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Risk-sharing agreements have been suggested as a tool to accelerate access to new innovative medicines by reducing risk for the stakeholders. Especially uncertainty in clinical effectiveness, safety and financial consequences for patients and buyers are aimed at being reduced. This article outlines the concept, a terminology and advantages and disadvantages of the agreements. We argue that all risk-sharing agreements involve both advantages and disadvantages among relevant stakeholders.

How do insurance firms respond to financial risk sharing regulations? Evidence from the Affordable Care Act

Many insurance markets have reinstated premium stabilization programs to ensure financial protection from market volatility. In this paper, we focus on one such regulation-risk corridors (RCs)-in the context of the Health Insurance Marketplaces established under the Affordable Care Act. We develop a model to show how the program provided incentives for some insurers to lower their premiums. The RCs program was defunded unexpectedly for coverage year 2016, before its legislated end in 2016. Consistent with the model, we find that making a RCs claim before the program ended is associated with higher premium growth after the program's demise. The model and empirical evidence are consistent with the view that the end of the RCs program contributed to premium growth in the Marketplaces.

Performance-Based Risk-Sharing Arrangements (PBRSA): Is it a Solution to Increase Bang for the Buck for Pharmaceutical Reimbursement Strategy for Our Nation and Around the World?

Due to the risks involved in not achieving desired health outcomes for the dollar spent on drugs, healthcare decision makers, including payers, providers, drug manufacturers, and patients, need a mechanism to share this financial risk among the involved parties. Performance-based risk-sharing arrangements (PBRSAs) are agreements that can potentially reduce the ‘drug lag’ in which patients wait for an unknown amount of time until a particular drug is covered under their health plan. In addition, PBRSAs can mitigate the risk of investing heavily in drugs that are ineffective or do not deliver good value or “bang for the buck”. This review describes and evaluates PBRSAs for drugs in the USA and juxtaposes to other developed nations (i.e. Germany) that adopted PBRSAs in their healthcare model. There are different types of outcomes-based health schemes, namely conditional coverage, which can be further broken down into coverage with evidence development (CED), conditional treatment continuation (CTC), and performance-linked reimbursement, which includes outcomes guarantees. Both CED and CTC are ‘conditional’ on the collected evidence of the new drug’s effectiveness, offering discount only if the drug delivers desirable results. The outcomes guarantee scheme offers discount or even a full refund if the outcome is less than expected, forcing the drug to meet the expected effectiveness. The USA can follow the German reference pricing model in which the assessment of new drugs is centralized and done collectively by representatives from a group of healthcare decision makers. In any shape or form, PBRSA is a clever mechanism to cope with uncertainty if drug price is scaled appropriately based on value.

The Use of Risk-Sharing Contracts in Healthcare: Theoretical and Empirical Assessments

OBJECTIVE

The aim of this review is to provide a summary of the literature on risk-sharing agreements, including conceptual, theoretical and empirical (number of agreements and their achievements) perspectives, and stakeholders'  perceptions.

METHODS

We conducted a systematic literature search in MEDLINE from 2000 to April 2019, following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology, and completed it with a manual search of other publications (mainly grey literature). The search was restricted to publications with English abstracts; the initial identification of articles was restricted to the title, abstract and key words fields. The geographical scope was not restricted.

RESULTS

Over 20 studies proposed different taxonomies of risk-sharing contracts, which can be summarised as financial and paying-for-performance agreements. Theoretical studies modelling the incentives to implement risk-sharing agreements are scarce; they addressed different types of contracts and regulatory contexts, characterizing the drug prices and the optimal strategies of the involved agents. Empirical studies describing specific agreements are abundant and referred to different geographical contexts; however, few articles showed the economic results and assessed the value of such contracts. Stakeholders' perceptions of risk-sharing contracting were favourable, but little is known about the economic and clinical advantages of specific agreements. Whether risk-sharing contracts have yielded the desired results for healthcare systems remains uncertain.

CONCLUSION

Risk-sharing contracts are increasingly used, although the lack of transparency and aggregated registries makes it difficult to learn from these experiences and assess their impact on healthcare systems.

Intervention on default contagion under partial information in a financial network

We study the optimal interventions of a regulator (a central bank or government) on the illiquidity default contagion process in a large, heterogeneous, unsecured interbank lending market. The regulator has only partial information on the interbank connections and aims to minimize the fraction of final defaults with minimal interventions. We derive the analytical results of the asymptotic optimal intervention policy and the asymptotic magnitude of default contagion in terms of the network characteristics. We extend the results of Amini, Cont and Minca’s work to incorporate interventions and adopt the dynamics of Amini, Minca and Sulem’s model to build heterogeneous networks with degree sequences and initial equity levels drawn from arbitrary distributions. Our results generate insights that the optimal intervention policy is “monotonic” in terms of the intervention cost, the closeness to invulnerability and connectivity. The regulator should prioritize interventions on banks that are systematically important or close to invulnerability. Moreover, the regulator should keep intervening on a bank once having intervened on it. Our simulation results show a good agreement with the theoretical results.

Expanding Enrollment Without the Individual Mandate: Options to Bring More People into the Individual Market

ISSUE

Recent changes to the Affordable Care Act, including elimination of the individual mandate penalty, the halting of federal payments for cost-sharing reductions, and expanded access to short-term plans, may reduce enrollment in the individual market.

GOAL

Analyze options to increase enrollment, accounting for recent policy changes.

METHODS

RAND’s COMPARE microsimulation model is used to analyze six policies that would expand access to tax credits, increase their generosity, and fund a reinsurance program.

KEY FINDINGS AND CONCLUSIONS

The options would increase individual market enrollment by 400,000 to 3.2 million in 2020. Net increases in total enrollment (300,000 to 2.4 million) are smaller because of offsetting decreases in employer-sponsored insurance. The largest gains are possible through two options: large-scale investment in reinsurance, and extension of tax credits to higher-income people combined with increases in the generosity of existing tax credits. If funded through a fee on health plans, reinsurance could be implemented without increasing the federal deficit. Additional taxpayer costs would increase by $1 billion to $23 billion, depending on the policy. While enhanced tax credits for young adults would lead to small coverage gains, they would entail the lowest costs to taxpayers among the six options.

Implementation of a Market Entry Reward within the United States

As part of a multifactorial approach to address weak incentives for innovative antimicrobial drug development, market entry rewards (MERs) are an emerging solution. Recently, the Duke-Margolis Center for Health Policy released the Priority Antimicrobial Value and Entry (PAVE) Award proposal, which combines a MER with payment reforms, transitioning from volume-based to "value-based" payments for antimicrobials. Here, the PAVE Award and similar MERs are reviewed, focusing on further refinement and avenues for implementation.

Encouraging Sustainable Use of Antibiotics: A Commentary on the DRIVE-AB Recommended Innovation Incentives

The ability to sustain antibiotic efficacy is directly affected by incentive models aiming to stimulate antibiotic research and development. This paper analyzes the extent to which the models proposed by the Innovative Medicine Initiative-funded research project DRIVE-AB can be expected to support sustainable use, drawing on basic economic theory and the incentives that derive from it. It then discusses the use of minimal safeguards that will be needed to support sustainable use where industry incentives have not been re-aligned with those of public health.

A Perspective on Incentives for Novel Inpatient Antibiotics: No One-Size-Fits-All

The need for new "pull" incentives to stimulate antibiotic R&D is widely recognized. Due to the global diversity of health systems, combined with different challenges faced by antibiotics used in different types of healthcare settings, there is no one-size-fits-all solution. Instead, different "pull" incentives should be tailored to local contexts, priorities, and antibiotic types. Policymakers and industry should collaborate to identify appropriate solutions at the local, regional, and global levels.

Harvard Pilgrim's Patrick Cahill Tries To Make Sense of It All

The 40-year-old vice president of regional markets for eastern Massachusetts wants enrollees and, especially, employers to know that there will continue to be a lot of public policy change as the ACA evolves. His course? Keep strengthening ties with providers.

New Hampshire Nurse Practitioners Take the Lead in Forming an Accountable Care Organization

In 2012, New Hampshire nurse practitioners (NPs), along with Anthem Blue Cross/Blue Shield, formed the first Patient Centered Shared Savings Program in the nation, composed of patients managed by nurse practitioners employed within NP-owned and operated clinics. In this accountable care organization (ACO), NP-attributed patients were grouped into one risk pool. Data from the ACO and the NP risk pool, now in its third year, have produced compelling statistics. Nurse practitioners participating in this program have met or exceeded the minimum scores for 29 quality metrics along with a demonstrated cost-savings in the first 2 years of the program. Hospitalization rates for NP-managed patients are among the lowest in the state. Cost of care for NP-managed patients is $66.85 less per member per month than the participating physician-managed patients. Data from this ACO provide evidence that NPs provide cost-effective, quality health care and are integral to the formation and sustainability of any ACO.

Sustainable Financing of Innovative Therapies: A Review of Approaches

The process of innovation is inherently complex, and it occurs within an even more complex institutional environment characterized by incomplete information, market power, and externalities. There are therefore different competing approaches to supporting and financing innovation in medical technologies, which bring their own advantages and disadvantages. This article reviews value- and cost-based pricing, as well direct government funding, and cross-cutting institutional structures. It argues that performance-based risk-sharing agreements are likely to have little effect on the sustainability of financing; that there is a role for cost-based pricing models in some situations; and that the push towards longer exclusivity periods is likely contrary to the interests of industry.

Achieving Mental Health Care Parity Might Require Changes In Payments And Competition

One of the most prominent features of the Affordable Care Act has been the promotion of individual health plans chosen by consumers in the Marketplaces. These plans are subject to regulation and paid by risk-adjusted capitation, a set of policies known as managed competition. Individual health insurance markets, however, are vulnerable to what economists describe as efficiency problems stemming from adverse selection, and Marketplaces are no exception. Health plans have incentives to discriminate against services used by people with certain chronic illnesses, including mental health conditions. Parity regulations, which dictate coverage for mental health benefits on par with medical and surgical benefits, can eliminate discrimination in coverage but redirect discrimination toward hard-to-regulate tactics from managed care such as restrictive network design and provider payment. This article reviews policy options to contend with ongoing selection issues. "Better enforcement" of parity has less chance of success than more fundamental but feasible changes in the way plans are paid or in the way competition among plans is structured.

Medicare Part D and Portfolio Choice

This study evaluates the impact of medical expenditure risk on portfolio choice among the elderly. The risk of large medical expenditures can be substantial for elderly individuals and is only partially mitigated by access to health insurance. The presence of deductibles, copayments, and other cost-sharing mechanisms implies that medical spending risk can be viewed as an undiversifiable background risk. Economic theory suggests that increases in background risk reduce the optimal financial risk that an individual or household is willing to bear (Pratt and Zeckhauser 1987; Elmendorf and Kimball 2000). In this study, we evaluate this hypothesis by estimating the impact of the introduction of the Medicare Part D program, which significantly reduced prescription drug spending risk for seniors, on portfolio choice.

Curing an ill healthcare system: transparent multilateral benefits, cost, and quality

A transparent, smart, multilateral benefits system can lead the way to healthcare reform with health and economic benefits for all based on: Provider competition guided by quality measurements, clinical nuance, and price competition. Shared risk among consumers, employers, and plans. Economic incentives for all parties.

The New Jersey Medicaid ACO Demonstration Project: seeking opportunities for better care and lower costs among complex low-income patients

A small but growing number of states are turning to accountable care concepts to improve their Medicaid programs. In 2011 New Jersey enacted the Medicaid Accountable Care Organization (ACO) Demonstration Project to offer local provider coalitions the opportunity to share any savings they generate. Impetus came from initiatives in Camden that aim to reduce costs through improved care coordination among hospital high users and that have received considerable media attention and substantial federal and private grant support. Though broadly similar to Medicare and commercial ACOs, the New Jersey demonstration addresses the unique concerns faced by Medicaid populations. Using hospital all-payer billing data, we estimate savings from care improvement efforts among inpatient and emergency department high users in thirteen communities that are candidates for participation in the New Jersey demonstration. We also examine their characteristics to inform Medicaid accountable care strategies. We find substantial variation in the share of high-user hospital patients across the study communities and high rates of avoidable use and costs among these patients. The potential savings among Medicaid enrollees are considerable, particularly if Medicaid ACOs can develop ways to successfully address the high burden of chronic illness and behavioral health conditions prevalent in the prospective demonstration communities.

Facilitating the formation of accountable care organizations in rural areas

This Policy Brief presents characteristics contributing to the formation of four accountable care organizations (ACOs) that serve rural Medicare beneficiaries. Doing so provides considerations for provider organizations contemplating creating rural-based ACOs. Key Findings. (1) Previous organizational integration and risk-sharing experience facilitated ACO formation. (2) Use of an electronic health record system fostered core ACO capabilities, including care coordination and population health management. (3) Partnerships across the care continuum supported utilization of local health care resources.

UK multiple sclerosis risk-sharing scheme: a new natural history dataset and an improved Markov model

OBJECTIVES

In 2002, the UK's National Institute for Health and Care Excellence concluded that the multiple sclerosis (MS) disease modifying therapies; interferon-β and glatiramer acetate, were not cost effective over the short term but recognised that reducing disability over the longer term might dramatically improve the cost effectiveness. The UK Risk-sharing Scheme (RSS) was established to ensure cost-effective provision by prospectively collecting disability-related data from UK-treated patients with MS and comparing findings to a natural history (untreated) cohort. However, deficiencies were found in the originally selected untreated cohort and the resulting analytical approach. This study aims to identify a more suitable natural history cohort and to develop a robust analytical approach using the new cohort.

DESIGN

The Scientific Advisory Group, recommended the British Columbia Multiple Sclerosis (BCMS) database, Canada, as providing a more suitable natural history comparator cohort. Transition probabilities were derived and different Markov models (discrete and continuous) with and without baseline covariates were applied.

SETTING

MS clinics in Canada and the UK.

PARTICIPANTS

From the BCMS database, 898 'untreated' patients with MS considered eligible for drug treatment based on the UK's Association of British Neurologists criteria.

OUTCOME MEASURE

The predicted Expanded Disability Status Scale (EDSS) score was collected and assessed for goodness of fit when compared with actual outcome.

RESULTS

The BCMS untreated cohort contributed 7335 EDSS scores over a median 6.4 years (6357 EDSS 'transitions' recorded at consecutive visits) during the period 1980-1995. A continuous Markov model with 'onset age' as a binary covariate was deemed the most suitable model for future RSS analysis.

CONCLUSIONS

A new untreated MS cohort from British Columbia has been selected and will be modelled using a continuous Markov model with onset age as a baseline covariate. This approach will now be applied to the treated UK RSS MS cohort for future price adjustment calculations.

In the mind of the market: theory of mind biases value computation during financial bubbles

The ability to infer intentions of other agents, called theory of mind (ToM), confers strong advantages for individuals in social situations. Here, we show that ToM can also be maladaptive when people interact with complex modern institutions like financial markets. We tested participants who were investing in an experimental bubble market, a situation in which the price of an asset is much higher than its underlying fundamental value. We describe a mechanism by which social signals computed in the dorsomedial prefrontal cortex affect value computations in ventromedial prefrontal cortex, thereby increasing an individual's propensity to 'ride' financial bubbles and lose money. These regions compute a financial metric that signals variations in order flow intensity, prompting inference about other traders' intentions. Our results suggest that incorporating inferences about the intentions of others when making value judgments in a complex financial market could lead to the formation of market bubbles.

Promoting universal financial protection: evidence from seven low- and middle-income countries on factors facilitating or hindering progress

Although universal health coverage (UHC) is a global health policy priority, there remains limited evidence on UHC reforms in low- and middle-income countries (LMICs). This paper provides an overview of key insights from case studies in this thematic series, undertaken in seven LMICs (Costa Rica, Georgia, India, Malawi, Nigeria, Tanzania, and Thailand) at very different stages in the transition to UHC.These studies highlight the importance of increasing pre-payment funding through tax funding and sometimes mandatory insurance contributions when trying to improve financial protection by reducing out-of-pocket payments. Increased tax funding is particularly important if efforts are being made to extend financial protection to those outside formal-sector employment, raising questions about the value of pursuing contributory insurance schemes for this group. The prioritisation of insurance scheme coverage for civil servants in the first instance in some LMICs also raises questions about the most appropriate use of limited government funds.The diverse reforms in these countries provide some insights into experiences with policies targeted at the poor compared with universalist reform approaches. Countries that have made the greatest progress to UHC, such as Costa Rica and Thailand, made an explicit commitment to ensuring financial protection and access to needed care for the entire population as soon as possible, while this was not necessarily the case in countries adopting targeted reforms. There also tends to be less fragmentation in funding pools in countries adopting a universalist rather than targeting approach. Apart from limiting cross-subsidies, fragmentation of pools has contributed to differential benefit packages, leading to inequities in access to needed care and financial protection across population groups; once such differentials are entrenched, they are difficult to overcome. Capacity constraints, particularly in purchasing organisations, are a pervasive problem in LMICs. The case studies also highlighted the critical role of high-level political leadership in pursuing UHC policies and citizen support in sustaining these policies.This series demonstrates the value of promoting greater sharing of experiences on UHC reforms across LMICs. It also identifies key areas of future research on health care financing in LMICs that would support progress towards UHC.

Risk bearing and use of fee-for-service billing among accountable care organizations

OBJECTIVES

To determine the willingness of accountable care organizations (ACOs) to bear financial risk for the healthcare they provide.

DESIGN AND METHODS

Structured interviews conducted between January and June 2012 with 57 ACOs led by hospitals and physician groups located throughout the United States. Findings are based on the 38 ACOs that were actively providing care under an ACO payment arrangement at the time of the interview.

RESULTS

Among these ACOs, 71% cover a portion of their ACO population with contracts that put the ACOs at some financial risk, while 45% have risk-based contracts for their entire ACO population. Payments based on fee-for-service (FFS) billing still dominate, as 92% of ACOs use FFS-based billing for at least a portion of their ACO population and 71% are fully reimbursed using FFS-based billing.

CONCLUSIONS

Under the auspices of an ACO, providers are accepting some financial risk for their accountable care patient population. There is still strong reliance on FFS-based billing methods as providers experiment with different payment models.

Optimal global value of information trials: better aligning manufacturer and decision maker interests and enabling feasible risk sharing

Risk sharing arrangements relate to adjusting payments for new health technologies given evidence of their performance over time. Such arrangements rely on prospective information regarding the incremental net benefit of the new technology, and its use in practice. However, once the new technology has been adopted in a particular jurisdiction, randomized clinical trials within that jurisdiction are likely to be infeasible and unethical in the cases where they would be most helpful, i.e. with current evidence of positive while uncertain incremental health and net monetary benefit. Informed patients in these cases would likely be reluctant to participate in a trial, preferring instead to receive the new technology with certainty. Consequently, informing risk sharing arrangements within a jurisdiction is problematic given the infeasibility of collecting prospective trial data. To overcome such problems, we demonstrate that global trials facilitate trialling post adoption, leading to more complete and robust risk sharing arrangements that mitigate the impact of costs of reversal on expected value of information in jurisdictions who adopt while a global trial is undertaken. More generally, optimally designed global trials offer distinct advantages over locally optimal solutions for decision makers and manufacturers alike: avoiding opportunity costs of delay in jurisdictions that adopt; overcoming barriers to evidence collection; and improving levels of expected implementation. Further, the greater strength and translatability of evidence across jurisdictions inherent in optimal global trial design reduces barriers to translation across jurisdictions characteristic of local trials. Consequently, efficiently designed global trials better align the interests of decision makers and manufacturers, increasing the feasibility of risk sharing and the expected strength of evidence over local trials, up until the point that current evidence is globally sufficient.

Bankruptcy cascades in interbank markets

We study a credit network and, in particular, an interbank system with an agent-based model. To understand the relationship between business cycles and cascades of bankruptcies, we model a three-sector economy with goods, credit and interbank market. In the interbank market, the participating banks share the risk of bad debits, which may potentially spread a bank's liquidity problems through the network of banks. Our agent-based model sheds light on the correlation between bankruptcy cascades and the endogenous economic cycle of booms and recessions. It also demonstrates the serious trade-off between, on the one hand, reducing risks of individual banks by sharing them and, on the other hand, creating systemic risks through credit-related interlinkages of banks. As a result of our study, the dynamics underlying the meltdown of financial markets in 2008 becomes much better understandable.

[Risk-sharing scheme in Israel--Kuvan as an allegory]

Healthcare systems worldwide are dealing with the uncertainty characterizing new and expensive health technoLogies, particularly aspects involving drug effectiveness and the extent and doses required for utilization. Reducing this uncertainty can be achieved mainly by using either coverage with evidence development methods or risk-sharing schemes (RSS). In 2011, the first phenylketonuria (PKU) risk-sharing scheme was set up in Israel, through the public funding health services updating process. This was done in order to ensure that people with PKU could access PKU sole treatment--sapropterin dihydrochloride, Kuvan. The apparent effectiveness of the treatment, on one hand, and the uncertainty regarding the number of patients and average treatment dosage, on the other hand, dictated the RRS. This scheme determined a ceiling number of tablets to be funded by the insurer, above this ceiling the manufacturer would finance Kuvan. Furthermore, it was agreed that after 3 years Kuvan would be brought to the public committee for updating reimbursement decisions. It is inevitable that risk sharing and conditional coverage agreements will become a common practice in the reimbursement process in the future. This will allow competent authorities and pharmaceutical companies to build clinical experience and other required data with medicines which might normally not be eLigible for reimbursement. Before it becomes the common practice in Israel, the RSS for Kuvan, process and outcomes, should be monitored and analyzed by the Ministry of Health, to ensure patients access to treatment, the effective collection of the research data and the effective interaction between Israel's four health funds and the manufacturer.

Coverage with evidence development, only in research, risk sharing, or patient access scheme? A framework for coverage decisions

BACKGROUND

Until recently, purchasers' options regarding whether to pay for the use of medical technologies have been binary in nature: a treatment is either covered or not. Policies, however, have emerged that expand the decision options, for example, linking coverage to evidence development, an option increasingly used for treatments with limited/uncertain evidence. There has been little effort to reconcile the features of technologies with the available decision options.

METHODS

We described a framework within which different decision options can be evaluated. We distinguished two sources of value in terms of health: the value of the technology per se and the value of reducing decision uncertainty. The costs of reversing decisions were also considered.

FINDINGS

Purchasers should weigh the expected benefits of coverage against the possibility that the decision may need to be reversed and the chance that adoption will hinder evidence generation. Based on the purchaser's range of authority over access, research, and price and on the characteristics of the technology with regard to reversibility and evidence, different decisions may be appropriate. The framework clarified the assessments needed to establish the appropriateness of different decisions. A taxonomy of coverage decisions was suggested.

CONCLUSIONS

A range of decision options may facilitate paying for the use of promising medical technologies despite their uncertain evidence. It is important that the option be chosen on the basis of not only the expected value of a technology but also the value of further research, the anticipated effect of coverage on further research, and the costs associated with reversing the decision.

Funding linked to ongoing research: impact of the bosentan patient registry on pricing in Australia

OBJECTIVES

Bosentan, a dual endothelin receptor antagonist (ERA), was the first oral drug approved for the treatment of pulmonary arterial hypertension (PAH), a rare disease with poor prognosis. In 2004 the Australian Department of Health agreed to fund bosentan on the pharmaceutical benefits scheme (PBS) on the condition that a registry was established to monitor mortality: if the observed mortality rate was higher than that claimed in the original funding submission then the price of bosentan would be reduced to maintain the original incremental cost-effectiveness ratio (ICER). This article presents the economic implications of the bosentan patient registry (BPR).

METHODS

An existing economic model was updated using the results of the BPR.

RESULTS

Participation rates were high and the BPR collected 821 patient years of follow-up on 528 patients. Based on the observed raw mortality a 23.7% price reduction would have been needed to maintain the original ICER in idiopathic PAH patients. After allowing for the higher risk patients actually treated in Australia, a 13.5% reduction in bosentan price would have been required. In 2008, however, sitaxentan, a new oral ERA PAH treatment was listed on the PBS at a 15% discount to bosentan. On the basis of cost-minimization, bosentan was forced to reduce its price to that of sitaxentan. After this price reduction the ICER for bosentan was similar to that originally proposed and hence, no additional price reduction was sought by the Pharmaceutical Benefits Advisory Committee (PBAC).

CONCLUSIONS

The bosentan PAH registry provided a useful mechanism for monitoring the cost-effectiveness of bosentan after funding approval.

'Strange money': risk, finance and socialized debt

This paper explores an essential but neglected aspect of recent discussions of the banking and financial system, namely money itself. Specifically, I take up a distinction drawn by Susan Strange which has never been fully elaborated: between a financial system that is global, and an international monetary system that remains largely territorial. I propose a sociological elaboration of this distinction by examining each category, 'finance' and 'money', in terms of its distinctive orientation to risk and debt. Money is distinguished by its high degree of liquidity and low degree of risk, corresponding to expectations that derive from its status as a 'claim upon society'- a form of socialized debt. But as Strange argued, these features of money are being undermined by the proliferation of sophisticated instruments of financial risk management -'strange money'- that, as monetary substitutes, both weaken states' capacity to manage money, and more broadly, contribute to 'overbanking'. The ultimate danger, according to Strange, is the 'death of money'. The paper concludes by exploring the implications of the distinction for sociological arguments about the changing nature of money.

[New drugs: money-back guarantee?]

When a new medical technology, for example a new drug, is introduced onto the market there should be a discussion of the balance between "uncertainty versus value to society and demand". The new technology is sometimes given the benefit of the doubt due to a lack of information. Follow-up investigation is actually essential but is seldom mandatory and hardly ever spontaneously initiated. Specific measures, based on stimulation or penalization, could reduce the degree of uncertainty concerning the efficacy, safety and efficiency of a new technology. A serious option when a new drug produces disappointing results is to pay the manufacturer less.

Designing the financial tools to promote universal access to AIDS care

We argue that reluctance to invest in drug treatments to fight the AIDS epidemics in developing countries is largely motivated by severe losses occurring from the future albeit uncertain appearance of a curative vaccine. We design a set of securities generating full insurance coverage against such losses, while achieving full risk-sharing with vaccine development agencies. In a General Equilibrium framework, we show that those securities are demanded to improve social welfare in developing countries, to increase current investment in treatments and the provision of public goods. Even though designed for AIDS, those securities can also be applied to other epidemics such as malaria and tuberculosis, as well as any innovative treatment to fight orphan diseases.