD OC intervention among participating and nonparticipating NHs. Results: Across the SHIELD OC intervention period, intervention NHs experienced a 44% decrease in hospitalization rates, a 43% decrease in hospital bed days, and a 53% decrease in Medicaid expenditures when comparing the last quarter of the intervention to the baseline period (Fig. 1). These data translated to a significant downward slope, with a reduction of 4% per quarter in hospital admissions due to infection (P < .001), a reduction of 7% per quarter in hospitalization days due to infection (P < .001), and a reduction of 9% per quarter in Medicaid expenditures (P = .019) per NH resident. Conclusions: The universal CHG bathing and nasal decolonization intervention adopted by NHs in the SHIELD OC collaborative resulted in large, meaningful reductions in hospitalization events, hospitalization days, and healthcare expenditures among Medicaid-insured NH residents. The findings led CalOptima, the Medicaid provider in Orange County, California, to launch an NH incentive program that provides dedicated training and covers the cost of CHG and nasal iodophor for OC NHs that enroll.

Funding: None

Disclosures: Gabrielle M. Gussin, University of California, Irvine, Stryker (Sage Products): Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes. Clorox: Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes. Medline: Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes. Xttrium: Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes.

Background: Suspicion of urinary tract infection (UTI) is the most common justification for prescribing antibiotics in nursing homes. More than half of antibiotic prescriptions for treatment of UTI in nursing homes are either unnecessary or inappropriate. Achieving a better understanding of the factors that underlie UTI treatment decisions is necessary to improve the quality of antibiotic prescribing in nursing homes. An ongoing hybrid type 2 effectiveness-implementation cluster randomized trial of a recently developed nursing home UTI recognition and management tool kit provided us with an opportunity to explore the influence of organizational, clinical, and staff attributes on UTI antibiotic prescribing practices in nursing homes. Methods: Data on antibiotic starts for suspected UTIs were collected in 29 nursing homes over a 9-month period. Antibiotic practices evaluated included total antibiotic starts per 1,000 resident days, % antibiotic starts with treatment duration >7 days, % antibiotic starts in which the initial antibiotic choice was a fluoroquinolone, and % antibiotic starts meeting UTI tool-kit criteria of appropriateness. Prior research and bivariate analyses were used to select clinical and organizational attributes as well as individual nursing staff-level retention rates for inclusion in a stepwise linear regression model for each antibiotic practice outcome. Results: In total, 602 UTI antibiotic events were evaluated. Four associations were identified for antibiotic starts including nursing home urine culture rate, ICP status, nonprofit and part-time LPN retention. Nursing homes with higher full-time LPN retention had a lower rate of antibiotic treatment duration >7 days. Full-time CNAs and part-time LPNs retention and for-profit status was associated with the proportion of fluoroquinolone antibiotic starts. No attributes influenced the proportion of antibiotic starts meeting appropriateness criteria (Fig. 1). Urine culture rates are driving overall nursing home antibiotic prescribing. Conclusions: Urine culture practices was strongly associated with UTI treatment rates in nursing homes. A variety of organizational characteristics were also associated with UTI treatment rates as well as other UTI antibiotic prescribing practices. Some of these associations appear paradoxical but may reflect increasing resident acuity and increased capacity to standardize practices through organizational centralization.

Funding: Support for the project provided by the Wisconsin Partnership Program.

Disclosures: None