A Noiseless Flash John Herseys Hiroshima - Free Essay Example

Sample details Pages: 4 Words: 1309 Downloads: 2 Date added: 2019/07/31 Category History Essay Level High school Tags: Hiroshima Essay Did you like this example? There, in the tin factory, in the first moment of the atomic age, a human being was crushed by books. He felt a sudden pressure, and then splinters and pieces of board and fragments of tile fell on him. He heard no roar. (Almost no one in Hiroshima recalls hearing any noise of the bomb) Don’t waste time! Our writers will create an original "A Noiseless Flash: John Herseys Hiroshima" essay for you Create order On August 6, 1945 , a traumatic event for the citizens of Hiroshima had happened caused by the United States in hope to end the war and cut all hopes of war with Japan ever again. The bombing of Hiroshima. The U.S. Department of Energy has estimated that after five years there were perhaps 200,000 or more fatalities as a result of the bombing, while the city of Hiroshima has estimated that 237,000 people were killed directly or indirectly by the bombs effects, including burns, radiation sickness, and cancer.(Atomic Heritage, 2014) This Bombing has an everlasting effect on citizen of Hiroshima. This bombing took place during the era of WWII which started in 1939 lasting until 1945. There are other significant events that took place during WWII. John Hersey traces the lives of two women, two doctors and two men telling the story of six survivors explaining how life was prior to the bombing to months after. Over 100,000 people were either injured or killed in a result of this. Imagine having difficulties finding jobs, coping with radiation poisoning and not being able to seek immediate needed medical attention. Being trapped in wreckage resulted from a deadly bomb being dropped in your city. The 6 survivors in this book are faced with a conflict that resulted in different negative effects making it difficult for them to go on with their lives. In this book the author portrays the viewpoints of these survivors throughout the time before and after this bombing in Hiroshima took place. In the book John Hersey decided to introduce the characters; Mrs.Toshinki Sasaki, Dr. Masakazu Fujii, Mrs. Hatsuyo Nakamura, Father Wilhelm Kleinsorge, Dr. Terefumi Sasaki, and the Reverend Mr. Kiyoshi Tanimoto, describing how each of them were dealing with how they were affected by the atomic bombing Before the Bomb The night before the atomic bomb was deployed on Hiroshima it was said at midnight it was announced that over 200 thousand B-29s; which was the planes the United States used to bomb Japan, headed towards Honshu advising the citizens of Hiroshima to evacuate.The 6 survivors were responding to the initial warning that the bomb was coming differently some engaged in their daily activity and some getting prepared for a upcoming B-29 raid that was coming to Hiroshima. Mrs.Nakumara had been misled many times because of false alarms that were let off because off bomb threats so she decided to stay at home with her 3 children rather leave and go to a safe place until they heard a more urgent siren only to see her neighbor trying to tear down his house to create a path but he was killed instantly. The effects that the atomic bombing had on the citizen of Hiroshima were fatalistic leaving them with everlasting health effects minutes after the bomb was deployed. As soon as the planes had passed, Mrs. Nakamura started back with her children. They reached home a little after two-thirty and she immediately turned on the radio, which, to her distress, was just then broadcasting a fresh warning. When she looked at the children and saw how tired they were, and when she thought of the number of trips they had made in past weeks, all to no purpose, to the East Parade Ground, she decided that despite the instructions on the radio, she simply could not face start ing out all over again. Mrs Nakumara is just one example of how the 6 survivors were responding to the warning and how they were acting before the bomb was deployed. Dr. Masakazu Fuji was another one of the 6 survivors whose whereabouts were described before the bomb was deployed. Dr.Fuji who had great luck during this time of disparity. Dr.Fuji got up earlier than usual to walk one of his friends to the train station then heads to his doctors office only to keep turning down patients all but two because of the chance of it being difficult to evacuate. He then sits on the porch of the office only to see a flash and then as he starts to stand the hospital gets tore down. Dr. Fujii sat down cross-legged in his underwear on the spotless matting of the porch, put on his glasses, and started reading the Osaki Asahi He liked to read the Osaka news because his wife was there. He saw the flash. To him†faced away from the center and looking at his paper†it seemed a brilliant yellow. Startled, he began to rise to his feet. In that moment (he was 1,550 yards from the center), the hospital leaned behind his rising and, with a terrible ripping no ise, toppled into the river. After the Bombing: After the bomb was deployed on Hiroshima the life of the citizens were affected drastically. Over 80,000 citizens died and some survivors; such as the 6 survivors described in the book, in which suffered from many health effects such as Radiation Poisoning.(American History,2014) in addition to the huge number of persons who were killed or injuried so that their services in rehabilitation were not available, a panic flight of the population took place from both cities immediately following the atomic explosion There were Mechanical injuries, Blast injuries, burns and even Radiation Injuries; one of the most severe, that effected these citizens of Hiroshima. According to a Eyewitness, Father John A Siemes, More and more of the injured come to us. The least injured drag the more seriously wounded There are wounded soldiers, and mothers carrying burned children in their arms. From the houses of the farmers in the valley comes word: Our houses are full of wounded and dying. Can you help, at least by taking the worst cases? The wounded come from the sections at the edge of the city. They saw the bright light, their houses collapsed and buried the inmates in their rooms. Ms. Sasaki for example, She is in her office sitting in front of a bookcase when the bomb hits and bookcase falls on top of her, crushing her leg which is one of the characters that was effected after the bomb had been set off in Hiroshima. Dr. Fujii is hurt by the blast and his hospital collapsing, , killing everyone else inside including the two patients that he had let have their appointment. Asano Park is a evacuation place that stayed intact despite the bombing where most of the survivors of the Atomic Bombing went. Mrs.Nakamuras house was destroyed but she couldnt manage to find her children digging through all the debris and wood finding them unhurt and decides to go to Asano Park. So Mrs. Nakamura started out for Asano Park with her children and Mrs. Hataya, and she carried her rucksack of emergency clothing, a blanket, an umbrella, and a suit-case of things she had cached in her air-raid shelter. In his book, John Hersey tells the lives of six people who survived this traumatic event that happened in there city; the bombing of Hiroshima on August 6, 1945. John Hersey explains what these six survivors were doing immediately before and after this tragedy took place on that fateful day when the first atomic bomb destroyed Hiroshima. The story illustrates in depth the lives of these six survivors from the time they woke on that terrible morning until the moment when their lives were irreversibly changed in a second. Herseys purpose in writing this book is to demonstrate how the dropping of the atomic bomb impacted the lives of these six citizens of Hiroshima hoping that nothing of this sort was to happen again.

Research Papers for College

Research Papers for College This research paper will focus on the analysis and comparison of the education level and effectiveness of particular educational systems on the college level. The scale of the analysis is based on comparison of college education systems in the following countries: UK, USA and Germany. The choice of the countries for this research was determined by the following factors: †¢ History and stability of the educational system All three countries have deep history of the development of educational system and well-established processes in this sphere as well. This helps the analysis and allows for gathering of valuable and reliable data. †¢ Average level of education in the country In order to identify the criteria for the selection of the countries for this research paper, it was decided to choose the educational systems, where graduates with college degree have relatively similar knowledge portfolio. †¢ Percentage of literate education in the country Based on the Bureau of Statistics of other responsible governmental institutions, the research group performed preliminary analysis of the educational statistics in the selected countries. The objective of these criteria is to ensure that selected sample can represent the population of the research. †¢ Differences in the educational processes Main target of the sample selection, apart from all the above criteria, is to choose the countries with similar college portfolio, but at the same time significant differences in the process or product design. These differences, that distinguish further effects and specifics of the education, will determine the scope of the analysis and help the writer provide recommendations and practical evaluation of the educational level and gaps in these processes in mentioned countries and educational systems.

Leadership Skills, Traits And Behaviors - 1667 Words

Leadership Skill, Traits and Behaviors Student’s Name: Instructor’s Name: Date: 26th February, 2015. I have selected the option 1 that is to interview the business leader or any professional. I found it a great opportunity to have an interview with my most favorite leader of Ford Motors. As I want to peruse my career in running my own car manufacturing company. This interview helped me a lot to grasp the clear understanding of the leadership styles and skills which a leader really needs to portray for the success of his organization. Ford Motor Company is the American International automaker founded by Henry Ford in 1903. It introduced the concept of the large scale manufacturing of cars and the management of large scale†¦show more content†¦He also said that the environment of an organization should be developed in such a way that people would love to help each other to get the problem solved easily and a safe environment should be created so the people would have open and honest dialogues about their mistakes. In his views leadership is all about having authentication on who you are and what you really believe in. and at Ford motors they have designed a card having a business plan on one side and the expected behaviors listed on the other side(DeRue, Nahrgang, Wellman, Humphrey, 2011). He also focused on the decision making power of leaders and their proactive approach towards the changes in the external environment. The leaders should recognize the changes occurring in the environment while trying to make sense of it and to respond it quickly. It will help the leaders to understand the environment and the necessary operations to operate in such complex environments. It is always a critical challenge to the leaders to identify and understand the happenings of the external environment and conducting the business operations in that environment. He also analyzed that the good leader must have the ability to take his organization to the large context by arranging the meetings of all the leadership teams and every business andShow MoreRelatedLeadership Is A Component Of Traits, Skills, Behaviors, And Processes918 Words   |  4 PagesLeadership is complex and has many meanings. Therefore, to craft one definitive definition of the word leadership is challenging as there are many facets to be considered. 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Should Abortion Be Legal - 2144 Words

Imagine a world where women are not allowed to get tattoos, eat fast food, or even paint their nails. That is what the world would look like if the government were to restrict people s everyday personal choices. Even though many people would think that having all of those things restricted has nothing to do with abortion, that is not the case. Abortion is a personal choice and therefore should have no limits placed on it when it comes to women over 16 because it takes away their rights that were set in the Constitution. The federal or state government should not have the power to dictate what a valid reason is for a woman to get an abortion no matter how horrific it may seem; however, they should have a legal age to get an abortion because children are not capable of making adult decisions on their own. Instead of restricting adults, the government should give women who want an abortion substantial information about the procedure so they can make a rational decision based on fact, no t emotion. Abortion should be a federal matter rather than a state matter because it forces women to go out of their hometown and travel for days just to get what they need. Sometimes women do not have the money or time to do the things they need, like abortion, because it is not right at their fingertips. This means the people in those different states have different opinions. States that support the pro-life movement can be restricting women’s rights to go to an abortion clinic because thereShow MoreRelatedAbortion Should Not Be Legal1647 Words   |  7 PagesOne of the most highly debated topics is abortion and whether or not it should be legal. 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Power of Wind Free Essays

Power of Wind Jason A. Jennings Principles of Marketing (BUS 330) Instructor: Debra McCoskey-Reisert January 28, 2012 Power of Wind There is a large sector in the United States that believes wind energy is an excellent alternative resource. There is also a group of people that believe that the wind turbines that are used to generate wind energy is a bad idea because they obstruct the natural view, causes death to birds, and generates noise pollution. We will write a custom essay sample on Power of Wind or any similar topic only for you Order Now They also argue that wind energy is not a dependable source of energy because the wind does not blow continually. Wind as a viable source of energy will be evaluated from a positive and negative perspective. Wind energy has long history of being used as a power source (Berry, History of Windmills, 2011). Considering the current issues that the global community faces concerning green house gases and pollution alternative energy sources must be evaluated. As of 2010 the United States Energy Information Administration listed Saudi Arabia, Russia, and the United States as being the top three world oil producers (U. S. Department of Energy). The top three oil consumers are the United States, China, and Japan. As of 2009 the United States Energy Information Administration listed Saudi Arabia, Canada, Iran, Iraq, and Kuwait as having the highest level of proven world oil reserves (U. S. Department of Energy). In 2010 the United States Imported close to forty nine percent of the petroleum products that it consumed in that same year (U. S. Department of Energy). About half of those imports came from nations located in the Western Hemisphere. The world currently faces a shrinking petroleum based energy supply and a rapidly growing pollution problem as a result of the dependency on petroleum. Countries around the world increasingly have to compete with each other in order to secure petroleum based energy resources. China and India continue to place a higher demand on the worlds petroleum supply because of their rapidly growing economies. High gasoline prices, global warming concerns, and fears that fossil fuel resources are likely hitting peak supply while global demand is surging demands the modern world’s undivided attention. Oil producing countries in the Middle East currently hold a forty percent share of the world’s oil market. Wind energy has the ability to market itself. There is a large sector around the world with a belief that wind energy is an excellent alternative resource. Wind farms are also one of the emerging green technologies that are beginning to show their true value. Between the year 2000 and 2010 the wind power capacity of the United States jumped exponentially (see page 6). That is a direct result of the hundreds of new wind farms that came on line in the American power grid. In 2010 global wind installation hit 196,000 gigawatts. In a recent study conducted by the United Nations said renewable energy accounted for sixty percent of new electricity generation capacity in Europe and more than half in the United States of America. The human relationship with the wind has been a long one with the use of sailing ships and windmills. For centuries past the wind was used as the main power source for sailing ships. The use of windmills seems to have started with the Persians for grinding grain (between 500 and 900 A. D. ). Windmills started appearing in Europe around the time of the Crusades (1096 -1270). The European design is very different from the Persian one and there is an ongoing debate whether the Europeans developed the windmill themselves or the Crusaders had taken the idea back to Europe (Berry, History of Windmills, 2011). The earliest windmills found in Europe were a post mill construction. The main structure of the windmill sits on top of a post and could be rotated to face the wind. Human power was needed to rotate the windmill to face the direction of the prevailing winds. The windmill was turned by a long beam that was attached horizontally to the body of the mill. The mills sat upon a tripod structure that consisted of two crossed beams resting on the ground with four angled beams coming up to support the post in the center. These windmills used a horizontal axis allowing the sails of the windmill to take better advantage of the wind. The power was then transferred to machines by cogs and gears. In 1650 smock mills were developed with just the top part of the windmill being turned to face the wind. This was a huge improvement to the windmill because the sail structure was much lighter and easier to turn. Permanent structures could be built to house the mill. Brick and stone tower mills were built using the new smock mill method. Smock mills received that name because they resembled a nineteenth century countryman’s smock. They were built in a tapered, boarded, Octagonal shaped tower form. The Chinese built their first documented windmill in 1219 A. D. and was used to grind grain. In the late 1300’s the Dutch developed a new sail design that increased efficiency. The sail was constructed with a leading edge that created aerodynamic lift. Windmill sails were made of cloth stretched over a wooden frame. Some windmill designs incorporated trimmed sails allowing them to take better advantage of the variable wind conditions. The English used a fantail on their windmills that allowed them to be turned by the wind. The large Dutch designed windmills continued to be used all across Europe until the development of the steam engine in the 1880’s. The use of steam power caused a decline in the use of large tower windmills. In the United States windmills were used in the west for pumping water to the ranchers live stock. In the mid 1900’s Charles Brush developed a huge wind dynamo that generated electricity and became fascinated with the possibility of producing free energy for the general public. Beginning in the 1930’s a group of disgruntled ranchers got together and started the development of wind energy. The ranchers were facing rising prices, power outages and poor customer service. Robert Righter is a historian that has done extensive research on wind energy in the United States. The first wind farms were built in the state of California in the 1980’s. The Altamont Pass, located near the San Francisco Bay area there are still some of the older and much smaller turbines. They only had a rotor diameter of 15 meters and a capacity of tens of kilowatts. The new turbines being manufactured today have a capacity of 1. 5 – 2. 5 megawatts (MW), rotor diameters as great as 100 meters allowing the blades to sweep an area the size of a football field. Wind power is on the rise in the United States with capacity jumping by 45 percent at the end of 2007 and capacity reaching to 17 gigawatts (GW). Wind power is an attractive alternative to fossil fuels such as coal and oil because it is an energy source that does not produce pollution or climate altering greenhouse gases. When the massive turbines have been installed the only fuel that is needed to run them is the wind. Wind resources found around the world are so massive that they could easily meet the worlds current energy needs. A study that was conducted by researchers at Stanford University found that global wind energy potential in the year 2000 was about 72,000 gigawatts (GW), almost five times the world’s total energy demand at that time. The technology used to tap into the wind energy resources is getting much cheaper. In the early 1980’s electricity produced by the wind cost as much as 30 cents per kilowatt hour. In 2007 the cost had fallen to 10 cents per kilowatt hour. There are various incentives in the form of tax credits and feed in tariffs that make electricity generated from the wind cost competitive with electricity generated from natural gas and coal. Maria Sicilia of the International Energy Agency (IEA) has stated that a $30. 0 dollar tax per ton of carbon dioxide emitted would allow electricity produced on wind farms could compete in most markets without subsidies [ (International Energy Agency, 2009) ]. Even with no tax being placed on carbon emissions the growth of wind power is very likely to continue. The European Union has set a goal of getting 20% of its energy from renewable resources by 2020, with a large portion of it coming from wind power. The United States Department of Energy has laid out a plan to get 20% of the energy needed in the United States from wind power by 2030 [ (U. S. Department of Energy, 2008) ]. Asia may become the biggest market for new wind installations over the next five years. The wind does not blow all of the time and wind farms cannot be placed in some areas of the United States. For wind to stay on the path of expansion the industry will have to build new transmission lines and improve the integration of electricity produced by the wind into the power grid [ (IBM) ]. The industry is also vulnerable financially if subsidies are suddenly phased out. Some groups will say that the massive wind turbines cause the needless deaths of birds. The effect that the wind farms have on the view is one reason that has been cited for saying no to wind power. There have been issues concerning the noise that the turbines create. Wind energy is an excellent and valuable resource that can be used as a replacement for dirty fossil fuels and the dangers of nuclear power. It cannot be the only replacement for those energy sources but it can be used in conjunction with solar power, geothermal, and hydroelectric to fulfill our nation’s energy requirements. The use of coal as an energy source for the generation of electricity can gradually be scaled down. Mankind has had a long relationship with the wind as an energy source and should continue to use it well into the future. Pollution has become a major problem that is affecting the climate and that problem should be resolved on a global scale with all nations working together for the common good. A comparison of year end wind capacity in the United States between 2000 – 2010 (U. S. Department of Energy, 2011) References Berry, M. (2011, May 24). History of Windmills. Retrieved January 28, 2012, from Windmill World: http://www. windmillworld. com/windmills/history. htm GWEC. (2011). GWEC. Retrieved January 5, 2012, from Global Wind Energy Council: http://www. gwec. net/http://www. gwec. net/index. php? id=28 IBM. (n. d. ). Wind power is the fastest growing source of electricity. Retrieved December 26, 2011, from IBM – Greener Energy – Smarter Planet: http://www. ibm. com/smarterplanet/us/en/smart_grid/article/wind_power. html International Energy Agency. (2009, October 1). Renewable Energy Essentials: Wind. Retrieved January 5, 2012, from iea. org: http://www. iea. org/Papers/2008/Wind_Brochure. pdf Kotler, P. , Armstrong, G. (2010). Principles of Marketing. Upper Saddle River: Pearson Prentice Hall. National Renewable Energy Laboratory. (2011, July 22). Wind Research. Retrieved December 28, 2011, from NREL: http://www. nrel. gov/wind/ U. S. Department of Energy. (2008, May). 20% Wind Energy by 2030. Retrieved January 1, 2012, from Increasing Wind Energy’s Contribution to U. S. Electricity Supply: http://www. 20percentwind. org/default. aspx U. S. Department of Energy. (n. d. ). Oil Production. Retrieved January 28, 2012, from Independent Staistics ; Analysis: http://38. 96. 246. 204/countries/index. cfm? view=production U. S. Department of Energy. (2010, September 1). Wind ; Water Program. Retrieved December 26, 2011, from Technologies: http://www1. eere. energy. gov/windandhydro/wind_how. html U. S. Department of Energy. (2011, September). Wind Powering America. Retrieved January 7, 2012, from Energy Efficency ; Renewable Energy: http://www. windpoweringamerica. gov/ How to cite Power of Wind, Essay examples

Innovation, new product development and why do new products fail free essay sample

Product innovation is the creation and subsequent introduction of a good or service that is either new, or improved on previous goods or services. Product innovation is defined as: the development of new products, changes in design of established products, or use of new materials or components in the manufacture of established products[1] Thus product innovation can be divided into two categories of innovation: development of new products, and improvement of existing products. Systemmatic Innovation of Products includes: Technology strategy Design thinking skills Customer needs analysis Systematic creativity methods Market and pricing strategy Design for environmental sustainability Design of services Capturing value from innovation Development process design Product and service leadership RD organization and teams Managing complex technical projects The future of design process and culture The development and market introduction of a new, redesigned or substantially improved good or service.might include a new products invention; technical specification and quality improvements made to a product; or the inclusion of newcomponents, materials or desirable functions into an existing product. Meaning of New Product Development: Product development is a broad field of endeavor dealing with the design, creation, and marketing of new products. Sometimes referred to as new product development (NPD), the discipline is focused on developing systematic methods for guiding all the processes involved in getting a new product to market. New product development (NPD) is the complete process ofbringing a new product to market. A product is a set of benefits offered for exchange and can be tangible (that is, something physical you can touch) or intangible (like a service, experience, or belief). There are two parallel paths involved in the NPD process: one involves the idea generation,product design and detail engineering; the other involves market research and marketing analysis. Companies typically see new product development as the first stage in generating and commercializing new product within the overall strategic process of product life cycle management used to maintain or grow their market share. There are a number of organizations dedicated to supporting product development professionals, such as the Product Development and Management Association (PDMA) and the Product Development Institute (PDI). According to the PDMA, the organizations mission is to improve the effectiveness of people engaged in developing and managing new products both new manufactured goods and new services. This mission includes facilitating the generation of new information, helping convert this information into knowledge which is in a usable format, and making this new knowledge broadly available to those who might benefit from it. As we move into the 21st century, new challenges and opportunities are arising driven by global markets, global competition, the global dispersion of engineering talent, and the advent of new information and communication technologies such as electronic mail, the world-wide web, and increased electronic bandwidth. The new vision of product development is that of a highly disaggregated process with people and organizations spread throughout the world. In the late 1980s and early 1990s a marketing focus on product development stressed customer satisfaction. Researchers in marketing believed that the key to success was a better understanding of the voice of the customer and a better ability to link that voice to the engineering decisions that are made in launching a product. Important research during that period included new ways to understand the voice of the customer (Griffin and Hauser 1993), new ways to develop optimal product profiles in the context of competition (Green and Krieger 1989a, 1991), more efficient preference measurements (Srinivasan 1988), and the ability to handle larger, more complex customer information (Wind, Green, Shifflet, and Scarbrough 1989). At the same time the quality movement focused product development engineering on improved reliability through continuous improvement such as Kaizen methods (Imai 1986), statistical quality control (Deming 1986), modified experimental design (Taguchi 1987), and design for manufacturing (Boothroyd and Dewhurst 1Today, both industry and academia view successful product development as an integrated process that must overcome many tradeoffs994). Trade offs includes time to market, Production cost, Deliver customer benefits and Development costs. All else equal, a product will be more profitable if it delivers customer benefits better, is faster to market, costs less to produce, and costs less to develop trade offs puts research on product development tools and methods into perspective. Research should be directed to assure that: (1) the firm is operating on the efficient frontier with respect to each of these strategic goals, and (2) the firm is making the best tradeoffs among these goals. Research must recognize that there are tradeoffs along the efficient frontier. For example, if wefocus on just two of the many goals of product development, then the efficient frontier suggests that there are tradeoffs between customer satisfaction and platform reuse. A firm can becometoo committed to either. For example, the significant reuse of components in platforms, software, and designs may get the product to the market faster and reduce development costs1994), but the firm may sacrifice the ability to satisfy customer needs and may miss out on ways to reduce product costs. Similarly, quality function deployment (QFD) may be an effective means to deliver customer benefits by improving communication and coordinating the efforts of multiple players in the NPD process, but some applications are too cumbersome reducing time-to-market and increasing development cost. 8 Steps for New Product Development Every entrepreneur knows that productivity is one of the key ingredients for successful product development. One of the two key processes in Robert’s Rules of Innovation is the A formalized, NPD process – also referred to and best practice: the Stage Gate ® Process – is a must, from simple to sophisticated. The New Product Development process is often referred to as The Stage-Gate innovation process , developed by Dr. Robert G. Cooper as a result of comprehensive research on reasons why products succeed and why they fail. When teams collaborate in developing new innovations, having the following eight ingredients mixed into your team’s  new product developmental repertoire will ensure that it’s overall marketability will happen relatively quick, and accurately – making everyone productive across the board. Step 1: Generating Utilizing basic internal and external SWOT analyses, as well as current marketing trends, one can distance themselves from the competition by generating ideologies which take affordability, ROI, and widespread distribution costs into account. Lean, mean and scalable are the key points to keep in mi nd. During the NPD process, keep the system nimble and use flexible discretion over which activities are executed. You may want to develop multiple versions of your road map scaled to suit different types and risk levels of projects. Step 2: Screening The Idea Wichita, possessing more aviation industry than most other states, is seeing many new innovations stop with Step 2 – screening. Do you go/no go? Set specific criteria for ideas that should be continued or dropped. Stick to the agreed upon criteria so poor projects can be sent back to the idea-hopper early on. Because product development costs are being cut in areas like Wichita, â€Å"prescreening product ideas,† means taking your Top 3 competitors’ new innovations into account, how much market share they’re chomping up, what benefits end consumers could expect etc. An interesting industry fact: Aviation industrialists will often compare growth with metals markets; therefore, when Boeing is idle, never assume that all airplanes are grounded, per se. Step 3: Testing The Concept As Gaurav Akrani has said, â€Å"Concept testing is done after idea screening. And it is important to note, it is different from test marketing. Aside from patent research, design due diligence, and other legalities involved with new product development; knowing where the marketing messages will work best is often the biggest part of testing the concept. Does the consumer understand, need, or want the product or service? Step 4: Business Analytics During the New Product Development process, build a system of metrics to monitor progress. Include input metrics, such as average time in each stage, as well as output metrics that measure the value of launched products,  percentage of new product sales and other figures that provide valuable feedback. It is important for an organization to be in agreement for these criteria and metrics. Even if an idea doesn’t turn into product, keep it in the hopper because it can prove to be a valuable asset for future products and a basis for learning and growth. Step 5: Beta / Marketability Tests Arranging private tests groups, launching beta versions, and then forming test panels after the product or products have been tested will provide you with valuable information allowing last minute improvements and tweaks. Not to mention helping to generate a small amount of buzz. WordPress is becoming synonymous with beta testing, and it’s effective; Thousands of programmers contribute code, millions test it, and finally even more download the completed end-product. Step 6: Technicalities + Product Development Provided the technical aspects can be perfected without alterations to post-beta products, heading towards a smooth step 7 is imminent. According to Akrani, in this step, â€Å"The production department will make plans to produce the product. The marketing department will make plans to distribute the product. The finance department will provide the finance for introducing the new product†. As an example; In manufacturing, the process before sending technical specs to machinery involves printing MSDS sheets , a requirement for retaining an ISO 9001 certification (the organizational structure, procedures, processes and resources needed to implement quality management . ) In internet jargon, honing the technicalities after beta testing involves final database preparations, estimation of server resources, and planning automated logistics. Be sure to have your technicalities in line when moving forward. Step 7: Commercialize At this stage, your new product developments have gone mainstream, consumers are purchasing your good or service, and technical support is consistently monitoring progress. Keeping your distribution pipelines loaded with products is an integral part of this process too, as one prefers not to give physical (or perpetual) shelf space to competition. Refreshing advertisements during this stage will keep your product’s name firmly supplanted into the minds of those in the contemplation stages of purchase. Post Launch Review and Perfect Pricing Review the NPD process efficiency and look for continues improvements. Most new products are introduced with introductory pricing, in which final prices are nailed down after consumers have ‘gotten in’. In this final stage, you’ll gauge overall value relevant to COGS (cost of goods sold), making sure internal costs aren’t overshadowing new product profits. You continuously differentiate consumer needs as your products age, forecast profits and improve delivery process whether physical, or digital, products are being perpetuated. Remember: The Process Is Loose The entire new product development process is an ever evolving testing platform where errors will be made, designs will get trashed, and loss could be recorded. Having your entire team working in tight synchronicity will ensure the successful launch of goods or services, even if reinventing your own wheel. Productivity during product development can be achieved if, and only if, goals are clearly defined along the way and each process has contingencies clearly outlined on paper. Why do new products fail? Marketers know that they’ve got to keep a steady stream of new products and/or services flowing—if for no other reason than to keep up with the competition. As circumstances, needs, wants, and trends change, no one wants to get left behind. At the same time though, marketers also know that innovation these days is pretty risky business. Neglect market research Inaccurate market research Poor marketing after launch Poor distribution Product performance below expectation(poor product quality) Product too complex Unforeseen events Market not ready for the product Inadequate support for the product Lack of USP Target market too small In Winning at New Products, author Robert Cooper estimates that about half of all resources allocated to â€Å"product development and commercialization† in the U. S. goes to products that a firm cancels or produce an inadequate financial return. In packaged goods, for instance, IRI calculated that less than a quarter of the new products introduced in 2008 broke the $7. 5 million in sales mark their first year of availability and less than one-half of 1% earned more than $100 million in sales. Though estimates of new product and service failure rates vary widely by company, category, industry, and reporting agency, the best-case-scenario chances of introducing a successful new product or service don’t get much better than 50-50. About 10%-20% of new products and services succeed, which means they remain in the market generating profits for the company three years after introduction. Here’s our top 10 list of reasons new products and services fail: Marketers assess the marketing climate inadequately. The wrong group was targeted. A weak positioning strategy was used. A less-than-optimal configuration of attributes and benefits was selected. A questionable pricing strategy was implemented. The ad campaign generated an insufficient level of awareness. Cannibalization depressed corporate profits. Over-optimism about the marketing plan led to a unrealistic forecast. Poor implementation of the marketing plan in the real world. New product development is critical to the firm’s long term survival for several reasons: First, new product development recognizes that all products have life cycles. Eventually, all products enter a decline phase with respect to sales and profitability. At some point, these products must be removed from the market. New products must exist to take their place if the firm wishes to maintain existing levels of sales and profits. New products can provide firms with a competitive advantage in the market. Firms that continually try to improve existing products and or develop new products stay a step ahead of their competitors. This advantage can translate into greater sales and higher profitability. New products also can enhance the firm’s image in the market. Consumers are attracted to things that are new. Firms that continually strive to introduce new products will likely be at the forefront of attention and have their names continuously in the media. This media exposure certainly cannot hurt the firm’s image and reputation as an innovator. Finally, new products may help the firm reduce risk by diversification. Company’s with large portfolios of products often are more stable than firms with smaller portfolios. Types of Product Failures There are two common interpretations of what is meant by a new product failure. Each interpretation has implications for which product failure rates are more believable. The Absolute Failure The first type of failure is referred to as the absolute failure. This failure is one that does not generate sufficient revenue to allow the firm to break even on its new product investment. The Relative Failure The less severe relative product failure generates sufficient product revenues to break even. However, profit objectives are not achieved. In other words, this product makes money it just does not make as much money as management hoped. The instances of relative product failures probably are substantially higher than the numbers of absolute failures. I suspect that the higher failure rates that have been reported in the literature refer to relative product failures. The number of absolute product failures probably is substantially less. The Causes of New Product Failure An important question is why do new products fail? What are the causes of failure? Several factors contribute to the high failure rates for new products in today’s highly competitive marketplace Lack of Relative Advantage The first, and probably most important reason for failure, is simply that the new product does nothing really new or unique for the consumer. This essentially means that the new product possess little relative or differential advantage over existing products already on the market. Inadequate Planning Many products fail because the manufacturer did not do enough homework. This is to say that the new product planning process was somehow flawed. Generally, this means that the market opportunity analysis (or MOA) was not conducted or missed some important information. For example, Anheuser Buschs Dewey Stevens Wine Cooler failed due to poor planning. In the mid 1980’s, Anheuser Busch, the worlds leading beer manufacturer, launched Dewey Stevens Wine Cooler with a poorly conceived and implemented promotion program that never targeted the right audience for the product. In its promotional material, Dewey Stevens alternately tried to appeal to woman, calorie counter consumers, and more sophisticated upscale consumers. The varied positioning of Dewey Stevens created substantial confusion in the market concerning Dewey Stevens’ image. A second example is provided by the test market of Eli Cutter cigarettes discussed in an earlier topic. Eli Cutter probably would have failed if it had been commercialized due to its poorly conceived positioning strategy. The brand was positioned directly against Marlboro, the leading brand in the market with a strong customer following. Better attention to marketing research and new product planning would have prevented taking Eli Cutter to test market. Poor Execution of Introduction Poorly executed marketing programs, no matter how well they are conceived, also can result in product failure. Poor execution entails an improperly conceived and poorly implemented marketing mix. The product may have been promoted incorrectly, priced either too high or too low, or distributed in inappropriate outlets. This is primarily a marketing failure. Technical Problems During Introduction Technical problems can also plague new product introductions leading to their failure. These problems are problems with the basic functionality of the product that were not uncovered during earlier functional testing and/or test marketing. Poor Timing of Introduction Poor timing of introduction can lead to failure. Introducing products during economic down-turns or at about the same time as competitors are introducing similar products can severely limit sales. Procter and Gamble introduced Encaprin in the mid 1980’s as an extra strength pain reliever. At introduction, Encaprin faced very intense competition both from Advil and Nuprin, which also were recently introduced as arthritis pain relievers. Advil and Nuprin together had in excess of a hundred million dollars in advertising budgets. The net effect was that Encaprin could not break out of the promotional noise generated by these two brands Conclusion Modern innovation management requires integrated structures. Social community network structures can promote innovation management in the sense of open innovation. Only by cooperation it will be able to develop suitable innovations for the customer in future. Otherwise one will run the risk developing innovations not wanted by the customers. Next to once, it is particularly necessary to do everything for a systematic innovation management which refer among others to responsibilities, know-how and concepts. In the end, this examination shall give libraries and information providers the possibility of using the identified and described improvement potentials for their own innovation management. In the consequence changes of the organization principles possibly require also courageous decisions by e. g. conventional structures being put and broken open within a furnishing but and customer also between supplier in question. Increasing competition intensity and a high dynamics of information scientific services force service providers to develop solutions and services for the customer to build up a positive image to the customer. The collection of qualitative data gives a profound insight into the practice of innovation management in information science institutions. It were primarily enterprises such studies focused on. Libraries and (public) information service providers werent subject of such survey till now. It is the aim also to draw conclusions in this sector from the results for trainings and further education as well as to generate possible offers to promote the innovation management further. Since this study is part of an on-going research and it is not fully completed, conclusions should be taken with care. Nevertheless, some concluding points deserve attention. NPD integrates different perspectives of new product development process, considering the nature of the elements as the basis for its elaboration. Finally, even as a preliminary study, the conceptual model here proposed seems to contribute to the understanding of the dynamics of the product development process, given theseparation of the operational dimension of the other five that constitute the structure of the development project. This gives a clear notion that, although the methods and techniques that compose each dimension are very well understoodRigorous processes and a more effective platform for managing an open development environment can reduce the costs of new-product-development and increase the chances of delivering products. A more effective delivery platform can meet today’s need to reduce costs while also positioning a company for market dominance and high performance in long run.

Three Essays on Health Care free essay sample

This dissertation has been motivated by the question of how countries should optimally structure health care. Especially, there are two important economic and policy questions asked that extend beyond the area of health economics. The †¦rst is how the expansion of health insurance coverage a ¤ects the utilization and health of its bene†¦ciaries (extensive margin); the second is how generous should health insurance be (intensive margin) to balance the provision of care and †¦nancial protection against risk while containing medical expenditures. The three chapters in this dissertation aim to make empirical contributions to these ongoing research questions. First Chapter, â€Å"The E ¤ect of Patient Cost-Sharing on Utilization, Health and Risk Protection: Evidence from Japan† addresses the second question. It investigates how cost-sharing, requiring patients to pay a share of the cost of care, a ¤ects the demand for care, health itself, and risk protection among the elderly, the largest consumers of health service. Previous studies of cost-sharing have had di? culty separating the e ¤ect of cost-sharing on patients from the in†¡ uence of medical providers and insurers. This paper overcomes that limitation by examining a sharp reduction in cost-sharing at age 70 in Japan in a regression discontinuity design. I †¦nd that price elasticities of demand for both inpatient admissions and outpatient visits among the elderly are comparable to prior estimates for the nonelderly. I also †¦nd that the welfare gain from risk protection is relatively small compared to the deadweight loss of program †¦nancing, suggesting that the social cost of lower cost-sharing may outweigh social bene†¦t. Taken together, this study shows that an increase in cost-sharing may be achieved without decreasing total welfare. Third Chapter, â€Å"E ¤ects of Universal Health Insurance on Health Care Utilization, Supply-Side Responses and Mortality Rates: Evidence from Japan† (with Ayako Kondo) address the †¦rst question. Even though most developed countries have implemented some form of universal public health insurance, most studies on the impact of the health insurance coverage have been limited to speci†¦c subpopulations, such as infants and children, the elderly or the poor. We investigate the e ¤ects of a massive expansion in health insurance coverage on utilization and health by examining the introduction of universal health insurance in Japan in 1961. We †¦nd that health care utilization increases more than would be expected from previous estimates of the elasticities of individual-level changes in health insurance status such as RAND Health Insurance Experiment in the US. The two chapters addressed above focus on consumers’ incentives. Second chapter, â€Å"Supply-Induced Demand in Newborn Treatment: Evidence from Japan† (with Kiyohide Fushimi) examines the incentives faced by medical providers. Since medical providers exert a strong in†¡ uence over the quantity and types of medical  care demanded, measuring the size of supply-induced demand (SID) has been a long-standing controversy in health economics. However, past studies may underestimate the size of SID since it is empirically di? cult to isolate SID from other confounding hospital behaviors, such as changes in the selection of patients. We overcome these empirical challenges by focusing on a speci†¦c population: at-risk newborns, and we measu re the degree of SID by exploiting changes in reimbursement caused by the introduction of the partial prospective payment system (PPS) in Japan, which makes some procedures relatively more pro†¦table than other procedures. We †¦nd that hospitals respond to PPS adoption by increasing utilization and increasing their manipulation of infant’ reported birth weight, which deters mines infants reimbursement and maximum length of stay. We also †¦nd that this induced demand substantially increases hospital reimbursements without improving infant health, implying that the additional money spent has no commensurate health gains. Contents List of Figures iv List of Tables vii Acknowledgements xi Chapter 1. The E ¤ect of Patient Cost-sharing on Utilization, Health and Risk Protection: Evidence from Japan 1 1. 1. Introduction 1 1. 2. Background 7 1. 3. Data and Identi†¦cation 15 1. 4. Utilization Results 31 1. 5. Results on Bene†¦t 45 1. 6. Cost-Bene†¦t Analysis 52 1. 7. Conclusion 61 Chapter 2. Supply Induced Demand in Newborn Treatment : Evidence from Japan 85 2. 1. Introduction 85 2. 2. Background 92 i 2. 3. Data 97 2. 4. Estimation 102 2. 5. Manipulation of Reported Birth Weight 104 2. 6. NICU utilization 109 2. 7. Health outcomes and the size of the induced demand 116 2. 8. Conclusion 119 Chapter 3. E ¤ects of Universal Health Insurance on Health Care Utilization, Supply-Side Responses, and Mortality Rates: Evidence from Japan 133 3. 1. Introduction 133 3. 2. Background 139 3. 3. Data 146 3. 4. Identi†¦cation Strategy 153 3. 5. Results Regarding Utilization 158 3. 6. Results vis-a-vis Supply-Side Response 162 3. 7. Results vis-a-vis Mortality Rates 166 3. 8. Conclusion 171 References 188 Appendix A. The E ¤ect of Patient Cost-sharing on Utilization, Health and Risk Protection: Evidence from Japan A. 1. Derivation of Out-of-Pocket Health Expenditures ii 201 201 A. 2. Data Apendix 206 Appendix B. Supply Induced Demand in Newborn Treatment : Evidence from Japan 224 Appendix C. E ¤ects of Universal Health Insurance on Health Care Utilization, Supply-Side Responses, and Mortality Rates: Evidence from Japan 228 C. 1. Evidence against the Crowding-out of Employment-based Health Insurance by the NHI 228 C. 2. Impact on Household Out-of-Pocket Health Care Expenditures iii 230 List of Figures 1. 1 Age Pro†¦le of Health Insurance Type 1. 2 64 Cost-Sharing Below 70 and Above 70: Year 2008 as an Example 65 1. 3 Seasonality in Day of Birth in the Patient Survey Data 66 1. 4 Age Pro†¦le of Employment by Gender (1987– 2007 CSLC) 67 1. 5 Age Pro†¦le of Outpatient Visits 68 1. 6 Age Pro†¦le of Outpatient Visits for Selected Diagnosis (log scale) 69 1. 7 Age Pro†¦le of Inpatient Admissions (log scale)  70 1. 8 Age Pro†¦le of Inpatient Admissions with and without Surgery (log scale) 1. 9 71 Age Pro†¦le of Inpatient Admissions for Selected Diagnosis (log scale) 72 1. 10 Age Pro†¦le of Overall Mortality 73 1. 11 Distribution of Out-of-Pocket Health Expenditure in 2007 74 1. 12 Age Pro†¦le of Out-of-Pocket Medical Expenditures in 2007 75 iv 2. 1 Length of Stay in NICU by Birth Weight Range 121 2. 2 Pre and Post PPS 122 2. 3 The Birth Distribution Pre and Post PPS 123 2. 4 McCrary’ density test (NICU hospitals post PPS) s 124 2. 5 Event-study Analysis: Change in Length of Stay in NICU 125 3. 1 National Time Series of Health Insurance Coverage Rates 173 3. 2 % of Population without Any Health Insurance as of April 1956 3. 3 174 Scatter Plots of Changes in Per Capita GNP and Health Insurance Coverage Rate 175 3. 4 Time Series of Health Care Utilization 176 3. 5 Time Series of Per Capita Supply of Health Care 177 3. 6 Time Series of Age Speci†¦c Mortality Rates 178 3. 7 E ¤ect of Health Insurance Coverage on Healthcare Utilization 179 3. 8 E ¤ect of Health Insurance Coverage on Supply of Health Care 180 3. 9 E ¤ect of Health Insurance Coverage on Age-Speci†¦c Mortality Rates 181 3. 10 Mortality Rates by Time to Full Implementation of the NHI 182 3. 11 E ¤ect of Health Insurance Coverage on Mortality Rates by Treatable Diseases 183 v A. 1 Age Pro†¦les for First Time and Repeated Outpatient Visits 212 A. 2 Robustness of Results on Inpatient Admissions 213 A. 3 Age Pro†¦le for Inpatient Admissions for Selected Surgery (log scale) 214 A. 4 Age Pro†¦le for Cause-Speci†¦c Mortality 215 A. 5 Age Pro†¦les for Fraction in Good or Very Good Health 216 B. 1 The distribution of universe of birth in 1995, 2000 and 2005 (750-1750 grams) 225 vi List of Tables vii 1. 1 Summary Statistics (Ages 65-75) 76 1. 2 Formula for Cost-Sharing Below and Above Age 70 77 1. 3 Estimated Out-of-Pocket Medical Expenditure per Month 78 1. 4 RD Estimates at Age 70 on Employment, and Family Structure 79 1. 5 RD Estimates at Age 70 on Outpatient Visits 80 1. 6 RD Estimates at Age 70 on Inpatient Admissions 81 1. 7 RD Estimates at Age 70 on Mortality 82 1. 8 RD Estimates at Age 70 on Out-of-Pocket Medical Expenditure 83 1. 9 Welfare Gain from Risk Protection 84 2. 1 Hazard analysis: Year to adoption of PPS 126 2. 2 Summary Statistics by hospital groups 127 2. 3 Density Test 128 2. 4 NICU Utilization 129 2. 5 Robustness checks for length of stay in NICU 130 viii 2. 6 Mortality 131 2. 7 Treatment Intensity 131 2. 8 The size of the inducement 132 2. 9 Medical spending on other procedures 132 3. 1 Mean of Dependent and Control Variables 184 3. 2 Robustness Checks for Utilization Outcomes 185 3. 3 Controlling for Pre-existing Trend: Utilization Outcomes 185 3. 4 Robustness Checks for Supply of Health Care 186 3. 5 Controlling for Pre-existing Trend: Supply of Health Care 186 3. 6 Robustness Checks for Age Specific Mortality 187 3. 7 Controlling for Pre-existing Trend: Age Specific Mortality 187 A. 1 Top 10 Diagnosis for Outpatient Visits, and Inpatient Admissions Robustness of RD Estimates on Outpatient Visits for Selected Outcomes 217 List of PQI (Ambulatory-Care-Sensitive Conditions) 219 A. 2 A. 3 ix 218 A. 4 Robustness of RD Estimates on Inpatient Admissions for Selected Outcomes 220 RD Estimates of Inpatient Admissions by Characteristics of Hospital 221 A. 6 RD Estimate at Age 70 on Morbidity 222 A. 7 Estimated Out-of-Pocket Medical Expenditure per Month across Survey Years 223 B. 1 Log difference in density for Figure B. 1 226 B. 2 Mother’s delivery method 227 C. 1 Variable Definitions and Data Sources 233 C. 2 The Effect of the NHI Expansion on the Changes in Selfemployment Ratio 1955-1960 234 A. 5 C. 3 The Effect of the NHI Expansion on Establishment Size C. 4 The Effect of Universal health Insurance on Households Out-ofpocket Medical Expenditure x 235 235 Acknowledgements During writing this dissertation, I bene†¦ted from a number of people. First of all, I would like to thank my main advisor, Douglas Almond, for his guidance at every stage of the my research. Without his continuous encouragement through my entire dissertation, I could not complete the dissertation. Wojciech Kopczuk and Tal Gross gave me invaluable advices and supports during job market. I am also grateful to helpful comments and suggestions from Prashant Bharadwaj, Kasey Buckles, Janet Currie, Joseph Doyle, Mark Duggan, Amy Finkelstein, Kiyohide Fushimi, Michael Grossman, Hideki Hashimoto, Masako Ii, Amanda Kowalski, Ilyana Kuziemko, Frank Lichtenberg, Jason Lindo, Bentley MacLeod, Shinya Matsuda, Robin McKnight, Matt Neidell, Cristian Pop-Eleches, Heather Royer, Bernard Salanie, Miguel Urquiola, Eric Verhoogen, Till von Wachter, Reed Walker, and the seminar participants at Bank of Japan, Columbia University, McGill University, National University of Singapore, Osaka University, Simon Frazer University, University of Michigan, Uppsala University, and NBER Japan project meeting. Special thanks go to Hideo Yasunaga and Hiromasa Horiguchi for their invaluable help in obtaining the data and for helpful discussions. xi I would also like to thank my friends and colleagues at Columbia for their helpful discussions and for making my time in graduate school memorable. At the risk of forgetting some names, I thank Bruno Giovannetti, Mariesa Herrmann, Takakazu Honryo, Ayako Kondo, Marcos Yamada Nakaguma, Yoichi Sugita, Kensuke Teshima, and Zhanna Zhanabekova. Finally, my family have supported the entire period of my graduate study in New York. I dedicate this dissertation to my family members in token of a ¤ection and gratitude. xii 1 CHAPTER 1 The E ¤ect of Patient Cost-sharing on Utilization, Health and Risk Protection: Evidence from Japan 1. 1. Introduction Governments increasingly face an acute †¦scal challenge of rising medical expenditures especially due to aging population and expansion of coverage. Spending growth for Medicare, the public health insurance program for the elderly in the United States, has continued unchecked in spite of a variety of government attempts to control costs. 1 As more than one third of current health spending is on the elderly, future cost control e ¤orts can be expected to focus on seniors. 2 One main strategy for the government to contain cost is cost-sharing, requiring patients to pay a share of the cost of care. However, cost-sharing has clear tradeo ¤s. While cost-sharing may reduce direct costs by decreasing moral hazard of health 1 Examples of supply-side attempts by the government to control cost are the introduction of prospective payment for hospitals and reductions in provider reimbursement rates (Cutler, 1998). 2 The elderly are the most intensive consumers of health care. Patient over age 65 consume 36 percent of health care in the US despite representing only 13 percent of the population (Centers for Medicaid and Medicare Services 2005). Furthermore, Medicare costs are expected to comprise over a quarter of the primary federal budget by 2035, or between †¦ve and six percent of GDP (CBO, 2011). Likewise, in Japan, the elderly consume †¦ve times as many health services as non-elderly (Okamura et al, 2005). Also Japan has the most rapidly aging population in the world (Anderson and Hussey, 2000). 2 care services, it may also reduce access to bene†¦cial and necessary health care that could mitigate future severe and costly health events. Moreover, very high levels of cost-sharing may undermine one of the primary reasons of having health insurance, which is †¦nancial protection from catastrophic health events. Thus, there is a desperate need for knowledge on how cost-sharing a ¤ects utilization, health itself and risk protection, especially among the elderly, to determine the appropriate level of cost-sharing. Credible evidence on the price sensitivity of health care consumption among the elderly is limited. For instance, individuals above age 62 were excluded from the well-known RAND Health Insurance Experiment (hereafter, RAND HIE), which randomly assigned individuals to insurance plans with di ¤erent generosities. It is not clear a priori whether the elderly are expected to have a larger or smaller price elasticity of demand for health care services than the non-elderly. On one hand, the price elasticity for the elderly may be larger if they tend to be poorer or more credit-constrained than the non-elderly. On the other hand, it can be smaller if their health problems are more severe than those of non-elderly. An exception that studied the elderly is Chandra et al. (2010) who examined the e ¤ect of a small increase in the copayments for physician o?  ce visits and prescription drugs in a supplemental Medicare insurance policy. Most U. S. studies, however, have di? culty separating the demand elasticities of patients from the responsive behavior by insurers and medical providers. This limitation arises because insurers prevent patients from freely choosing medical 3 providers through managed-care, and medical providers determine which treatments to provide based on the patients’health insurance plans. Indeed, there is substantial evidence that the medical providers are reluctant to treat patients with government-funded health insurance bene†¦ciaries due to low reimbursement rates as well as frequent delays in reimbursement. If insurers and medical providers limit the patients’demand for health care services, the elasticities of demand that are estimated in these studies could be underestimated. By contrast, the unique setting in Japan permits isolation of the demand elasticity for health care services since medical providers and insurers typically play a small, if any, role in patients’demand for health care services. Under universal health insurance coverage in Japan, there are no restrictions on patients’choices of medical providers. Also physicians’payments are based on a national fee schedule that does not depend on patients’insurance type. This institutional setting limits physicians’ incentives to in†¡uence patient demand and prevents cost-shifting, a well-known phenomenon in the U. S. where medical providers charge private insurers higher prices to o ¤set losses from the bene†¦ciaries of government-funded health insurance (Cutler, 1998). My re search design exploits a sharp reduction in patient cost-sharing at age 70 in Japan in a regression discontinuity design to compare the outcomes of those just below versus those just over age 70. Due to national policy, cost-sharing for 3 For example, see Cunningham and O’ Malley (2009) and Garthwaite (2011). 4 outpatient visits and inpatient admissions is as much as 60-80 percent lower at age 70 than at age 69 in Japan. This reduction is substantial, especially for inpatient admissions: out-of-pocket medical expenditures for inpatient admissions can reach as much as 25 percent of the average annual income of a 69-year-old patient among those admitted. Since turning 70 in Japan does not coincide with changes in any other confounding factors such as employment or pension receipt, I can plausibly isolate the e ¤ect of the cost-sharing on demand for health care services. This setting also o ¤ers additional advantages over previous empirical settings. While the change in co-payment in Chandra et al. (2010) is limited to o? ce visits and prescription drugs, in Japan cost-sharing for inpatient admissions also changes abruptly at age 70. Thus I can estimate the elasticity of inpatient admissions of the elderly as well. Also, since I have detailed information on outpatient visits, I can investigate the price sensitivity of preventive care in the outpatient setting. 4 In contrast, most existing datasets capture either outpatient visits or inpatient admissions. 5 Finally, I examine the e ¤ect of cost-sharing on exposure to out-ofpocket medical expenditure risk. While there is a large literature on the impact of cost-sharing on health care utilization and health, there is remarkably little 4 Outpatient visits are visits to a clinic or hospital without being admitted. It is common for individuals to visit hospitals for outpatient care rather than clinics (similar to physicians’o? ce visits in the U. S. ) in Japan. 5 In fact, the Agency for Healthcare Research and Quality (AHRQ) has recognized the need to develop a methodology for studying preventive care in an outpatient setting by using inpatient data to identify admissions that should not occur in the presence of su? cient preventive care (AHRQ, 2011). This issue is more discussed in section 4. 5 analysis of the impact of cost-sharing on expenditure risk, which is arguably the primary purpose of health insurance (e. g. , Zeckhauser, 1970). 6 I reach three conclusions. First, I †¦nd that reduced cost-sharing at age 70 discontinuously increases health care consumption. The corresponding elasticity is modest, around -0. 2 for both outpatient visits and inpatient admissions. As it turns out, the elasticity I estimate is similar to the estimates found in the HIE for the non-elderly, and slightly larger than that estimates for the elderly by Chandra et al. (2010). The †¦nding indicates that the price elasticity of the elderly is similar in magnitude to that of the non-elderly. Second, looking in more detail at patterns of utilization, I †¦nd that lower costsharing is associated with increase in the number of patients presenting with both serious and non-serious diagnoses. Thus, I †¦nd that demand for both more and less bene†¦cial care is price sensitive. For example, I †¦nd large increases in outpatient visits for diagnoses that are de†¦ned as Ambulatory Care Sensitive Conditions (ACSCs), for which proper and early treatment reduce subsequent avoidable admissions. Finally, on the bene†¦t side, I do not †¦nd statistically signi†¦cant improvements in health at age 70. Both mortality, and self reported physical and mental health are unchanged despite utilization changes, implying that patient cost-sharing can reduce health care utilization without adversely a ¤ecting health. But I †¦nd that 6 See Chandra et al. (2008) and Swartz (2010) for an excellent summary of the past literature on cost-sharing and utilization. 6 lower cost-sharing at age 70 yield reductions in out-of-pocket expenditures since lower cost-sharing overwhelms the increase in utilization. I then compute the gain in risk premiums through increased generosity in health insurance at age 70 by combining the expected utility framework with the quantile RD estimates. Although somewhat speculative, my estimates suggest that the welfare gain of risk protection from lower cost-sharing is small for most, suggesting that the social cost of lower cost-sharing may outweigh the social bene†¦t. Taken together, this study shows that increased cost-sharing may be achieved without decreasing the total welfare. This paper is related to an in†¡ uential literature that examines Medicare eligibility at age 65 in a similar RD framework as this paper. Card et al. (2009) and Chay et al. (2010) show that Medicare eligibility has a modest positive e ¤ect on the health of those above age 65. However, these studies cannot de†¦nitely address whether these health improvements are the result of health insurance provision per se (extensive margin) or changes in health insurance generosity (intensive margin). This issue arises because turning age 65 in the US entails a number of coincident changes: transitions from private to public health insurance, increases in multiple coverage due to supplementary coverage (e. g. , Medigap), and fewer gatekeeper restrictions due to the change from managed care to fee-for-services. Indeed, Card et al. (2009) conclude that it is not clear whether reductions in mortality are due 7 to health insurance provision or generosity. 7 In contrast, the change at age 70 only re†¡ ects increases in bene†¦t generosity in my case. The rest of the paper is organized as follows. Section 1. 2 brie†¡ describes y the institutional background. Section 1. 3 describes the data, and presents the identi†¦cation strategy. Section 1. 4 shows the main results on utilization. Section 1. 5 turns to the analysis on bene†¦t, and examines the health outcomes as well as risk reduction. Section 1. 6 carries out simple cost-bene†¦t analysis and section 1. 7 concludes. 1. 2. Background This section describes the universal health insurance system in Japan, focusing on the di ¤erences in cost-sharing between the elderly and non-elderly. 8 1. 2. 1. Institutional Setting Japan’ universal health insurance system consists of two parallel subsystems: s employment-based health insurance and National Health Insurance (hereafter, 7 In a companion paper, Card et al. (2008) also †¦nd that both supply-side incentives and shifts in insurance characteristics play an important role for the utilization of health care services. 8 Japan achieved universal health insurance coverage in 1961. See Kondo and Shigeoka (2011) for more details about the e ¤ect of the introduction of universal health insurance on utilization and health. 8 NHI). Employment-based health insurance covers the employees of †¦rms that satisfy certain requirements and employees’dependents. 9 NHI is a residential-based system that provides coverage to everyone else, including the employees of small †¦rms, self-employed workers, the unemployed, and the retired. For this study, there are two important features of Japanese medical system that arguably permits isolation of the patient demand for health care services from responsive behavior by insurers and medical providers: universal coverage and the uniform national fee schedule. First, under universal coverage, patients in Japan have unrestricted choices of medical providers unlike in the U. S where managed-care often restricts the set of the providers at which bene†¦ciaries can receive treatment. For example, it is common for individuals to visit hospitals for outpatient care rather than clinics (similar to physicians’o? ce visits in the U. S. ) in Japan. Patients have direct access to specialist care without going through a gatekeeper or referral system. There is also no limit on the number of visits a patient can have. Patients may go either hospitals or clinics for outpatient visits and go to hospitals for admissions, unlike in the U. S. , where those who lack insurance use hospitals as primary care. 9 Employment-based health insurance is further divided into two forms; employees of large †¦rms and government employees are covered by union-based health insurance, whereas employees of small †¦rms are covered by government-administered health insurance. Enrollment in the government-administered health insurance program is legally required for all employers with †¦ve or more employees unless the employer has its own union-based health insurance program. 9 Second and perhaps more importantly, all medical providers are reimbursed by the national fee schedule, which is uniformly applied to all patients regardless of patients’ insurance type and age. Since patients’ insurance type and age do not a ¤ect reimbursements, physicians have few incentives to in†¡ uence patients’ demand. 10 For example, from physicians’ perspective, there are few reasons to delay surgeries until age 70 because reimbursements do not di ¤er by age of patients. The uniform fee schedule also implies that there is little room for cost-shifting, a well-known behavior of medical providers in the U. S. where they charge private insurers higher prices to compensate for losses from bene†¦ciaries of public health insurance (Cutler, 1998). 11 As a result, while people in Japan enjoy the relatively easy access to health care services, Japan has the highest per-capita number of physician visits among all OECD countries; physician consultations (number per capita per year) is 13. 2 in Japan, which is more than three times larger than 3. 9 in the U. S. (OECD, 2011). While some blame universal coverage for high frequency of unnecessary physician visits, others claim that these medical services contribute to the longevity of the Japanese (Hashimoto et al. , 2011). 10 The national schedule is usually revised biennially by the Ministry of Health, Labor and Welfare through negotiation with the Central Social Insurance Medical Council, which includes representatives of the public, payers, and providers. See Ikegami (1991) and Ikegami and Campbell (1995) on details. 11 Japan introduced prospective payment for hospitals since 2003 for only acute diseases, but the reimbursement does not di ¤er by the insurance type or age of the patients. See Shigeoka and Fushimi (2011). 10 1. 2. 2. Changes in Cost-sharing at Age 70 Unlike a normal health insurance plan that has three basic components (a deductible, a coinsurance rate, and a stop-loss), there is no deductible in Japan. 12 A patient pays coinsurance which is the percentage of medical costs for which bene†¦ciary is responsible. 13 Since inpatient admissions are more expensive than outpatient visits, coinsurance rate of inpatient admissions tends to be set lower than that of outpatient visits in Japan. The insurer pays the remaining fraction of expenses until the bene†¦ciary meets the stop-loss (also known as the maximum out-of-pocket), and the insurer pays all expenses above the stop-loss. The Japanese government passed the Act on Assurance of Medical Care for Elderly People, which imposed cost-sharing on those over 70 starting in February 1983 after the 10 years of generous policy that provided free care for the elderly over age 70. 14 Even after its introduction, there has been still a large discrepancy in cost-sharing between those just above and below age 70 as described in detail below. 12 A deductible is lump-sum amount of spending that bene†¦ciary must pay before the insurers cover any expenses. 13 14 Typically coinsurance is applied for medical costs above the deductible in the US. Japan introduced free care for the elderly in January 1973. However, this policy substantially increased the utilization of health care services and medical expenditures. In fact, the medical expenditures rose by 55 percent in just one year, from 429 billion Yen in 1973 to 665 billion Yen in 1974. Due to data availability, this study focuses on the period after the implementation of the cost-sharing for the elderly. 11 The elderly become eligible for lower cost-sharing on the †¦rst day of the next month after they turn 70. They receive a notice from the government that indicates that they are eligible for Elderly Health Insurance and a new insurance card, which they can present at medical institutions to receive the discount. Elderly Health Insurance is also provided to bedridden people between the ages of 65 and 70. Figure 1. Shows the age pro†¦le of health insurance coverage from the pooled Patient Surveys described later in the data section. Age is aggregated into months. The percent of patients with Elderly Health Insurance abruptly rises from 20 percent to nearly 100 percent once they turn 70. I also see a small jump in Elderly Health Insurance coverage at age 65. Table 1. 2 displays the cost-sharing formulas for those below and above age 70 for outpatient visits and inpatient admissions separately for each survey year of the Patient Survey. For those below age 70, the coinsurance rate is determined by the type of health insurance (employment-based health insurance or NHI), employment status (retired or not), and whether the person is a (former) employee or is a dependent. Employment-based health insurance had a lower coinsurance rate than NHI until 2003, when both were equalized to a common coinsurance rate of 30 percent for both outpatient visits and inpatient admissions. At the age of 70, people switch to Elderly Health Insurance and in principle face the same 12 cost-sharing. 15 Note that on the other hand, physicians’reimbursements are based on a national fee schedule that does not depend on patients’insurance type or age. Figure 1. 2 illustrates the amount of out-of-pocket expenditures with respect to total monthly medical expenditures for year 2008 as an example based on the formula in Table 1. 2. Unlike in the US, in Japan, the stop-loss is set monthly rather than annually. 16 The horizontal axis is total monthly medical expenditures, and the vertical axis shows the corresponding monthly out-of-pocket medical expenditures. Since the stop-loss di ¤ers for outpatient visits and inpatient admissions for those over age 70, I show separate lines for outpatient visits and inpatient admissions. For those below 70, there is no distinction between these two services in 2008. Figure 1. 2 shows that the price schedule of out-of-pocket medical expenditures for those above 70 always lies below that of those below age 70. Unfortunately, the actual out-of-pocket expenditure information among the general population is only available for year 2007, and this data does not distinguish outpatient visits and inpatient admissions. However, I have individual level insurance claim data for outpatient visits and inpatient admissions respectively, 15 In fact, high income earners above age 70 are charged higher coinsurance rate (20 percent instead of 10 percent) since October 2002. The bar for high income level is set quite high, so that a limited number of patients is in this category (7 percent according to Ikegami et al. 2011). Since income is not collected in the Survey of Medical Care Activities in Public Health Insurance, which I use to derive the monthly out-of-pocket expenditures, I compute the monthly out-of-pocket expenditures for a normal family. See Appendix A. 1 for detai