Total foreign tourists in Bali in 2019.
\\n\\n
IntechOpen was founded by scientists, for scientists, in order to make book publishing accessible around the globe. Over the last two decades, this has driven Open Access (OA) book publishing whilst levelling the playing field for global academics. Through our innovative publishing model and the support of the research community, we have now published over 5,700 Open Access books and are visited online by over three million academics every month. These researchers are increasingly working in broad technology-based subjects, driving multidisciplinary academic endeavours into human health, environment, and technology.
\\n\\nBy listening to our community, and in order to serve these rapidly growing areas which lie at the core of IntechOpen's expertise, we are launching a portfolio of Open Science journals:
\\n\\nAll three journals will publish under an Open Access model and embrace Open Science policies to help support the changing needs of academics in these fast-moving research areas. There will be direct links to preprint servers and data repositories, allowing full reproducibility and rapid dissemination of published papers to help accelerate the pace of research. Each journal has renowned Editors in Chief who will work alongside a global Editorial Board, delivering robust single-blind peer review. Supported by our internal editorial teams, this will ensure our authors will receive a quick, user-friendly, and personalised publishing experience.
\\n\\n"By launching our journals portfolio we are introducing new, dedicated homes for interdisciplinary technology-focused researchers to publish their work, whilst embracing Open Science and creating a unique global home for academics to disseminate their work. We are taking a leap toward Open Science continuing and expanding our fundamental commitment to openly sharing scientific research across the world, making it available for the benefit of all." Dr. Sara Uhac, IntechOpen CEO
\\n\\n"Our aim is to promote and create better science for a better world by increasing access to information and the latest scientific developments to all scientists, innovators, entrepreneurs and students and give them the opportunity to learn, observe and contribute to knowledge creation. Open Science promotes a swifter path from research to innovation to produce new products and services." Alex Lazinica, IntechOpen founder
\\n\\nIn conclusion, Natalia Reinic Babic, Head of Journal Publishing and Open Science at IntechOpen adds:
\\n\\n“On behalf of the journal team I’d like to thank all our Editors in Chief, Editorial Boards, internal supporting teams, and our scientific community for their continuous support in making this portfolio a reality - we couldn’t have done it without you! With your support in place, we are confident these journals will become as impactful and successful as our book publishing program and bring us closer to a more open (science) future.”
\\n\\nWe invite you to visit the journals homepage and learn more about the journal’s Editorial Boards, scope and vision as all three journals are now open for submissions.
\\n\\nFeel free to share this news on social media and help us mark this memorable moment!
\\n\\n\\n"}]',published:!0,mainMedia:{caption:"",originalUrl:"/media/original/237"}},components:[{type:"htmlEditorComponent",content:'
After years of being acknowledged as the world's leading publisher of Open Access books, today, we are proud to announce we’ve successfully launched a portfolio of Open Science journals covering rapidly expanding areas of interdisciplinary research.
\n\n\n\nIntechOpen was founded by scientists, for scientists, in order to make book publishing accessible around the globe. Over the last two decades, this has driven Open Access (OA) book publishing whilst levelling the playing field for global academics. Through our innovative publishing model and the support of the research community, we have now published over 5,700 Open Access books and are visited online by over three million academics every month. These researchers are increasingly working in broad technology-based subjects, driving multidisciplinary academic endeavours into human health, environment, and technology.
\n\nBy listening to our community, and in order to serve these rapidly growing areas which lie at the core of IntechOpen's expertise, we are launching a portfolio of Open Science journals:
\n\nAll three journals will publish under an Open Access model and embrace Open Science policies to help support the changing needs of academics in these fast-moving research areas. There will be direct links to preprint servers and data repositories, allowing full reproducibility and rapid dissemination of published papers to help accelerate the pace of research. Each journal has renowned Editors in Chief who will work alongside a global Editorial Board, delivering robust single-blind peer review. Supported by our internal editorial teams, this will ensure our authors will receive a quick, user-friendly, and personalised publishing experience.
\n\n"By launching our journals portfolio we are introducing new, dedicated homes for interdisciplinary technology-focused researchers to publish their work, whilst embracing Open Science and creating a unique global home for academics to disseminate their work. We are taking a leap toward Open Science continuing and expanding our fundamental commitment to openly sharing scientific research across the world, making it available for the benefit of all." Dr. Sara Uhac, IntechOpen CEO
\n\n"Our aim is to promote and create better science for a better world by increasing access to information and the latest scientific developments to all scientists, innovators, entrepreneurs and students and give them the opportunity to learn, observe and contribute to knowledge creation. Open Science promotes a swifter path from research to innovation to produce new products and services." Alex Lazinica, IntechOpen founder
\n\nIn conclusion, Natalia Reinic Babic, Head of Journal Publishing and Open Science at IntechOpen adds:
\n\n“On behalf of the journal team I’d like to thank all our Editors in Chief, Editorial Boards, internal supporting teams, and our scientific community for their continuous support in making this portfolio a reality - we couldn’t have done it without you! With your support in place, we are confident these journals will become as impactful and successful as our book publishing program and bring us closer to a more open (science) future.”
\n\nWe invite you to visit the journals homepage and learn more about the journal’s Editorial Boards, scope and vision as all three journals are now open for submissions.
\n\nFeel free to share this news on social media and help us mark this memorable moment!
\n\n\n'}],latestNews:[{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"},{slug:"introducing-intechopen-book-series-a-new-publishing-format-for-oa-books-20210915",title:"Introducing IntechOpen Book Series - A New Publishing Format for OA Books"}]},book:{item:{type:"book",id:"7104",leadTitle:null,fullTitle:"Gastroesophageal Reflux Disease - Theory and Research",title:"Gastroesophageal Reflux Disease",subtitle:"Theory and Research",reviewType:"peer-reviewed",abstract:"Gastroesophageal reflux disease (GERD) is a very common, global clinical problem. It affects any age group, both males and females, and is seen mainly in developed countries, especially among obese individuals. GERD needs to be treated to prevent nuisance symptoms and long-term complications. The book deals with the diagnosis of GERD, including clinical presentations and diagnostic investigations, and describes the different available conservative, medical, surgical and endoscopic treatments. The book also covers gastroesophageal disease in children, its presentation and treatment. It also deals with the refractory type of gastroesophageal disease including different theories. It is very useful for gastroenterologists and upper gastrointestinal surgeons.",isbn:"978-1-78984-481-8",printIsbn:"978-1-78984-480-1",pdfIsbn:"978-1-83962-105-5",doi:"10.5772/intechopen.73897",price:100,priceEur:109,priceUsd:129,slug:"gastroesophageal-reflux-disease-theory-and-research",numberOfPages:74,isOpenForSubmission:!1,isInWos:null,isInBkci:!1,hash:"738f7a3225a21396cd5d58099b8b2d87",bookSignature:"Ali Ibrahim Yahya",publishedDate:"April 3rd 2019",coverURL:"https://cdn.intechopen.com/books/images_new/7104.jpg",numberOfDownloads:5039,numberOfWosCitations:1,numberOfCrossrefCitations:1,numberOfCrossrefCitationsByBook:0,numberOfDimensionsCitations:2,numberOfDimensionsCitationsByBook:0,hasAltmetrics:0,numberOfTotalCitations:4,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"February 26th 2018",dateEndSecondStepPublish:"May 1st 2018",dateEndThirdStepPublish:"June 30th 2018",dateEndFourthStepPublish:"September 18th 2018",dateEndFifthStepPublish:"November 17th 2018",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6",editedByType:"Edited by",kuFlag:!1,featuredMarkup:null,editors:[{id:"222438",title:"Prof.",name:"Ali Ibrahim",middleName:null,surname:"Yahya",slug:"ali-ibrahim-yahya",fullName:"Ali Ibrahim Yahya",profilePictureURL:"https://mts.intechopen.com/storage/users/222438/images/system/222438.jfif",biography:"Dr. Ali Ibrahim Yahya is dean of Zliten Medical School. \r\nHis previous positions include teaching medical students at Misrata University Medical School till 2007, teaching medical students at Al Mergeb Medical School from 2007 and holding the professor of surgery position at Al Mergeb University under Koms medical school. In 2017, dr. Yahya\\'s academic file was transferred to Al Asmarya University and he has begun acting as dean of Zliten Medical School which started in 2013.",institutionString:"Al Asmarya University for Islamic Sciences",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"4",totalChapterViews:"0",totalEditedBooks:"1",institution:null}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"181",title:"Gastroenterology",slug:"gastroenterology"}],chapters:[{id:"65991",title:"Introductory Chapter: Gastroesophageal Reflux Disease",doi:"10.5772/intechopen.84879",slug:"introductory-chapter-gastroesophageal-reflux-disease",totalDownloads:876,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:null,signatures:"Ali I. Yahya",downloadPdfUrl:"/chapter/pdf-download/65991",previewPdfUrl:"/chapter/pdf-preview/65991",authors:[{id:"222438",title:"Prof.",name:"Ali Ibrahim",surname:"Yahya",slug:"ali-ibrahim-yahya",fullName:"Ali Ibrahim Yahya"}],corrections:null},{id:"63453",title:"Challenges to Unravel Mechanisms of GERD",doi:"10.5772/intechopen.80793",slug:"challenges-to-unravel-mechanisms-of-gerd",totalDownloads:857,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Gastroesophageal reflux disease (GERD) encompasses a spectrum of disorders caused by a reflux of gastric contents into the esophagus or complications of gastroesophageal reflux. Although depending on the definition, the prevalence of GERD is higher in the West than in the East, and the prevalence has been slightly increasing, so that the clinicians, even though they are not gastroenterologists, must encounter GERD patients and treat them. However, the clinicians do feel difficulty in treating GERD patients, since prescription of acid neutralizing agents, such as proton pump inhibitors (PPIs), sometimes fail to resolve their complaints. This may be partly explained by the discrepancies between clinical complaint and endoscopic findings; some patients present endoscopic esophagitis while some do not, and be partly explained by the potentially wide spectrum of pathophysiological etiologies than has been thought. This chapter describes current knowledge on heterogeneous mechanisms of GERD development. Clarifying the mechanisms of GERD on the individual basis may realize conceptual shift from uniform prescription of acid neutralizing agents to establishment of patient-oriented therapies.",signatures:"Shouji Shimoyama",downloadPdfUrl:"/chapter/pdf-download/63453",previewPdfUrl:"/chapter/pdf-preview/63453",authors:[{id:"59239",title:"Dr.",name:"Shouji",surname:"Shimoyama",slug:"shouji-shimoyama",fullName:"Shouji Shimoyama"}],corrections:null},{id:"63508",title:"Refractory Gastroesophageal Reflux Disease (GERD) Symptoms",doi:"10.5772/intechopen.80792",slug:"refractory-gastroesophageal-reflux-disease-gerd-symptoms",totalDownloads:1335,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Gastroesophageal reflux disease (GERD) is a chronic condition in which patients suffer troublesome symptoms and/or complications as the reflux of stomach contents occurs. GERD is a common disease worldwide with the range of estimated prevalence 18.1–27.8% in North America, 8.8–25.9% in Europe, 2.5–7.8% in East Asia, 8.7–33.1% in the Middle East, 11.6% in Australia and 23.0% in South America. It causes significant morbidity, considerable decrease of quality of life and high costs of exams and treatment derived from repeated visit doctor. The patients with GERD suffer from typical symptoms such as heartburn and regurgitation, as well as other atypical symptoms including chest pain, cough, asthma, and hoarseness. With the usage of pump inhibitors (PPIs) in clinic, a dramatic improvement in symptom resolution and life quality, as well as in mucosal healing is expected. However, the treatment of GERD fails in a proportion of patients despite the high efficacy of PPIs. This situation is getting more and more common in clinical practices. In this chapter, we will discuss about this difficult situation, emphasizing diagnosis and treatment, combined with suggested management of these patients.",signatures:"Xia Chen and Fei Wang",downloadPdfUrl:"/chapter/pdf-download/63508",previewPdfUrl:"/chapter/pdf-preview/63508",authors:[{id:"250058",title:"Dr.",name:"Xia",surname:"Chen",slug:"xia-chen",fullName:"Xia Chen"}],corrections:null},{id:"65881",title:"Clinical Picture of Gastroesophageal Reflux Disease in Children",doi:"10.5772/intechopen.82453",slug:"clinical-picture-of-gastroesophageal-reflux-disease-in-children",totalDownloads:1029,totalCrossrefCites:1,totalDimensionsCites:2,hasAltmetrics:0,abstract:"Gastroesophageal reflux (GER), defined as the passage of gastric contents into the esophagus, is a normal physiologic process occurring several times per day in healthy infants, children, and adults. The majority of GER episodes occur in the postprandial period, last in <3 min, and cause few or no symptoms. Conversely, when the reflux of gastric contents into the esophagus causes troublesome symptoms and/or complications, we talk about “gastroesophageal reflux disease (GERD).” Distinguishing physiologic GER from GERD may often be tricky for clinicians, especially in infants. The typical presentation of GERD includes the following symptoms: recurrent regurgitation, vomiting, weight loss or poor weight gain, excessive crying and irritability in infants, heartburn or chest pain, ruminative behavior, hematemesis, and dysphagia. Besides these esophageal symptoms, there is a set of extra-esophageal symptoms, mainly respiratory, which may occur along with typical symptoms or may represent the only clinical picture of GERD: odynophagia, wheezing, stridor, cough, hoarseness, dental erosions, and apnea/apparent life-threatening events (ALTEs). While infantile GER tends to resolve spontaneously and does not deserve pharmacological treatment, GERD management includes lifestyle changes, pharmacologic therapy, and surgery. Therefore, a proper diagnosis of these two conditions, besides other possible conditions mimicking reflux, is crucial in order to target the treatment, avoiding the overuse of antacid drugs that currently represents a major source of concern.",signatures:"Paolo Quitadamo and Annamaria Staiano",downloadPdfUrl:"/chapter/pdf-download/65881",previewPdfUrl:"/chapter/pdf-preview/65881",authors:[{id:"252446",title:"Prof.",name:"Annamaria",surname:"Staiano",slug:"annamaria-staiano",fullName:"Annamaria Staiano"},{id:"252449",title:"Dr.",name:"Paolo",surname:"Quitadamo",slug:"paolo-quitadamo",fullName:"Paolo Quitadamo"}],corrections:null},{id:"63589",title:"The Role of Increased Gastric Acid Secretion and Reactive Oxygen Species in the Pathophysiology of Reflux Esophagitis",doi:"10.5772/intechopen.81021",slug:"the-role-of-increased-gastric-acid-secretion-and-reactive-oxygen-species-in-the-pathophysiology-of-r",totalDownloads:944,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Gastroesophageal reflux (GER) disease is a chronic disease characterized by the recurrent ascension of some of the gastric contents in the esophagus. Indeed, gastric acid secreted by parietal cells and the gastric pepsin activity, but not the intestinal alkaline content, are the most important pathogenic factors of GER. Several pathophysiological mechanisms are involved, the most important of which is the imbalance of the redox state of the esophageal tissue. Indeed, several studies have shown that reflux esophagitis is mediated by oxygen-derived free radicals. In this chapter, we describe the pathophysiology and important pathways, especially acid gastric contents and reactive oxygen species involved in pathology of GER.",signatures:"Mohamed-Amine Jabri and Hichem Sebai",downloadPdfUrl:"/chapter/pdf-download/63589",previewPdfUrl:"/chapter/pdf-preview/63589",authors:[{id:"217733",title:"Dr.",name:"Hichem",surname:"Sebai",slug:"hichem-sebai",fullName:"Hichem Sebai"},{id:"259950",title:"Dr.",name:"Mohamed-Amine",surname:"Jabri",slug:"mohamed-amine-jabri",fullName:"Mohamed-Amine Jabri"}],corrections:null}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},subseries:null,tags:null},relatedBooks:[{type:"book",id:"6164",title:"Metagenomics for Gut Microbes",subtitle:null,isOpenForSubmission:!1,hash:"672dc229a6318cc2b7b7ef16b314e046",slug:"metagenomics-for-gut-microbes",bookSignature:"Ranjith N. 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He has been a practicing gastroenterologist for twenty-two years. He has a special interest in inflammatory bowel disease, eosinophilic esophagitis, gastrointestinal motility, and dysphagia. Dr. Ahmed also serves as an editor in chief for the World Journal of Gastrointestinal Oncology.",institutionString:"Thomas Jefferson University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"8",totalChapterViews:"0",totalEditedBooks:"2",institution:{name:"Thomas Jefferson University",institutionURL:null,country:{name:"United States of America"}}},equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10315",title:"Crohn’s Disease",subtitle:"Recent Advances",isOpenForSubmission:!1,hash:"1ddf7dda3ec43e99aefd9d1ac1ecc35e",slug:"crohn-s-disease-recent-advances",bookSignature:"Monjur Ahmed",coverURL:"https://cdn.intechopen.com/books/images_new/10315.jpg",editedByType:"Edited by",editors:[{id:"206355",title:"Associate Prof.",name:"Monjur",surname:"Ahmed",slug:"monjur-ahmed",fullName:"Monjur Ahmed"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10309",title:"Endoscopy in Small Bowel Diseases",subtitle:null,isOpenForSubmission:!1,hash:"a7c515b4add9ecf0a5de381a72d145e5",slug:"endoscopy-in-small-bowel-diseases",bookSignature:"Mahesh Goenka, Usha Goenka and Gajanan A. 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Cristina Álvarez-Mateos",dateSubmitted:"June 28th 2016",dateReviewed:"August 12th 2016",datePrePublished:null,datePublished:"February 1st 2017",book:{id:"5372",title:"Eating Disorders",subtitle:"A Paradigm of the Biopsychosocial Model of Illness",fullTitle:"Eating Disorders - A Paradigm of the Biopsychosocial Model of Illness",slug:"eating-disorders-a-paradigm-of-the-biopsychosocial-model-of-illness",publishedDate:"February 1st 2017",bookSignature:"Ignacio Jauregui-Lobera",coverURL:"https://cdn.intechopen.com/books/images_new/5372.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",editors:[{id:"323887",title:"Prof.",name:"Ignacio",middleName:null,surname:"Jáuregui-Lobera",slug:"ignacio-jauregui-lobera",fullName:"Ignacio Jáuregui-Lobera"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:[{id:"188555",title:"Prof.",name:"Francisco J.",middleName:null,surname:"Vaz-Leal",fullName:"Francisco J. Vaz-Leal",slug:"francisco-j.-vaz-leal",email:"fjvazleal@gmail.com",position:null,institution:null},{id:"188719",title:"Dr.",name:"María Cristina",middleName:null,surname:"Álvarez Mateos",fullName:"María Cristina Álvarez Mateos",slug:"maria-cristina-alvarez-mateos",email:"cristinaalvarezmateos@gmail.com",position:null,institution:null},{id:"195142",title:"Dr.",name:"Laura",middleName:null,surname:"Rodríguez Santos",fullName:"Laura Rodríguez Santos",slug:"laura-rodriguez-santos",email:"laura@unex.es",position:null,institution:null},{id:"195143",title:"Dr.",name:"María I",middleName:null,surname:"Ramos Fuentes",fullName:"María I Ramos Fuentes",slug:"maria-i-ramos-fuentes",email:"miramos@unex.es",position:null,institution:null}]}},chapter:{id:"52200",slug:"eating-disorders-as-new-forms-of-addiction",signatures:"Francisco J. Vaz-Leal, María I. Ramos-Fuentes, Laura Rodríguez-\nSantos and M. Cristina Álvarez-Mateos",dateSubmitted:"June 28th 2016",dateReviewed:"August 12th 2016",datePrePublished:null,datePublished:"February 1st 2017",book:{id:"5372",title:"Eating Disorders",subtitle:"A Paradigm of the Biopsychosocial Model of Illness",fullTitle:"Eating Disorders - A Paradigm of the Biopsychosocial Model of Illness",slug:"eating-disorders-a-paradigm-of-the-biopsychosocial-model-of-illness",publishedDate:"February 1st 2017",bookSignature:"Ignacio Jauregui-Lobera",coverURL:"https://cdn.intechopen.com/books/images_new/5372.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",editors:[{id:"323887",title:"Prof.",name:"Ignacio",middleName:null,surname:"Jáuregui-Lobera",slug:"ignacio-jauregui-lobera",fullName:"Ignacio Jáuregui-Lobera"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:[{id:"188555",title:"Prof.",name:"Francisco J.",middleName:null,surname:"Vaz-Leal",fullName:"Francisco J. 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\r\n\tDementia has become the leading neurological problem for human beings associated not only with the old population but newer generations as well. Various environmental and genetic factors are reported to be involved in the disease. This book hopes to comprise a detailed discussion on the relationship between different brain areas and cognition. Pathophysiology of dementia containing molecular mechanisms will be explained as well as the memory function that depends on the neuronal circuits among the different brain areas. Other neuronal circuits involved in memory, learning, and dementia will also be discussed. Mechanism of neuronal circuits involved in memory consolidation, the main neurological disorders associated with dementia, dementia screening, and its validation, along with neurophysiological tests, will be covered. Another aspect that this book hopes to cover is the modern therapeutic trends for the management of dementia. Biologics will be changing the therapeutic world of dementia in the near future. We aim to have a project that consists of various cutting-edge technologies that have been adopted for the treatment of dementia.
",isbn:"978-1-80356-783-9",printIsbn:"978-1-80356-782-2",pdfIsbn:"978-1-80356-784-6",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,isSalesforceBook:!1,isNomenclature:!1,hash:"d40f707b9ef020bb202be89404f77a1e",bookSignature:"Dr. Devendra Kumar, Prof. Sushil Kumar Singh and Dr. Ankit Ganeshpurkar",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11637.jpg",keywords:"Cognition, Neuronal Circuits, Learning and Memories, Memory Consolidation in Dementia, Neuropsychological Tests, Treatments, New Therapeutic Tools, Biologics, Brain Areas and Cognition, Neuropsychology, Neurological Disorders, Modern Therapeutic Trends",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"April 1st 2022",dateEndSecondStepPublish:"June 16th 2022",dateEndThirdStepPublish:"August 15th 2022",dateEndFourthStepPublish:"November 3rd 2022",dateEndFifthStepPublish:"January 2nd 2023",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"11 days",secondStepPassed:!0,areRegistrationsClosed:!1,currentStepOfPublishingProcess:3,editedByType:null,kuFlag:!1,biosketch:"Dr. Devendra Kumar's research interest includes the Design, Devolvement, and Biological screening of Small molecules, Metal complexes, Peptides for the management of Alzheimer's disease, Fragile X Syndrome, and Tuberculosis. Dr. Kumar worked on Alzheimer's disease and developed CNS active small molecules such as Acetylcholine, Butyl choline, Beta-secretase 1, Matrix Metalloprotein-2 and 9 inhibitors, and NMDA receptor antagonist.",coeditorOneBiosketch:"Dr. Singh is an eminent scientist and teacher in the field of neurodegenerative disorders. He was the Principal Investigator in the Development of bioactive molecules as therapeutic agents for Alzheimer’s disease and screening of their toxicity; IIT (BHU), Varanasi, as well as the Principal Investigator in Design and synthesis, is of Matrix Metallo Proteinase (MMP -2 & 9) inhibitors as therapeutic agents for Alzheimer’s disease; DBT, New Delhi.",coeditorTwoBiosketch:"Dr. Ganeshpurkar's objective is to create a niche in the field of medicinal chemistry and drug design research with an emphasis on the use of computational tools and artificial intelligence in lead identification and optimization. His research interest is in silico drug designing, lead identification, and optimization as well as design, synthesis and biological evaluation of Novel leads for various pathophysiological conditions such as Alzheimer’s and other neurodegenerative diseases.",coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"454030",title:"Dr.",name:"Devendra",middleName:null,surname:"Kumar",slug:"devendra-kumar",fullName:"Devendra Kumar",profilePictureURL:"https://mts.intechopen.com/storage/users/454030/images/system/454030.jpg",biography:"Dr. Devendra Kumar is an Assistant Professor in the Department of Pharmacy. Dr. Kumar did his Ph.D. in Pharmaceutical Sciences from the Indian Institute of Technology (Banaras Hindu University) and completed his postdoctoral research at the University of Texas, USA (2019-2021). His research interest includes Design, Devolvement, and Biological screening of Small molecules, Metal complexes, Peptides for the management of Alzheimer\\'s disease, Fragile X Syndrome, and Tuberculosis. Dr. Kumar worked on Alzheimer\\'s disease and developed CNS active small molecules such as Acetylcholine, Butyl choline, Beta-secretase 1, Matrix Metalloprotein-2 and 9 inhibitors, and NMDA receptor antagonist.\nAlong with the Drug Discovery, he is also working on the Pathophysiology of Fragile X Syndrome. His work on the Fragile X Syndrome includes identification of spine abnormality and the role of Microglia. The study of Microglia-Neuron communication in genetically modified animals is his thrust area. He is also working on the gene-editing tools using CRISPR (Clustered Regularly Interspaced Short Palindromic Repeats) technology and the development of Blood-Brain Barrier penetrating Polymers as a delivery vehicle for CRISPR molecules.",institutionString:"Dehradun Institute of Technology University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"0",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"Dehradun Institute of Technology University",institutionURL:null,country:{name:"India"}}}],coeditorOne:{id:"182874",title:"Prof.",name:"Sushil Kumar",middleName:null,surname:"Singh",slug:"sushil-kumar-singh",fullName:"Sushil Kumar Singh",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bSAm4QAG/Profile_Picture_2022-04-07T11:17:21.JPG",biography:"Principal Investigator, Development of bioactive molecules as therapeutic agent for Alzheimer’s disease and screening their toxicity; IIT (BHU), Varanasi.\r\nPrincipal Investigator, Design and synthesis is of Matrix Metallo Proteinase (MMP -2 & 9) inhibitors as therapeutic agents for Alzheimer’s disease; DBT, New Delhi.\r\nCo- Principal Investigator, Cestocidal activity of glands and hairs of fruits of Mallotus phillippinensis (Kampillaka Plant); ICMR, New Delhi.\r\nPrincipal Investigator, Ethno-medicinal plants as a source of new therapeutic agents against psoriasis; National medicinal Plant Board, AYUSH, New Delhi.\r\nPrincipal Investigator, Isolation of marker compounds from Withania somnifera; Natreon Inc., Kolkata.\r\nPrincipal Investigator, Isolation of marker Compounds from natural Sources; Drug Research and Development Center, Kolkata.\r\nOne of the Investigators of the Centre, Establishment of facilities for identification, chemical characterization, standardization and quality control of medicinal plants found in tribal area in central India; DST, New Delhi.",institutionString:"Banaras Hindu University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"0",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"Banaras Hindu University",institutionURL:null,country:{name:"India"}}},coeditorTwo:{id:"465935",title:"Dr.",name:"Ankit",middleName:null,surname:"Ganeshpurkar",slug:"ankit-ganeshpurkar",fullName:"Ankit Ganeshpurkar",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00003RKF6EQAX/Profile_Picture_2022-04-07T11:30:06.jpg",biography:null,institutionString:"Bharati Vidyapeeth Deemed University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"0",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"Bharati Vidyapeeth Deemed University",institutionURL:null,country:{name:"India"}}},coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"18",title:"Neuroscience",slug:"life-sciences-neuroscience"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"453623",firstName:"Silvia",lastName:"Sabo",middleName:null,title:"Mrs.",imageUrl:"https://mts.intechopen.com/storage/users/453623/images/20396_n.jpg",email:"silvia@intechopen.com",biography:null}},relatedBooks:[{type:"book",id:"6628",title:"Circadian Rhythm",subtitle:"Cellular and Molecular Mechanisms",isOpenForSubmission:!1,hash:"628bbcbfaf54a56710498540efe51b87",slug:"circadian-rhythm-cellular-and-molecular-mechanisms",bookSignature:"Mohamed Ahmed El-Esawi",coverURL:"https://cdn.intechopen.com/books/images_new/6628.jpg",editedByType:"Edited by",editors:[{id:"191770",title:"Dr.",name:"Mohamed A.",surname:"El-Esawi",slug:"mohamed-a.-el-esawi",fullName:"Mohamed A. 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It is proven by a report by World Tourism Organization (UNWTO) explains that foreign tourism development that has been submitted to UNWTO World Tourism Barometer data in January 2019 indicates that international tourists have grown by 6% in 2018 and the UNWTO estimates 1.4 billion will be achieved in 2020 considering stronger economic growth, affordable flight, technology development, new business models and broader visa facilitation in the whole world that accelerates tourism growth for the last few years [1].
This expectation, however, crushes due to corona virus (Covid-19) pandemic that creates disturbance in global tourism. The newest report from the UNWTO explains that travel restrictions cause deterioration in tourism activities [2, 3].
Based on the report, almost all global destinations enact a travel restriction since January 2020. A full restriction of traveling also applies as an effort to surmount the pandemic. According to a research in April 6, 96 percent destinations in the whole world apply travel restrictions. There are 90 destinations that completely or partially close the border for tourists, whereas other 44 destinations are closed for specific tourists depending on their country of origin.
The increasingly threatened tourism sector causes the UNWTO to urge the governments to review the travel restrictions. If it is considered as safe, then the travel restrictions are immediately lifted.
The UNWTO global review suggests that global areas are mostly consistent in encountering the Covid-19 pandemic. Africa, Asia Pacific and Middle East, based on accumulation, have set restriction in almost 100% destinations regarding the Covid-19 since January 2020. In America, 92 percent destinations have taken the same measure as well as Europe of 93 percent per April 6 data.
Results of an observation indicate that there are four things regarding the restriction measure. First, full or partial border closure for tourists. Second, specific-purpose travel restrictions, such as transit passengers or passengers who are already in a certain location but are not permitted to enter. Third, full or partial flight delay. Fourth, various different measures including requirement for quarantine or self-isolation, medical certificates, visa issuance cancelation or delay. The tourism delay threats the sector since millions of jobs could vanish. Progress made in sustainable economic equality and growth could be canceled.
Indonesia is one of countries that has an income source from tourism foreign exchange. Bali tourism destinations contribute 55.6% of the foreign exchange source. Bali Island relies on income source from tourism to support the regional development. Based on National Bureau of Statistics record in 2019, tourism foreign exchange contribution was 9.346 million USD. Countries that provide the biggest contribution to Bali include Australia 23%, China 16%, United Kingdom 6%, USA 5%, and India 5% [4]. Due to Covid-19 Bali experiences a decline in the number of tourist arrival in the first quarter of 2020 of 42.3% and the decline is estimated to be sharper in the second quarter [3].
The tourism sector performance decline during Covid-19 must be ended. The tourism sector should rise to prevent further problems. This will trigger some questions: how Bali to rise from this darkness to become bright again? Would Bali be able to adapt to the new life order (new normal) by considering cleanliness, health, and safety factors and one of them is minimizing physical contact (contactless) in all business processes of the tourism industry.
Based on several studies, a strategy is needed to resurrect the slumped destinations to keep their competitiveness by using their own internal abilities [5]. This resource-based view is a view that applies basic competitive advantages where the main thing lies in a set of tangible and intangible assets owned by a destination. The theory describes the destination abilities to provide sustainable competitive advantages when resources are managed in such a way that the results will be hard to imitate or create by competitors and in the end it will create competition barriers [6].
The resource-based theory that is rooted from Penrose’s [7] economic theory and strategic theory of Ansoff [7] and Selznick [7] states that competitive advantages in a long term depend on: (1) resources and (2) core competences. It is this resource that differentiates a destination to the competitors. It is durable, hard to imitate, and irreplaceable [8, 9]. Each destination has its own uniqueness that comes from its resource characteristics and abilities, knowledge, and expertise in using the resources make its competitive advantages more durable since resources are relatively fixed in nature [4]. Resources are basically could be classified into two categories, namely: (1) tangible resources and (2) intangible resources. The tangible resources are inputs in the destinations that visible, touchable, and countable. These resources consist of eco-tourism, agro-tourism, alternative tourism, rural tourism, and marine tourism. The intangible resources include factors such as cultural tourism, spiritual, and destination reputation [10]. The most important thing in understanding the intangible resource definition as a tool to develop competitive advantages is the creation of harmonious atmosphere that full of peace between human or community, government, and nature that is based on local wisdom values as a guiding philosophy of a tourism area. Peaceful atmosphere is not the same for each competing destination. The atmosphere could only be felt but invisible. Destinations that could provide a safe, tranquility, and peace feeling will be able to continuously arouse motivation and new ideas beneficial for competitiveness improvement. As stated by [11], intangible resources are harder to imitate and understand than tangible resources.
Grant [8] divides resource groups important for competitive advantages into six groups, namely: physical, technology, finance, human, organization, and reputation. The resource-based theory, however, does not consider all resources owned instead it focuses only on important or strategic resources as a base for its competitive advantage model. Some studies [12, 13] have tried to test resources’ strategic level to destination abilities to create sustainable competitive advantages. The test includes: (1) competing superiority test that evaluates whether the destinations’ certain specific resources provide contribution to differences between the destination and competitors. (2) Impersonation test that analyzes difficulty level of potential and actual competitors in impersonating resources due to, for example, its physical uniqueness, natural beauty, employees’ friendliness, harmony of relationship between people and the nature, human and God, convenience, and religious atmosphere that provides peace and tranquility vibrations. (3) Duration test that analyzes whether the current unique resource benefits provide positive contribution to long term competitive advantages. (4) Accuracy test assesses whether companies that have the resources could utilize their competitive advantages in the market. (5) Substitution ability test analyzes how difficult it is for the competitors to replace resources with other alternatives that able to provide the same advantages.
The fundamental principle of competitive advantages of the resource-based theory is ability improvement of a developed area to act, form, and transform its environment; hence, the main goal is no longer to adapt to the environmental strengths, but to select strategies that allow the best utilization of its resource combination and main competences toward external potential [14]. The competitive advantages that are bigger than the resource-based model occur due to the existence of main competences. Main competences, according Hollensen [14], could be explained from its three characteristics, namely: (1) competence due to a set of unique resources, (2) learning, a competence results in from the accumulation of years of experiences in various fields where the destination dominates it, (3) multiplier effect, a competence that spread to all destination elements in its several product lines or strategic business units. Core competence as clearly stated by Prahalad and Hamel [15] has 3 (three) properties, namely: (1) it creates contribution to consumer values felt, (2) it is difficult for competitor to imitate, and (3) it could be elevated to various broader markets.
Johnson, Allison, Stewart, David [16] classify core competences into 2 (two) broader categories, namely: (1) personal competences, and (2) organizational competences. The personal competences owned by each individual include the following characteristics: knowledge, expertise, abilities, experiences, and personalities. The organizational competences are process and structures that are embedded and tend to stay in the organization although a competence individual leaves the organization. The two competence categories are not always independent of each other but they synergize in the organizational environment. Collection of individual competences could form a more effective way to do something in an organization and are capable of establishing a company culture that attached and embedded within the organization. In addition, company competences could determine type of personal competence most suitable to organization. According to [14] another approach model that is also interesting as a business model for competitive advantage strategy is a Market Orientation View (MOV) model or known as a fit model. The MOV strategic model suggests a company to develop competitive advantages by adjusting its assets to constraints in an environment where the company operates to obtain suitability with its environment.
Kohli and Jaworski [17] opine that a market orientation view is basically an adjustment to market environment. This market orientation model is more understandable as a culture instead of a collection of supporting behaviors and values [18]. The market orientation view (MOV) is understood as a culture with all employees are bound to the creation of superior values for consumers continuously [19]. The MOV model main weakness is that different consumers from different countries could be a very expensive business model. It means that a company could obtain satisfied consumers, but it involves high operational costs to create customer values.
Other important factors that become a fundamental principle for sustainable competitive advantages in globalization era include organizational culture and design. According to Schein [20], culture is an abstraction; however, power produced in social and organizational situation that comes from the cultural factor will strongly attach. If we do not understand the power operation, we will be its victim. The cultural power becomes very strong since it operates beyond our consciousness. When many leaders and executive managers of a destination talk about the development of “appropriate type of culture”, “quality culture”, and “customer service culture” it signifies the importance of culture to be applied and conducted with certain values that they want to implement. In other words, culture have an important implication on the effectiveness of organizational performance. The stronger the culture influence in an organization the more effective the organization to achieve its goals; thus, an increase in market competitiveness.
Several empirical studies such as one conducted by Wilderom et al., [21] supports a view that a strong culture has a significant influence on organizational effectiveness. A certain cultural value dimension is closely related to economic performance. Some cross-cultural organizational studies as those conducted by Hofstede [22] indicate that culture has an effect in determining an organizational effectiveness thus it encourages the creation of better organizational design. As a consequence, it makes global companies to be superior in competition. Next, Hofstede explains 5 (five) cultural value dimensions in a global organization that create differences between countries in the world. The dimensions include:
Individualism versus Collectivism: The dimension refers to the degree of culture that will encourage people’s tendency to pay attention on their selves and their close relatives or people who are within their groups and considered as defending their members as a form of loyalty.
Power Distance: The dimension refers to the degree of culture that encourages less powerful group members to accept that powers are distributed unevenly.
Uncertainty Avoidance: The dimension refers to level of people who are threatened by unknown and uncertain situations and have developed a belief, principle or ritual to avoid it.
Masculinity versus Femininity: The dimension is illustrated in two milestones, one milestone by success, money, and objects and the other milestone by attention to other person and life quality. The dimension refers to emotional role distribution between man and woman.
Long versus Short Term Orientation: The dimension refers to the degree of culture that triggers gratification of material, social, and emotional needs between the members.
Further cultural value study by Hofstede adds cultural value elements developed in Asian people that relate to time orientation, namely: between short term versus long term orientation. The cross-country cultural dimensions influence management methods in designing organization that more suitable to its competitive environment and affect ways of company managers and executives in formulating business models and operating its business. The development of Hofstede’s cultural value study is further conducted by [23] as part of a research project of Global Leadership and Organizational Behavior Effectiveness (GLOBE). The study adds cultural dimension between human orientations versus performance orientation. Further cross-cultural study is conducted by [24] based on a research to managers in 23 countries that adds national cultural dimension, namely: (1) universal versus specific, (2) individualism versus collectivism, (3) introvert versus emotion, (4) public space versus personal space, and (5) achievement versus ascription. Cultural dimensions affect organizational design and effectiveness. Organizational culture forms from the behavior of employees, leaders, and the surrounding communities. Cultural values developed could be used as an organizational cultural power. The most relevant cultural dimensions for an organization or destination to achieve superior effectiveness and performance will depend on local wisdom cultural values. Destination design that includes structures, functions, and strategies will be adjusted to cultural and environmental conditions where the destination operates. Therefore, this study focuses on the creation of a tourism development strategic model based on Balinese cultural values or local wisdom in a new normal condition that includes health protocol of CHS (cleanliness, health, and safety). Approaches used in the study consist of qualitative approach with ethnomethodology [25] to explore culture implemented by traditional villages. There are 1493 traditional villages in Bali that led by a traditional leader known as
Bali Island is one of popular islands in the world based on a research result by Travel from Jerman Tourlane in April 8, 2020 [2]. The island carries cultural tourism that attracts tourists. Number of tourist visits in January—April 2019 is 1.819.664. Detail on the number of foreign tourists visiting Bali in 2019 is presented in Table 1.
No | Country | Total |
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1 | Australia | 222,359 |
2 | Hong Kong | 117,074 |
3 | India | 67,363 |
4 | Russia | 56,563 |
5 | Japan | 48,143 |
6 | USA | 46,275 |
7 | England | 46,509 |
8 | South Korea | 42,487 |
9 | Malaysia | 30,924 |
10 | French | 29,307 |
11 | Other | 343,206 |
Total foreign tourists in Bali in 2019.
The condition is different in 2020 where foreign tourists directly arrive on Bali Island in April 2020 is 327 visits. The tourist arrival through I Gusti Ngurah Rai airport is 273 visits and through the seaports is 54 visits. The number of foreign tourists declines by −99.79 percent compared to March 2020 (m to m). Compared to April 2019 (y on y), the number declines by −99.93 percent. The big five of tourists visiting Bali in April 2020 consist of domestic tourist (16.21 percent), Philippines (16.21 percent), China (12.23 percent), India (10.40 percent), and Russia (8.56 percent) [4].
Star hotel room occupancy rate in April 2020 is 3.22 percent, a decline of −22.19 percent compared to previous mount (m to m) at 25.41 percent. Compared to April 2019 (y on y) that achieves 60.33 percent, the room occupancy rate in April 2020 declines by −57.11 point. Average length of stay of foreign and domestic guests at the star hotels in Bali in April 2020 is 2.49 days, a decline of −0.31 point compared to those in March 2020 (m to m) of 2.80 days. In comparison with April 2019 (y on y) at 2.77 days, the average length of stay in April 2020 declines by −0.28 point.
Based on Porter and Treacy and Wieserma’s competitive advantage concepts, Bali has a strong competitive advantage in terms of differentiate strategies [26], and customer intimacy [27]. Balinese Hindus have various values and local wisdoms that could not be found in other countries. The Balinese Hindus, just like other Asian people, are known for their natural friendliness to others. All these local wisdoms are based and relied on Balinese Hinduism. For the Balinese Hindus, religion and custom are two sides of a coin that are unseparated yet differentiable. Religion surely comes from the truth of God’s teachings and it explicit and implicit in holy books. Customs, on the contrary, are originated from human behavioral habits that are viewed as having truth values although it does not have to be maintained. According to Windia [28], since religion is originated from the truth of God’s teachings thus it is sanatha dharma (an immortal truth).
Changes that occur and influence human civilization could not change the truth of religious teachings. Those that could change and tend to keep up with the change are those that related to material aspects that support the implementation of the religious teachings. For example, such things related to upakara (a traditional religious ceremonial tools) that have been conducted among the Balinese Hindus, such as the use of
Three basic frameworks of Balinese Hinduism religious teachings consist of Tattwa (philosophy), Ethics (susila), and ceremonies (rituals). The three basic principles are an inseparable part in the Balinese Hindus life. According to Astawa and Sudika [29], if the three frameworks of the Hinduism is analogue with an egg, the ceremonies (rituals) are the outer part or the “skin”, which is the most visible part, whereas ethics (susila) and tattwa (philosophy) are the “egg white” and “egg yolk”, which are the “core” of Balinese Hinduism.
As a unit, parts of the three basic frameworks of the Balinese Hinduism are mutually animating. It means that traditional-religious ceremonies are actually the manifestation of ethics and tattwa.
The three basic frameworks are interrelated and are the foundation of Balinese culture. Balinese culture gains its form in various arts, painting, sculpture, dance, gamelan, and others. All Balinese Hinduism traditional-religious activities thus could not be separated from art activities. On the contrary, every art activity contains religious elements originated from religious teachings.
The Balinese Hinduism is basing its teachings on Panca Sradha or five believes, namely: Believe in the existence of Ida Sang Hyang Widhi Wasa or God the All Mighty; Believe in Atman (spirit), which is a small splash of God and becomes a life-giving spirit in the human body; Believe in the existence of Karmaphala, which means that whatever humans do in this world, good or bad, will have consequences; Believe in the existence of Punarbawa, which is the re-birth into the world or known as reincarnation; Believe in the existence of Moksa, which is freeing of the spirit from worldly bonds and uniting with the Creator. Someone who has achieved Moksa do not born again to the world (reincarnate).
According to Windia [30], human is a territorial being since they will always follow changes occurred in their territory or settlement area. Human culture is also change along with the territory; likewise, agrarian culture that changes current Balinese culture. The agrarian culture gives birth of many local wisdom values, such as sekaa (association) that is specifically related to farming activities, such as sekaa nandur, sekaa manyi, sekaa makajang, sekaa ngabut, and so on. Many values could be emulated in sekaa, such as togetherness, gotong royong (mutual assistance), and volunteerism in conducting something together. The Balinese Hindus culture essentially comes from agriculture. The culture term actually refers to agriculture.
Joesoef [31] states that in the western world, culture term comes from “cultuur” (Dutch), “culture” (England, French), and “kultur” (Germany) that is rooted from Latin word of “colere” (cultivating land). This is the same with the words “cultivate” and “agriculture”. Anthropologists use culture term as a value system that is lived by human (individual and group). Therefore, the word culture, since the beginning, has an implication as something that grows and unspontaneous as a result of human wills. The term refers to beneficial efforts or efforts that generate results (cultivation) and value systems as well as vital ideas (mind and feeling creation).
According to Hofstede, culture is a set of behavioral patterns, values, assumptions, and common general experiences. Culture defines social structures, decision making practices, and communication methods in a social environment as well as dictates behaviors, ethics, and protocols in each of our social interaction with the society. Thus, culture is a set of beliefs that are developed from childhood till the rest of our lives. Several value elements then become relatively fixed, whereas other elements could change according to the society’s social condition and situation. This process is known as socialization. Further [22] suggests that we should uphold and strengthen different working processes in different regions and respect differences in each organization as a uniqueness that could create competitive advantages.
Bali has several local wisdoms sourced from basic principles of Balinese Hinduism teachings and its culture. The local wisdoms consist of Tat Twam Asi (a view that all beings in the world are the same), Ngayah (willingness to work for common interest), Asta Kosala-Kosali (a holy book of Balinese architecture guidance and traditional building layout), Awig-awig (customary rules in banjar level and pakraman village), Yadnya (holy offerings), Tri Hita Karana (three harmonious relationships that cause happiness), Subak (an agricultural irrigation system and organization that has received a recognition from UNESCO as World Culture Heritage in 2012), and many more. Various Balinese local wisdoms become a guide in daily life behaviors. Therefore, the local wisdoms will continue to live and develop as well as sustainable from generations.
A tourism destination could use competitive strategies of differentiation strategy, cost leadership strategy, focus strategy, or a combination of the existing strategies [32, 33]. Differentiation strategy is based on product offering that is different to what the competitor is offering in a certain characteristic or quality. Therefore, the product could be sold in higher prices than the competitor and profit will be higher due to decrease in elasticity demand price. Differentiation could be achieved through several ways including: Create a more superior product than competitor based on design, technology, performance, etc.; Offer superior service level; Have access to superior distribution channels; Create a strong brand name through design, innovation, advertisement, frequent flyer program, and so on; Specific or superior product promotion.
Cost leadership strategy aims at achieving competitive advantages by reducing cost below the competitors. Therefore, by maintaining low cost, the company (goal) could sell its products or services in lower prices and achieve income realization. The cost leadership strategy potential benefits consist of: It is able to obtain higher profit by charging the same price as competitors or reduce the price below the competitors since costs are lower; It allows to increase sales and market share by reducing prices below those charged by the competitors; It allows to enter new markets by charging price in the lower level than the competitors; It is important for a market where demand is elastic; It creates additional obstacles for new competitors to enter the industry.
Focus strategy is used when a tourism destination wants to attract a market segment that will canalize its offering. The market segment could be identified through various demographic categories, such as age, income, life style, geography, and so on or through benefits expected, members of the expected target market, and from the travel as well as suitable tourism product and destination. In the selected market segment, differentiation or cost leadership strategies could be applied. The main benefits of focus strategy are: It requires lower resource investment compared to strategy intended to all markets; it allows more specialization and knowledge on served segments; it facilitates new market entry to be cheaper and simpler. It should be noted that the three strategies (Porter) are existed in every tourism market and tourism destination. Selecting the suitable strategy, however, is a result of an immediate and broader change occurred in the environment as well as efforts to response to the changes according to its abilities and resources.
There are four aspects to be achieved in sustainable tourism, namely: environmental aspect, economic aspect, social aspect, and cultural aspect. The four aspects have been clearly scheduled from the start for companies in tourism industry that are based on harmonious management that put forward values of honesty, humanity, and respect to environment. The condition is supported by a fact that natural resources could be exploited intensively in a tourism business. Tourism activities will sometimes have a big impact on environment, ecosystem, economy, society, and culture. Therefore, a holistic balance between the four aspects must be considered to guarantee a short-term as well as long term sustainable development for tourism sector to face climate change. Sustainable development principles must be applied for various tourism activities and operations by determining long term as well as short term strategies and programs. Sustainable tourism could be conceptually defined as a tourism activity development with a balance between the dimensions of environmental, economic, and socio-cultural aspects to guarantee long term sustainability. In other words, sustainable tourism development must achieve sustainable environment, sustainable economy, sustainable society, and sustainable culture. Key elements in tourism regarding environmental sustainable management consist of:
Eco-tourism: Eco-tourism term is initially proposed in the end of 1970s. It is considered as a nature-based tourism and has become a way to protect natural landscape of a certain area. It refers to segment in tourism sector with the main focus is on environmental and ecological preservation; thus, it attracts many tourists as an alternative tourism. It could play an essential role in green growth for developing countries with significant natural abilities since this activity usually require less capital and investment. It could also connect to local communities that could lead the tourism activities and ecosystem preservation operations. Through these activities, ecotourism could provide employment for unskillful workers in rural communities and create export opportunities in remote locations to ensure green economy. Therefore, it must be considered as an appropriate industrial effort to promote economic development in developing countries with capital scarcity yet abundance natural resources.
Low-carbon tourism: Society is increasingly concern about the impact of actions on the world and this planet ability to maintain sustainable development. There is a growing awareness in the tourism industry as well as among the tourists on tourism carbon footprint. Tourism is one of the fastest growing industries in the world; thus, its rapid global expansion brings out environmental, behavior and socio-cultural impacts in many regions. At the same time, more and more tourists need information on tourism package carbon footprint. The same prevails for tourism industry, such as tour operators, travel agents, e-business sales operators, and business travel companies. They increasingly realize the importance of reducing greenhouse gas emission and calculating carbon footprint of their products and services in reliable and automatic ways.
Agro-tourism: Agro-tourism is a tourism activity that refers to activities of visiting farmers who work on their agricultural land. In this case, tourists would likely see the nursery process, planting, harvesting and even agricultural product processing in the context of agribusiness activities.
Alternative tourism: A form of tourism that put natural, social, and societal values first and allow local communities as well as tourists to enjoy positive and beneficial interaction and the experience together.
Behavioral economics: It studies the impact of psychological, social, cognitive, and emotional factors on individual and institutions’ economic decisions and its consequences on market prices, profit, and resource allocation.
Political economics: A study on production and trade and its relationship with law, customs, and government as well as income distribution and national wealth.
Circular economics: It utilizes society as a whole through a design of separating consumption from economy based on three principles: design waste and pollution, save products and materials used, and natural system regeneration.
Sustainable society: is a society that is capable of fulfilling their needs without reducing future generation opportunities. There are three measurement used in sustainable society, namely: Environmental prosperity: nature and environment (for example, air quality), climate and energy (for example, reduce in greenhouse gas), and natural resources (for example, biodiversity); Human prosperity: Basic needs (for example, clean water), personal and social development (for example, gender equality), and health (for example, clean water); Economic prosperity: Transition (for example, organic agriculture) and economy (for example, jobs).
Based on the indicators, components should be focused on in tourism development include: population and health: healthy society could offer various healthy foods for guests; accessible tourism: tourism development for disable people; community tourism: a community concept could be applied in tourism. In the community tourism, local communities are responsible for developing initiatives and managing tourism activity schedules. A community-based tourism connects balanced tourism development goals with ecological considerations into the existing business model. Sustainable development concept in community tourism applies to improve people’s life quality by protecting the environment and the built environment, to provide high quality experiences for tourists, and optimize local economic benefits.
Sustainable culture: cultural tourism is increasingly being developed as a way to protect ancestral heritage. Natural and cultural heritage should be considered as a base for sustainable tourism. The natural heritage comprises vegetation, flora and fauna, geological and hydrological phenomenon or natural events, such as climate, astrology incidents, and volcano. Likewise, cultural heritage includes living cultures (such as festivals, rituals, education, religion, costume, legend, behavior, habits, music, dance, and culinary), immobile historic monuments (such as parks, gardens, buildings, facilities, and archeological sites), and mobile historic monuments (such as paintings, statues, art works, handicrafts, agricultural tools, industrial machines, and documents/objects). Efforts to protect tourism-related culture could be divided into four tourism categories.
Rural tourism: It emphasizes on healthy activities and proper life with the joy of clean air, fresh water, landscape, culture, and tradition. Therefore, rural tourism has similarity to ecotourism, but its main attraction lies on traditionally managed landscapes and cultures.
Cultural tourism: One of tourisms that utilizes culture as its object. The implementation of cultural-based tourism in Indonesia is indicated by several provinces, namely: Bali and DI (Special Region) of Yogyakarta, especially Yogyakarta City since 2008.
Spiritual tourism: Spiritual tour is one of emerging cultural tourism heritages since more people are trying to develop their own spirituality. In 2007, the UNWTO rates the spiritual tourism as a segment that has a rapid development, although it is not easily framed. The tourism is based on various motivations, traditional religious tourism to alternative health treatment. Heritage integrity: Cultural heritage values are maintained in cultural tourism development.
A qualitative approach was used in this study [34]. The 10 largest of each tourism actor as an informant based on recommendations from local governments which consist of travel agencies, accommodation (hotels), restaurants, academics, and tourist villages. Before the interview began to 50 leaders of tourism actors were preceded by a delivery activity through post and email. The letter’s content is to ask for his willingness to respond to questions about; how to apply the application of Harmony culture within the company [36]; what are the factors used as an indicator of sustainable tourism [35, 36] and how to have health protocol [37]. Of the 50 informants, only 35 (70%) Who are willing to be interviewed and the other fifteenth (30%) cannot be contacted. Data collection time starts from January to April 2020 with an average interview length of 45 minutes. The Data is collected compared to cultural theories, sustainable tourism, and the Health Protocol [38] and coding using Miles and Huberman [39]. Qualitative results are used to design the model of Bali’s future tourism development strategy.
The in-depth interview results regarding the implementation of local wisdom-based tourism activities in the form of harmonious culture that emphasizes on a harmonious relationship between human being and the Creator (God), between fellow human being, and human being and natural environment are presented in Table 2. The main goal of the harmony of relationship or harmonization is the creation of the happiness of life. Happiness is a goal mostly searched by all human being. Happiness in the Balinese people concept is the establishment of a harmonious relationship between God, human being, and the nature or a balance between macrocosm and microcosm nature. The concept brings out cultural values that recognize a difference in a unity of goal, which is the happiness of life.
Indicator | Market orientation view | Resource-based view |
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Basic Principles | Adaptation of a company’s resources to the needs of its competitive environment is its main success factor. | Active search on business environment that allows the best exploitation of a company’s resources |
Strategic analysis | An industrial structure and market properties-centered | Gives emphasize on internal diagnosis |
Formulation Process | ||
Advantage Sources | Market position regarding local competitive environment | A collection of a company’s special resources and core competences |
Main differences between RBV and MOV.
Table 3 indicates that harmonious culture is a local wisdom that uphold the harmonious relationship with God, human being, and the nature as the spirit of Balinese tourism. It produces tourism forms of spiritual tourism, cultural tourism, and heritage tourism. These tourisms are the reflection of cultural activities related to God. The implementation of these tourism models is reflected by many tourists who conduct religious trips and visit sacred sites and watch dances and religious ceremonies.
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Harmonious culture | Harmony with God |
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Sustainable tourism | Economic benefits |
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Health protocol | Clean |
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Qualitative data processing results of cultural-based tourism activities, sustainable tourism, and health protocol.
Other cultural activities are related to harmonization with human being that create Mice tourism, health tourism, culinary tourism, and community tourism. These four tourism models are indicated from tourist activities of meetings, traveling to enjoy unique foods, and having traditional and medical treatments. Moreover, there are tourists who conduct the activities since they join a group, such as bike lover groups, plant lover groups, and many more.
Cultural activities that are related to natural environment bring out tourisms that reside with natural environmental preservation, such as eco-tourism, agro-tourism, rural tourism, alternative tourism, and marine tourism. These tourism models could be seen from activities conducted by the communities to perform environmental conservation of land, marine, and air. In addition, there are activities that utilize the nature as an attraction by promoting the sustainability of the tourism development.
The cultural implementation results are interesting to discuss since through the cultural activities, the Balinese people have supported sustainable tourism as stated by several researchers, such as [34, 39, 40, 41, 42, 43]. There are uniqueness found in the cultural activities related to God. The uniqueness is related to religious ceremonies to conduct natural preservation since the communities believe the existence of God in all of His creations; therefore, respect is done through ceremonies to all lives in this world. The ceremonies are, among others, tumpek kandang, which is a ceremony to respect all animals; tumpek uduh, a ceremony to respect all plants, and otonan, a ceremony to respect human being. This ceremonial model can be explained in Figure 1.
Ceremonies to humans, animals, and plants.
Table 3 explains that sustainable tourism implemented in Bali focuses on four benefits. First, economic benefit that will influence behavior, politics, and community economic activities. The condition could be observed from purchasing power, prosperity, society income improvement, ceremony costs, unemployment, costs for cultural and natural protection, and health. The remaining benefits include social, cultural, and environmental benefits that give rise to various tourisms. It is in line with a research by Yuan Pan [34] and a direction from UNWTO. The concept of Covid-19 management through health protocol is in accordance with WHO guidance. Another interesting finding of the research is that each activity related to sustainable tourism and health protocol is linked to cultural or religious activities. The unique condition is different to the finding of [34, 39, 43, 44] where communities believe that behind every success in activities there is a beyond reason and influential power; thus a ceremony is used to respect it [35].
The results of in-depth interview have been explained in Table 2 and compared to the existing theories [37, 45]; thus, a model could be designed to create Bali tourism development in the future. The model could be explained in Figure 2. The center of Balinese tourism is in the harmonious culture that provides spirit to maintain harmonization between God, human, and the nature. The cultural activities create a tourism models that are supported by the local government, traditional villages, and global environment that contain technologies to form a new tourism order. The new order concept intended is that Bali tourism is no longer sell the cultures as an icon instead it is shifted to the nature and human. Cultural values are a booster in the natural tourism implementation by considering health protocol set based on local wisdom. The natural tourism that is combined with cultural value-based health protocol will be a unique product and it supports strategies developed by Barney.
Bali tourism development model.
According to the Balinese cultural concept what is meant by clean, health and safe is linked to both real world according to the WHO and unreal world through religious rituals. Cleanliness, health, and safe that will be legitimated either physically or non-physically are completely different to models implemented by other destinations in the world.
Cultural values implemented by Balinese people amid Covid-19 condition will experience a shift in the cultural tourism development. At the beginning, it is offered as equal to natural and human-based tourism, but in the future, it will become a spirit of the two tourisms. The change brings impact on tourism business actors in marketing their products.
The tourism model development concept with a new order is a model that could change stakeholders in maintaining sustainable tourism. The concept will also provide legitimacy that Bali rises with a deep collaboration between modern and traditional to package a natural and human-oriented tourism. The results provide good color in the development of competitive strategy theories for a tourist area.
This research will be more perfect if it involves tourists who have visited Bali as an informant to give their views on the new way of tourism that will be carried out so that Bali remains a favorite destination. This deficiency becomes a gap for future studies to come so that the concepts of demand and bidding can be viewed in a balanced manner in formulating sustainable tourism policies.
The author expressed a deep sense of gratitude to the Indonesian government who had funded the project. The tourism village Pinge as a place to apply the results of the research.
All data relating to this project have been approved by the parties so that there will be no claims in the presentation.
Thanks to the Bali State Polytechnic that has facilitated the project, the head of the tourism village, the head of the Tabanan District tourism Office, the head of research and community service and students of Tourism Business Management Study program.
At its most fundamental, health risk (either clinical or financial) is a combination of two factors:
The chronic disease management (DM) programs of the early 2000s were implemented by payers and aimed to identify high risk or high need patients, particularly those that were not compliant with their treatments or who had gaps in care. Patient management was usually performed externally, often by telephone, by nurses employed by large disease management organizations. Although attempts were made to involve the patient’s providers, providers were not party to the payer contract. This model reached its peak with a number of Medicare Coordinated Care and Support demonstration programs between 2005 and 2008 [1, 2]. Because of the growth and importance of chronic disease management programs, the Centers for Medicare and Medicaid Services (CMS) of the US Dept. of Health and Human Services (HHS) established a major demonstration project, the Medicare Coordinated Care Project to evaluate 15 different models of care coordination [2, 3]. Although the demonstration program showed some improvement in the quality of care delivered to patients, the lack of demonstrated savings led to a decline in the type of vendor-based disease management programs popular up to that time, and an interest in programs that involved contracting directly with providers to take risk for patient outcomes.
By the end of the first decade of the 21st Century two things began to become clear: first, that these programs were not containing medical trend2 and second that the solution to rising costs had to include providers. As a result, CMS’s attention shifted to alternative payment models incorporating providers directly and focusing on a combination of cost, quality and patient satisfaction, an objective expressed by Berwick and others [4] as the “Triple Aim” in a heavily cited article. This shift was a reaction to the quality of care delivered within the US Healthcare system. A 2003 study [5] found that adults in the United States receive the generally accepted standard of preventive, acute, and chronic care only about 55% of the time. Quality of care “varied substantially according to the particular medical condition, ranging from 78.7 percent of recommended care to 10.5 percent of recommended care for alcohol dependence.” Pay for quality was intended increase the frequency of these measures by rewarding physicians for their achievement of evidence-based quality measures (such as screenings, tests for patient populations or adherence to prescriptions). The theory was that closing gaps in care and identifying health issues earlier would lead to reduced utilization of more expensive healthcare services later. The achievement of reduced cost of care in exchange for incentive payments made this a value-based initiative.
Following the failure of the disease management model to demonstrate financial success, Congress has passed a number of laws promoting different value-based initiatives, in addition to initiatives introduced by the Center for Innovation at CMS:
Medicare Improvements for Patients and Providers Act (MIPPA) 2008;
Affordable Care Act (ACA) 2010;
Bundled Payments for Care Improvement (BPCI and its successors) 2011;
Protecting Access to Medicare Act (PAMA) 2014;
The Medicare Access and CHIP Reauthorization Act (MACRA) 2015;
Medicare’s direct contracting model: Global and Professional Direct Contracting Model (GPDC) 2020.
In addition, CMS has introduced a number of alternative payment models (APMs). In these models, providers agree to accept a portion of their reimbursement, often in the form of a share of savings, based on achievement of certain goals, including improved quality, reduced utilization and reduced cost. APMs include Accountable Care Organizations (ACOs) as well as models aimed at specific conditions or provider organizations: Bundled Payments for Care Improvement (BPCI), Comprehensive Care for Joint Replacement, Comprehensive Primary Care, Comprehensive End-stage Renal Disease model, Kidney Care Choices model, and the Oncology Care Model (OCM). CMS’s stated objective is to move the entire health care market toward paying providers based on the quality, rather than the quantity of care they give patients.3
The Health Care Payment Learning and Action Network (HCP-LAN) is a group of public and private health care leaders launched by the U.S. Department of Health and Human Services (through CMS) in March 2015. HCP-LAN aligns public and private sector stakeholders in shifting away from the current fee-for-service, volume-based payment system to one that pays for high-quality care and improved health. HCP-LAN has published estimates of value-based contract penetration in different payer segments. Figure 1 illustrates a study published in 2019 predicting that as much as 100% of care will be delivered via a value-based contract by 2025.
Estimates of value-based contract growth in different payer segments.
The HCP-LAN 2020 survey of payers indicated that 40.9% of U.S. health care payments, representing approximately 238.8 million Americans and 80.2% of the covered population, flowed through HCP-LAN Categories 3&4 models (shared-risk and population-based payments).
As noted by Werner et al. in a 2021 study [6] “the complexity of the current suite of alternative payment models” and the variety and lack of standardization of different models make value-based contracting challenging. Figure 2 illustrates the development and growth of alternative payment models over time. The following discussion of contract types covers a broad (but not necessarily exhaustive) spectrum: new variations are frequently introduced. Over time, models have become more comprehensive and the risk assumed by providers and healthcare management organizations (HCMs) has increased.
Risk and VBC contract types. *BPCI: Bundled Payment for Care Improvement; **OCM: Oncology Care Model; ***MSSP: Medicare Shared Savings Program.
Figure 2 illustrates the two dimensions of risk that are accepted by a provider or HCM: the x-axis indicates increasing degrees of financial risk, from none (pay for performance or pay for quality which represent supplemental payments on top of regular provider reimbursement) to capitation (which represents the potential for significant gain but also losses). The y-axis illustrates the extent of the services at risk incorporated in the contract, which may range from a risk limited to a single episode of care only (for example knee surgery) to population risk. Population risk in turn may be limited to certain services only (for example for maternity services those associated with the pregnancy only) to “total cost of care” in which the provider or HCM accepts financial risk for all expenses incurred by the target population.
As we discussed above, the original reimbursement model was fee-for-service: each time the patient received a service from a physician, hospital or pharmacist a bill was generated and then paid by the patient or the payer (or both). As this system began to impose a financial strain on payers, different models evolved, beginning with payment for quality. Payment for quality models addressed the “gaps in care” issue identified in [5], as well as attempting to limit the provision of excess and ultimately redundant services. While these models resulted in improvement in quality metrics (such as HEDIS https://www.ncqa.org/hedis/) they did not lead to significant reduction in healthcare costs. Closely allied to pay for quality models is pay for performance in which physicians are rewarded for patient metrics (such as mammograms for women, eye and foot exams for people with diabetes, etc.).
The big breakthrough in terms of financial risk transfer occurred with disease management programs in the early 2000s. Insurers that purchased disease management programs from vendors needed assurance that the programs would reduce medical cost. Lacking convincing randomized studies, vendors and payers contracted around a financial outcome; initially vendors put a portion of their fees at risk of a favorable financial outcome. Later models allowed vendors to share in actual savings generated (gain-sharing), to the extent that the vendor reduced costs below a target. There are different variations of gain-sharing models, with some being one-sided (only positive savings are shared) while others are two-sided (if costs increase relative to the target, the vendor must reimburse some portion of the excess). More discussion of these models and methods for measuring financial outcomes may be found in Duncan [7].
CMS introduced another value-based arrangement with its Bundled Payment initiative in which organizations entered into payment arrangements that included financial and performance accountability for episodes of care. These models aimed to increase quality and care coordination at a lower cost to CMS. Providers continue to bill CMS in the usual way, with a retrospective reconciliation of claims against a previously agreed upon target price. Depending on which of four payment models the provider enters into, the provider receives a payment that covers hospital only or hospital plus physician services. To the extent that the provider is able to manage the financial risk, it keeps the financial margin (in some models the provider is responsible for reimbursing CMS if costs exceeded target prices). See [8] for a description of the different BPCI models and the results of evaluations.
The Affordable Care Act (2010) [9] introduced Accountable Care Organizations (ACOs): provider groups that accept payment risk for their attributed populations in return for the opportunity to share savings when costs are reduced below an adjusted benchmark. In the original model providers only accepted upside risk (shared savings only). In later models providers could achieve a greater share of savings but at the cost of having to share also in losses. More detail may be found in [10]. ACO arrangements exist among all payers and payer types, including commercial insurers, traditional Medicare and Medicaid. CMS’s Oncology Care Model is a similar initiative but limited to cancer patients undergoing treatment by oncologists.
All these models involve some sharing of risk between the payer and providers. Full risk transfer is achieved with capitated models. With capitation the provider accepts full financial responsibility for all costs of a population (or sub-population, for example primary care only).
Value-based contracting requires a clinical organization that is different to the traditional practice management. Several texts discuss necessary re-organization of clinical practice and the necessary infrastructure [11, 12, 13, 14, 15, 16] etc. For the purposes of this chapter we assume that clinical delivery has been optimized and the provider of clinical services is ready to begin the financial modeling required to negotiate contract with a payer.
We illustrate the contract modeling and implementation steps in Figure 2.
Successful value-based contracting requires sophisticated analytics, and at the heart of the analysis is a robust data warehouse that integrates claims data, preferably with clinical data. The importance of claims data is often overlooked by providers, with their focus on clinical data, charts and electronic medical records. Healthcare claims in the US system are the basis of reimbursement, containing valuable information about the nature and diagnosis of a patient’s condition, the treatment applied by the physician or health system, the place of service and (in the case of drugs) the therapeutic class and dosage of a drug. Complete medical and drug claims—claims that include all providers utilized by a population—are essential for financial contracting but are seldom present in provider records: they must be obtained from a payer. Providers rarely have as complete a view of the patient’s care that the payer has (due to its contracts with multiple providers).4 Once a robust warehouse has been built, it is possible to begin the five steps to successful value-based contracting (Figure 3).
Five steps to successful value-based contracting.
For any start-up or mature company wishing to enter a value-based contract, the essential first step is to assess the financial opportunity. Payers are subject to multiple new opportunities weekly; a provider or HCM must make a compelling economic case to gain attention. The compelling economic case begins with
Frequency: the condition or procedure must occur with sufficient frequency to be of concern to the payer.
Severity: the cost imposed by the condition or procedure must be high enough to command the payer’s attention.
Some conditions impose one but not the other of these elements: for example, in an employer population, an episode of stroke is very high cost but occurs with sufficiently low frequency that the average employer may not have experienced a recent stroke in its population. Employees that suffer strokes experience lengthy episodes, during which another payer (such as Social Security disability, or a retirement plan) may become responsible for reimbursement. As a result, the employer may not view strokes as a concern. Cancer, in the other hand, imposes high costs episodically but with cancer diagnoses occurring frequently enough for a payer to be concerned with managing cancer costs.
Modeling opportunity, particularly for individual diagnoses, requires access to large databases. These may be purchased from data vendors, or providers/HCMs may contract with a consultant for this phase of work.
Pricing a value-based contract requires an estimate of the value that will be created by a program, device or other intervention (in addition to estimates of the cost of delivery of the VBC solution). Value estimation requires identification of the patient’s current treatment pathway and a projection of an alternative pathway once a VBC solution is implemented. The treatment pathway is a transition or multi-state model that identifies different branches that a patient can follow together with the probability and cost of each different branch. Figure 4 is an example of a simple multi-state model of a specific condition for which the patient can choose to receive treatment in an urgent care setting or a hospital Emergency Department (ED). Depending on the severity of the condition, a patient in the urgent care setting could be sent home or referred to ED. A patient seeking care in the ED could be tested and sent home or, after referral for further evaluation, either sent home or admitted to hospital.
Current patient pathway.
A detailed claims database will allow the analyst to assess the services, their frequency and the pathway that a typical patient follows. As Figure 4 shows, we associate transition frequencies with the different states, as well as the cost of treatment at different stages. A disruptive device or intervention in this model would reduce the frequency of transition to higher-cost pathways. Figure 4 is a simple pathway; pathways can become extremely complex, in which case some simplification will be necessary. Complexity arises not because of the variety of settings but because the services that the patient receives may be delivered in a different order (for example for some cancer patients, oncology may be delivered first, followed by surgery while for other patients, surgery may be performed first, followed by oncology). Episodes of care that involve physician or auxiliary providers (for example physical therapy) may involve a few treatments over time, to as many as one or two per week.
Once the typical patient pathway is defined and its frequencies and costs have been developed, the analyst can develop an alternative pathway, assuming the provider/HCM intervention has been applied. The alternative pathway illustrates the disruption to the current standard of practice that the provider intervention generates; this may be estimated from prior studies or simply by clinicians who understand the intervention. The difference between the current and proposed pathways, however, is the source of the estimation of the provider’s or HCM’s economic value added. The result of this analysis is an economic model which is the basis of the HCM’s pricing. The economic model is developed by comparing frequencies and unit costs under the current and proposed pathways.
Understanding pathways is a critically important component of the financial estimation process. Providers/HCMs often spend time and effort on the financial estimation phase and assume that the actual work of caring for patients and driving behavior change will take care of itself, if left to clinicians. Clinicians, however, need to know where and how they can perform interventions, with what patients and what outcome to expect. Operationalizing the model to achieve the projected savings is as important as understanding the opportunity. Pathway analysis can provide valuable input to this process because it provides a basis for breaking savings assumptions into drivers/components. We will return below to considering the implementation of a value-based contract.
The Economic Model (Table 1) illustrates the estimation of the value created by the sample intervention illustrated in the pathways in Figure 5, which moves patients from the Emergency Dept. to Urgent Care, as well as more accurately identifies those patients that may safely be sent home after evaluation.
Current patient pathway | Proposed patient pathway | |||||
---|---|---|---|---|---|---|
Setting | Patients | Charge | Cost | Patients | Charge | Cost |
Urgent care | 30 | $170 | $5100 | 70 | $170 | $11,900 |
Emergency | 70 | $750 | $52,500 | 30 | $750 | $22,500 |
Referred from UC | 27 | $750 | $20,250 | 35 | $750 | $26,250 |
ED evaluation | 67.9 | $1000 | $67,900 | 32.5 | $1000 | $32,500 |
Inpatient transfer | 6.79 | $30,000 | $203,700 | 6.79 | $30,000 | $203,700 |
TOTAL COST | $349,450 | $296,850 | ||||
Intervention | $0 | $250 | $25,000 | |||
Cost/patient | $3495 | $3269 | ||||
Savings % | 7.9% |
Economic model.
Proposed patient pathway.
Combining the predicted savings with the cost of delivery of the program allows the Provider/HCM to price its intervention in a manner that allows an appropriate margin for the HCM while also generating an acceptable ROI for the payer. The economic model also allows the HCM to price its contract: in this example the projected savings after intervention charges is 7.9% of projected costs. For a 50/50 gainsharing contract the HCM could each expect savings of 3.95%. This is a point estimate, however, subject to considerable volatility. Before entering into a contract the parties will want to evaluate the uncertainty around the point estimate, which we discuss next.
In Step 2 we created the current and proposed patient pathways, estimated the value created by the HCM and the basic pricing parameters. However, this estimate is a mean; we do not know the variance around the estimated outcome. Variance estimation is important for healthcare models: healthcare claims are highly variable for two reasons. First, the distribution of healthcare claims itself is a convolution of two highly-variable distributions, frequency and severity. Second, outcomes of a healthcare program are subject to performance risk. Step 3 begins with modeling the distribution of the predicted outcome. Additionally, there are multiple variables involved in the predicted outcome; many of these variables can be controlled in order to limit the contract risk. The Risk Assessment step helps the analyst to understand the contribution of individual variables to the predicted outcome and to choose values in such as way as to mitigate some of the inherent stochastic risk of the contracted outcome. Figure 6 shows some of the variables that comprise a value-based contract that an analyst should consider when modeling contract risk.
Key parameters for a value-based contract.
Figure 6 shows that designing a value-based contract is a complex undertaking. While we will not discuss all the variables in Figure 6, we will discuss some key variables and use them to illustrate the complexity of the modeling that is required as part of the Value-based Contract pricing.
Risk assessment requires simulation of the distribution of outcomes. The provider/HCM will contract at a target rate or price assuming its performance will achieve a particular outcome level. In Table 1 this was illustrated as $2,969 per patient. The question to be addressed in the Risk Assessment phase is: what is the confidence interval around this estimate and how may variation be mitigated by choosing different values of the parameters in Figure 6?
Risk mitigation can be illustrated by looking at an example from the Medicare Shared-savings program, assuming that the provider/HCM is considering a contract with both upside and downside risk. The provider will want to maximize its chance of upside gains and minimize the chance of a downside loss (reimburse Medicare). In a recent studies [10, 17] the authors illustrate that even in the absence of an intervention there is a non-trivial risk that a provider will have to reimburse the payer simply because of the stochastic nature of claims, giving rise to the need for
Figure 7 illustrates this important concept. Note that Figure 7 illustrates stochastic (claims variability) risk only; in addition, the provider/HCM will be at risk of performance variability as well. Figure 7 simulates the outcome (calculated savings
ACO gain/(loss) distribution: 10,000 simulations.
One of the biggest challenges for providers/HCMs entering into value-based contracts is population size. This problem has become especially acute in recent years as providers focus more on specific conditions and sub-populations that may be relatively small or where the condition prevalence results in a small number of target patients. Figure 7 is an example of a 3,000 life population where a target condition could result in only a few hundred patients being managed. The variance in claims of a few hundred patients is significant; the variance may be mitigated with appropriate truncation and risk corridors but in small samples will remain a major risk to the provider/HCM. A number-needed-to-treat analysis could provide some guidance to the contracting parties regarding their potential variance and risk, but the answer is invariably (except in the case of large insurers) that the provider/HCM will need to manage a much larger population than available to be comfortable with the outcomes. In this case the parties should probably consider an alternative contractual form.
The risk corridor is only one variable that can be modeled; modeling the outcomes using the key variables from Figure 6 will give the provider/HCM a better idea of the risk that it undertakes and how to mitigate that risk—for example with risk corridors, different attribution definitions, and stop-loss insurance.
Once the modeling is completed the contract terms will be known and it should be a straightforward matter to prepare a contract. Once the contract is signed, however, it is important that the provider/HMC prepare an implementation and operational plan with appropriate targets, preferably on a monthly basis. Contractors often lose sight of the fact that they are managing a risk contract, often with a one-year term. If the contractor does not adhere to a plan and falls behind, however, it is often impossible to make up patient engagement and cost-reduction numbers later in the contract year. For this reason a projection of the ultimate results and likely reconciliation on a regular basis is important. For some providers/HCMs (particularly those that are publicly traded) an estimate of the final gain/(loss) will also be required because of the need to set up a balance sheet reserve for any ultimate payable or receivable, and to demonstrate revenue recognition.
Operationalizing the contract also may require sophisticated modeling to identify at-risk patients, alert providers to changes in patient status and report on clinical gaps and gap closure. Delivery of programs that rely on clinical resources is also costly and requires that the contractor maximize efficiency. A workflow system incorporating the latest real-time information for providers (if they are managing patients) or patients (self-management) is essential for efficiency and for achieving contracted outcomes. Monitoring the progress of the contract against the plan and reporting on the key performance indicators identified at Step 2 is essential to achieving successful outcomes.
Some models are relatively simple to administer and reconcile: capitated contracts for example may require no reconciliation because the provider is paid a capitated amount from which the provider derives its margin. Shared savings and bundled payment models, on the other hand, can be complicated to reconcile. One challenge with this type of contract is that reconciliation requires complete data, meaning that run-out claims5 are included in the calculation. Allowing for run-out often imposes a delay of 6 months or more post-contract period before complete claims are available. Reconciliation also requires the application of key contract terms: attribution, services, inclusions/exclusions, truncation and corridors etc.
Because value-based contracts are often very different from contract to contract, payers may need to administer contracts manually. This makes final reconciliation difficult both in terms of actual calculation and payments. Reconciliation payments may be delayed as much as 2 years from contract inception. A provider/HCM will need to plan for this delay in receipt of revenue, and have sufficient capital to carry through to the final reconciliation.
Payments are an important part of the Value-based Contract. They represent the result of an intervention, and being part of the operation of the contract, are not a component of the five analytical steps discussed above. Their importance to a contractor and a payer, however, make it important to discuss payments.
A successful contract will result in a payment from the payer to the provider/HCM. Some models such as capitation and bundled payments result in prospective payments: the provider/HCM receives a fixed amount and there is usually no reconciliation or further exchange of funds. For performance-based contracts such as shared-savings or pay-for-performance, a reconciliation will be necessary to calculate amounts owed or owing. Administration of claims for these contracts can be complicated because providers will submit claims in the normal way to the payer, who must then turn off payment (because the provider will be reimbursed from a pool of funds at reconciliation). It is clearly not satisfactory to the provider/HCM to wait 18 months for reimbursement. The challenge of administering partial payments (or payments after the fact) from a typical claims system, particularly in a payer with multiple different contracts, can be challenging to the payer. In many cases these contracts are administered manually. Solutions such as the application of Stochastic Control processes, in which the ultimate settlement payment is continually estimated and payments are made on account of the ultimate payments offer some promise as a way to satisfy provider/HCM need for near real-time payments. That, however, is a topic for a different chapter.
Value-based contracts offer providers of healthcare services an opportunity for higher rewards than traditional payment models, but with considerable additional risk. Risk comes in many forms, from definitions to execution. This chapter has not touched on performance risk, which is the province of other professionals, mostly clinical. But aside from clinical risk a provider/HCM that accepts value-based risk is open to numerous other forms of risk. The good news is that with appropriate planning and modeling these risks can be managed and mitigated. Doing so will allow the provider or healthcare management organization to capitalize on a growing trend in healthcare finance.
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