IMPORTANCE Financial integration between physicians and hospitals may help health care provider organizations meet the challenges of new payment models but also may enhance the bargaining power of provider organizations, leading to higher prices and spending in commercial health care markets. OBJECTIVE To assess the association between recent increases in physician-hospital integration and changes in spending and prices for outpatient and inpatient services. DESIGN, SETTING, AND PARTICIPANTS Using regression analysis, we estimated the relationship between changes in physician-hospital integration from January 1, 2008, through December 31, 2012, in 240 metropolitan statistical areas (MSAs) and concurrent changes in spending. Adjustments were made for patient, plan, and market characteristics, including physician, hospital, and insurer market concentration. The study population included a cohort of 7 391 335 nonelderly enrollees in preferred-provider organizations or point-of-service plans included in the Truven Health MarketScan Commercial Database during the study period.

IMPORTANCE There is increasing interest in using price transparency tools to decrease health care spending. OBJECTIVE To measure the association between offering a health care price transparency tool and outpatient spending. DESIGN, SETTING, AND PARTICIPANTS Two large employers represented in multiple market areas across the United States offered an online health care price transparency tool to their employees. One introduced it on April 1, 2011, and the other on January 1, 2012. The tool provided users information about what they would pay out of pocket for services from different physicians, hospitals, or other clinical sites. Using a matched difference-indifferences design, outpatient spending among employees offered the tool (n=148 655) was compared with that among employees from other companies not offered the tool (n=295 983) in the year before and after it was introduced. EXPOSURE Availability of a price transparency tool. MAIN OUTCOMES AND MEASURES Annual outpatient spending, outpatient out-of-pocket spending, use rates of the tool.

Insurers, employers, and states increasingly encourage price transparency so that patients can compare health care prices across providers. However, the evidence on whether price transparency tools encourage patients to receive lower-cost care and reduce overall spending remains limited and mixed. We examined the experience of a large insured population that was offered a price transparency tool, focusing on a set of "shoppable" services (lab tests, office visits, and advanced imaging services). Overall, offering the tool was not associated with lower shoppable services spending. Only 12 percent of employees who were offered the tool used it in the first fifteen months after it was introduced, and use of the tool was not associated with lower prices for lab tests or office visits. The average price paid for imaging services preceded by a price search was 14 percent lower than that paid for imaging services not preceded by a price search. However, only 1 percent of those who received advanced imaging conducted a price search. Simply offering a price transparency tool is not sufficient to meaningfully decrease health care prices or spending.

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Prior research has suggested that children living in a disadvantaged neighborhood have lower achievement test scores, but these studies typically have not estimated causal effects that account for neighborhood choice. Recent studies used propensity score methods to account for the endogeneity of neighborhood exposures, comparing disadvantaged and nondisadvantaged neighborhoods. We develop an alternative propensity function approach in which cumulative neighborhood effects are modeled as a continuous treatment variable. This approach offers several advantages. We use our approach to examine the cumulative effects of neighborhood disadvantage on reading and math test scores in Los Angeles. Our substantive results indicate that recency of exposure to disadvantaged neighborhoods may be more important than average exposure for children's test scores. We conclude that studies of child development should consider both average cumulative neighborhood exposure and the timing of this exposure.

Purpose Social environment and family context exert substantial influence on adolescent sexual behaviors. These influences are especially important to examine in countries undergoing rapid demographic and social change. This study employs unique, intergenerational and longitudinal data (1998–2009) to examine the effects of parental, peer, and household influences on sexual initiation among young adults in Cebu, Philippines. Methods Intergenerational and longitudinal cohort data from the 1998 Cebu Longitudinal Health and Nutrition Survey (CLHNS) are analyzed to examine the effects of household, peer, family, and young adults’ sexual attitudes on age at first sex by 2009 among young men and women. Gender-stratified Cox proportional hazards models and Cox regression models are used to model time to first sex. Results Household, family, peer, and individual characteristics have disparate influences on sexual initiation among Filipino boys and girls. Boys’ sexual initiation was positively associated with urbanicity, household wealth, and the presence of a family member working abroad, whereas for girls, these variables had no significant effects. Unique effects were also found for girls - mother’s education was negatively associated, and girls’ number of siblings was positively associated, with higher hazards of sex. Additionally, the effects of some variables on the occurrence of first sex differed across time, indicating that boys and girls may be differentially influenced by contextual characteristics across adolescence. Conclusions Amid substantial sociodemographic changes and persistence of traditional gender norms, this study highlights the importance of examining the unique influences and intersections of gender and context on sexual initiation in the Philippines.

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Habitat fragmentation can alter the trophic structure of communities and environmental conditions, thus driving changes in biodiversity and ecosystem functions. Quantifying niches of generalist predators can reveal how fragmentation alters ecosystems. In a habitat fragmentation experiment, we used stable isotopes of a generalist predator skink to test predictions from spatial theory on trophic structure and to quantify abiotic changes associated with fragmentation among continuous forest, fragments, and matrix habitats. We predicted that in fragments and the matrix, isotopic niches would shift due to decreases in skink trophic positions (δ15N) from reductions in trophic structure of arthropod food webs and abiotic changes over time (δ13C) relative to continuous forest. Contrary to theoretical predictions, we did not find evidence of reductions in trophic structure with fragmentation. In fact, skink δ15N values were higher in the matrix and fragments than continuous forest, likely due to changes in distributions of a detritivorous prey species. In addition, δ13C values in the matrix decreased over years since fragmentation due to abiotic changes associated with matrix tree maturation. We show how isotopic niches are influenced by fragmentation via shifts in biotic and abiotic processes. The potential for either or both spatial and abiotic effects of fragmentation present a challenge for theory to better predict ecological changes in fragmented landscapes.