dear dr. doshi, - bmj.com€¦ · dear dr. doshi, thank you very much for giving us the opportunity...

Dear Dr. Doshi,

Thank you very much for giving us the opportunity to revise and improve our manuscript. We

have incorporated many of the editors’ and reviewers’ comments and believe the article is

significantly stronger. We have included as many suggestions as possible, though are somewhat

limited by the word count requirements and, at times, competing suggestions from reviewers.

Please see our detailed responses to the reviewers’ suggestions below. Please do not hesitate to

contact us with any questions or requests for clarification.

Thank you for your continued consideration of our work.

Sincerely,

Dhruv Khullar, MD, MPP

Dept. of Healthcare Policy

Dept. of Medicine

Weill Cornell Medical College

EDITORS:

The reviewers have set out a significant number of issues, all of which we think are helpful

and addressable in a revision, and look forward to reading your point-by-point

response. One specific note, however, is we did not agree that the piece necessarily needs

reframing, as Dr. Desai recommends, but we definitely would like you to address her

concern about your “separate and independent treatment of price vs utilization.”

Thank you for these comments. We have addressed Dr. Desai’s concern by expanding our

discussion on the interaction between price and utilization. Specifically, we note that price and

utilization are determined simultaneously and that changes in price have variable effects on

quantity, depending on the service being delivered and other market conditions. We have also

added several citations to support our arguments. The relevant text (page 4, paragraph 2) is

copied below:

“These efforts should recognize that prices and quantities are simultaneously determined: When

prices change, quantities change too. If a service is priced too high or too low relative to its

value, it can generate an excess or shortage of that service.10,11 The effect of price changes on

the volume or quality of care is complex and variable, and should be studied closely as new

pricing models are piloted. Providers may respond to price reductions by increasing volume to

compensate for lost revenue, or by decreasing volume as they shift to more lucrative goods and

services.12,13 We should not, however, assume that the current level of utilization is socially

optimal — there is evidence of both over- and underutilization — and possible utilization

changes should not be a justification for eschewing pricing reform.14”

The introduction felt a bit light on references; we would like to see more citations here.

Thank you for this suggestion. We have added a number of new citations in the revised

manuscript.

REVIEWER #1:

Page 3 line 38 -- The authors might consider pointing out that the reason reducing

utilization might not solve the cost problem is that it is easy for healthcare providers to

raise the prices to compensate for lower volumes.

Thank you for this suggestion. We have added an expanded discussion on the effects of price

changes and utilization, along with citations. The relevant text (page 4, paragraph 2) is copied

below:










Page 3 line 52 -- "acquiesce" I think is the wrong word, even if it were spelled correctly.

Isn't the challenge facing payers that they don't have enough market share. As a result, if

one payer stood strong the providers would just work with the other payers? Acquiescence

sounds like they just give up.

Thank you for this comment. We agree and have removed “acquiesce” from the text. We instead

emphasize the market power of commercial insurers versus providers. We have also taken care

to separate the reason for high prices in the private market compared to Medicare, as suggested

later by Reviewer #3. The relevant text (page 3, paragraph 5) is copied below:

“Higher prices across the United States have many root causes, which may differ for public and

private payers. In Medicare, providers generally receive the same administratively set rate with

relatively minor adjustments for geography, case-mix, and quality, but these prices are

influenced by powerful industry lobbies that advocate for higher rates. For private payers, prices

are often driven by their relatively weak bargaining power compared to consolidated providers.8

Private payers may find it difficult to negotiate with or exclude high-priced providers with

considerable brand (e.g., academic medical centers), those in rural areas, and those that have

become increasingly consolidated in the era of delivery system reform.9”

More general comment -- the six strategies pertain to different levels of government and

industry. It would be more helpful for the authors to direct their attention to different

parts of the system. For example, Medicare should revise the fee schedule, states should

consider rate setting, public and private payers should establish bundles, Medicare should

do more competitive bidding, etc. This could go in the table as well.

Thank you for this suggestion. We agree and have added a separate column in the Table, which

describes the policymaking entity (Medicare, states, private payers, etc.)

The discussion of high deductible plans should be revised. The authors should take a

position, rather than talk around all sides of the issue. Is expecting consumers to pay far

more under a high deductible plan promising or not? (Maybe there should be only 5

strategies and this one dismissed.)

Thank you for this comment. We have opted to keep the proposal of high-deductible health plans

and have taken a stronger position on it, arguing that pairing it with reference pricing may be a

path to more effective consumerism. We offer several evidence-based examples of where this has

been successful. The relevant text (page 6, paragraph 2) is copied below:

“This may however be due to suboptimal standardization of services and transparency of prices

— problems potentially mitigated by reforms like bundled payments — and pairing high-

deductible plans with reference pricing may offer a path to more effective consumerism. Through

reference pricing, insurers pay a set price for a drug, technology, or service in a given class, and

the additional cost of higher priced therapies is borne by the consumer. When the California

Public Employees’ Retirement System (CalPERS) introduced reference pricing for orthopedic

surgeries, surgical volume increased by 21% at low-price facilities and decreased by 34% at

high-price facilities without any change in quality or access, and average prices declined across

all facilities.22 Similar effects were found when reference pricing was paired with consumer cost-

sharing for diagnostic colonoscopies.23”

Page 6 line 8. This discussion of bundles seems repetitive.

Thank you for this comment. We have removed the repetitive discussion from the text.

The paper should address the obvious question about pricing solutions -- what about

volume? Reducing fees can be expected to drive up volumes further. This is noted only in

passing as a weakness to bundled payments, but it's totally on point. To solve this issue, the

authors might consider mentioning how pricing interventions intersect with other types of

payment reform.

Thank you for this suggestion. We agree and have included an expanded discussion on how the

price and volume of services intersect. The relevant text (page 4, paragraph 2 and page 6,

paragraph 4) is copied below:










“Price changes may have variable effects on utilization and quality, both of which should be

closely evaluated when testing pricing innovations.”

REVIEWER #2

The paper is tackling a very important, mostly ignored, policy topic in the U.S., as correctly

observed by the authors. The first page in which the problem is identified and summarized

is excellent (some quibbles later). It makes a compelling case for the paper. However, I

think the paper needs work, mostly to clarify the purpose and correct some

confusing/contradictory elements.

Thank you for these comments. We have kept much of the first page, which you suggested is

particularly strong. We have tried to clarify the purpose of the paper and improve the areas you

suggest, as detailed below.

Page 3, Line 50: The paper correctly makes the important point that Medicare sets prices,

whereas commercial insurers have to negotiate prices with increasingly powerful providers

who are gaining market power. But at line 50 the paper associates Medicare with

commercial payers, distinguishing both from “Medicaid-like payers.” So readers would be

confused, as I was, about the paper’s viewpoint about Medicare – is it a price setter, which

you emphasized at the outset, or does it “acquiesce” to paying too much, like commercial

payers?

Thank you for this suggestion. We have clarified this issue in the text. We have now taken care to

separate commercial payers and Medicare, describing separately why each may pay high prices.

We have removed the phrase “Medicaid-like” payers.” Please see the relevant text (page 3,

paragraph 5) copied below:

“Higher prices across the United States have many root causes, which may differ for public and

private payers. In Medicare, providers generally receive the same administratively set rate with

relatively minor adjustments for geography, case-mix, and quality, but these prices are

influenced by powerful industry lobbies that advocate for higher rates. For private payers, prices

are often driven by their relatively weak bargaining power compared to consolidated providers.8

Private payers may find it difficult to negotiate with or exclude high-priced providers with

considerable brand (e.g., academic medical centers), those in rural areas, and those that have

become increasingly consolidated in the era of delivery system reform.9”

Having competitive pricing for DME as one of your six avenues of innovation, aside from

being relatively trivial compared to the others you review, is very confusing in what

otherwise is a consideration of approaches to addressing high prices for commercial

insurance. I strongly suggest maintaining the crucial distinction between price setting and

price negotiating and address only opportunities to address commercial insurance price

with pricing innovations.

Thank you for this suggestion. We have made a clearer distinction between private and public

payers in the text, as described above. We have chosen to keep competitive bidding as one of our

six proposals, as we believe it offers an opportunity for a market-based alternative to

administratively imposed price reductions and could be expanded beyond DMEPOS. Moreover,

DMEPOS items for which Medicare has introduced competitive bidding cost the government

more than $11 billion annually. CMS estimates it could save nearly $26 billion from 2013 to

2022 through competitive bidding, suggesting it is a proposal worth considering and possibly

expanding (source: Newman et al, Health Aff, 2017).

You have described both good ideas and what comes across as flawed ideas for innovative

pricing approaches to address high prices. Fundamentally, I can’t tell the purpose of the

paper. You write that you want “to explore six avenues to pricing innovation.” Are these

supposed to represent pricing innovations currently in policy discussion, i.e., a cataloging

of current ideas, good and bad; payment innovations you think are most promising; or

something else? ... In this regard, if you intend a cataloguing of current pricing ideas in

current policy discussions, you have missed a couple that have received important, recent

attention. For example, the paper by Altman and Glied in the Health Affairs, Sept. 2017

Market Concentration issue have suggested placing ceilings on negotiated rates, as a

percentage of Medicare, initially focused on hospitals, as a practical option in lieu of

adopting a full-fledged, all-payer rate setting program like in Maryland.

Thank you for this comment. We have tried to further clarify the purpose of our paper, which is

to offer proposals for pricing reform we believe have promise and should be tested. We have

added a paragraph clarifying this. We have also added the Altman and Glied suggestion as a

closely related alternative to All-Payer Rate Setting. The relevant text (page 4, paragraph 3 and

page 5, paragraph 1) is copied below:

https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2016.1323

“We propose six avenues to explore health care pricing innovation (Table). While each has

limitations, we believe they offer promising initiatives that should be piloted and evaluated to

understand their effects on health care prices, and relatedly, on quality and utilization. These

proposals are meant to highlight ways in which high prices can be addressed more directly —

distinguishing them from indirect approaches that aim to facilitate competitive health care

markets more broadly, such as aggressive anti-trust enforcement, repeal of some licensing

requirements, and policies that lower barriers to market entry.15 Our proposals exist on a

spectrum from government-driven to market-based approaches and should be of interest to both

public and private payers.”

“A related, more flexible approach would allow for some price variation within states, but limit

privately negotiated prices to a multiple of Medicare rates to curtail outsize bargaining power of

select providers.9”

For context for presenting the direct pricing approaches, I suggest you might explain that

there are a much broader set of policy approaches that attempt to address pricing power,

only indirectly addressing how prices are determined, but that the paper will not discuss in

any detail, as you prefer to explore specific approaches to “pricing innovation.”

Thank you for these suggestions. We have expanded our discussion of where our proposals fit

within the broader landscape of policies aimed at increased health care competition. We note

that our proposals are more direct attempts than other policies that might indirectly lower

prices. We have also included the suggested citation from the National Academy of Social

Insurance you suggest. The relevant text (page 4, paragraph 3) is copied below:

“These proposals are meant to highlight ways in which high prices can be addressed more

directly — distinguishing them from indirect approaches that aim to facilitate competitive health

care markets more broadly, such as aggressive anti-trust enforcement, repeal of some licensing

requirements, and policies that lower barriers to market entry.15”

Finally, I have suggested above that DME bidding in Medicare doesn’t belong in your list.

It is a Medicare-specific proposal and one of many you might have identified to address

Medicare prices. It’s a different topic. I don’t think you should confuse the reader by

contradictory views of whether Medicare pays too much or is a price setter. In contrast,

you creatively included the Medicare Fee Schedule on your list of pricing innovations, not

because it is a Medicare pricing reform opportunity, but rather because private payers

typically use the relative values for their own fee schedules.

Thank you for this suggestion. As noted above, we have decided to keep this proposal as it

accounts for non-trivial Medicare spending and we believe broader, creative use of competitive

bidding may offer a market-based approach to lowering prices. We also believe that having a

clearer distinction between Medicare and private payers, as you suggested and as we have done

above, makes the logic of this proposal easier to follow.

I fail to follow the logic for why you have included bundled payments here. I don’t follow

how bundled payments increases “price and quality competition.” It clearly promotes cost

reduction as you describe, but I don’t follow how any efficiencies necessarily would be

passed back to payers.

Thank you for this comment. We have strengthened the discussion of bundled payments and tried

to clarify how it might lead to lower prices. We have added two studies suggesting that a driver

of lower costs through bundled payments is not reduced utilization, but rather lower prices. The

relevant text (page 5, paragraph 3) is copied below:

“Standardization of bundles is vital for greater competition and meaningful price shopping.

Currently, a different bundle is developed for each payer-provider dyad, reducing the ability of

patients to shop for care, but progress is being made in some regions. One successful example

comes from Arkansas’ Health Care Payment Improvement Initiative (APII) by which private

insurers and Medicaid agreed to pay for some medical episodes using bundled payments. In the

first year of the program, perinatal spending decreased by 3.8%. The decline was driven not by

changes in utilization patterns, such as cesarean section rates or length of stay, but rather by

patients being referred to lower priced facilities.19 Ultimately, if bundled payments are

standardized and well developed, new drugs and technologies could be included in the price of

the care bundle, thereby incentivizing providers to choose whether to invest in them based on

their added value. For example, recent evidence suggests that the largest savings from bundled

care for joint replacements may have resulted from providers purchasing lower-priced

implants.20”

You present high deductibles as a means of promoting consumer shopping, including -- and

especially -- over price. But then you reasonably challenge the concept. I think it a cop-out

to conclude, “it is hard to imagine healthcare pricing reform without engaging patients.”

“Engaging patients” does not address whether or not using high deductibles -- $5000 or

more – is an effective and desirable strategy for restraining prices.

Thank you for this suggestion. We have taken a stronger stance on consumer shopping and

believe it is a worthwhile proposal. Specifically, we argue that consumerism paired with

reference pricing allows for more effective price shopping. We provide evidence of this from

joint replacements and colonoscopies in the CalPERS program. The relevant text (page 6,












Page 4 – line 11-12. I don’t think your suggestion that consolidated providers are

negotiating with fragmented payers is correct. Using antitrust indeces for concentration,

including the HHI, commercial insurance markets are also quite concentrated; often there

is a dominant payer with market shares in the 70-80 percent range. In these markets, it

turns out that the dominant payer does get better prices than in "fragmented" insurance

markets but have no reason to pass back savings to consumers in lower premiums. See

Dafny for documentation.

While we believe there is evidence that consolidated providers increase commercial prices

(including from Dafny NEJM 2014, Dafny NEJM 2015) and providers are relatively

consolidated compared to private payers, we have removed this specific line from the manuscript

for space considerations.

Page 4 – line 23 – the observation that fee schedule rates influence how physicians spend

their time and what specialties they choose is taken directly from Berenson and Goodson. It

needs to be cited here, not just later, for a less important point.

Thank you for this comment. We have included this citation earlier, where suggested.

Page 4 – lines 36-38. Your notion that value-based pricing sets maximums but that

competition should ideally result in even lower prices is an interesting one. But it comes out

of the blue. It is another reason why I think earlier in the paper, you should describe the

broader policy discussion of how to address high prices, that is, the desire to also promote

competition such that the pricing innovations you mention are part of a broader approach

to altering the environment in which high and rising prices flourish.

Thank you for this suggestion. We have included a discussion of where our proposals fit within

the broader policy context of health care prices and competition. The relevant text (page 4,


“These proposals are meant to highlight ways in which high prices can be addressed more

directly — distinguishing them from indirect approaches that aim to facilitate competitive health

care markets more broadly, such as aggressive anti-trust enforcement, repeal of some licensing

requirements, and policies that lower barriers to market entry.15”

Page 4 – line 54. The more relevant example of regulatory capture is in Maryland itself.

Robert Murray, former long-term staff director of the MD Cost Review Commission in a

few publications has described the periods when the Commission deferred to the interests

of the hospitals, to detrimental impact on spending.

http://www.nejm.org/doi/full/10.1056/NEJMp1313948

http://www.nejm.org/doi/full/10.1056/NEJMp1502338

Thank you for this suggestion. We have included a citation from Dr. Murray in the text. We

chose not to further expand our discussion to the Maryland experience because of space

constraints.

REVIEWER #3:

First and foremost, price and utilization are interdependent and intertwined, so a policy is

unlikely to affect one without affecting the other, and therefore, consideration of any policy

should take into account the potential effects on both price and utilization. While the

authors mention this in passing: “These efforts should recognize that prices and quantities

are simultaneously linked…”, this interdependence needs to be core to evaluation of any

policy rather than a side note.

Thank you for this comment. We agree that price and utilization are intertwined and have now

expanded our discussion of this issue. The relevant text (page 4, paragraph 2) is copied below:










Second, as mentioned above, it is not clear what previous reforms that have focused on

utilization but not price the authors are referring to. If they decide to stick with this

premise, they should provide examples and then contrast them to the alternate strategies to

argue why in fact they are superior.

Thank you for this comment. A number of delivery system reforms in the Affordable Care Act

attempt to reduce utilization and care fragmentation, including Medicare readmissions penalties,

Accountable Care Organizations, and bundled payments (which, while we argue are a path to

lower prices, have traditionally been understood as a mechanism to integrate and coordinate

care). For example, CMS itself argues that its delivery system reforms aim to “increase care

coordination and quality and reduce redundancies, needless delays, and unwarranted referrals,

thereby saving money and improving the quality of care.” It describes its bundled payment

initiatives as addressing “fragmented care with minimal coordination” and argues that bundles

may reduce the “quantity of services offered” and allow providers to “work closely together

across all specialties and settings.” We have also added a citation to a widely cited paper by

Don Berwick on waste in the U.S. health system. Overall, we agree with Reviewer #2 who states

the current introduction and framing are strong.

https://www.cms.gov/apps/files/aca-savings-report-2012.pdf

https://innovation.cms.gov/initiatives/bundled-payments/

Third, for reasons discussed in the first point, the strategies they discuss do not only affect

price but not utilization as claimed. For example, previous literature has shown that

providers respond to price changes, so reforming the Medicare Physician Fee Schedule or

All Payer Rate Setting would likely lead to quantity responses by providers. Bundled

payments are a form of capitation and there is a robust literature on the effects of

capitation on quantity provided. The key question is what are the ramifications of quantity

(and quality for that matter) changes in response to any of these reforms. Will patient care

be worse or social welfare be lower?

Thank you for this comment. We agree that price and utilization are closely related and have

added an expanded discussion to this effect. We also agree that an important question is how

price changes will affect quality of care and social welfare, and state that these issues should be

closely studied as pricing proposals are introduced.

Moreover, the paper would be more unified and also provide a unique perspective, if it

discussed each of the proposed reforms relative to each other. Creating a conceptual

framework to compare the reforms (or some of them) might provide useful context for

readers to understand the strategies. For example, they could compare the proposals on a

spectrum of consumer-focused to provider-focused or on a spectrum of laissez faire to

government driven.

Thank you for this suggestion. While we have chosen to keep the overall framing of the paper, we

agree that thinking of our proposals on a spectrum from government-driven to market-based

provides an interesting structure. We have added a sentence to this effect. The relevant text

(page 4, paragraph 3) is copied below:

“Our proposals exist on a spectrum from government-driven to market-based approaches and

should be of interest to both public and private payers.”

The paper would benefit from a clarification of the setting/audience.

Thank you for this suggestion. We have added a sentence regarding the paper’s intended

audience. The relevant text (page 4, paragraph 3) is copied below:

“Our proposals exist on a spectrum from government-driven to market-based approaches and

should be of interest to both public and private payers.”

Reform Medicare PFS to pay for value and these rates will trickle down to the commercial

markets - How does this square with the authors’ earlier citation of evidence that there is

little correlation between Medicare payment rates and commercial prices?

Thank you for this comment. While there are areas in which private spending does not correlate

with Medicare spending, overall Medicare rates have significant influence on commercial rates.

We have, however, removed the assertion in question to avoid confusion and because it is not

central to our overall argument.

The authors mention that Medicare should pay for value, but what are the complexities of

defining value and putting a dollar figure on value? There is a growing literature and

debate on this complex issue and the authors should acknowledge the complexity of this

proposal.

Thank you for this comment. We agree that the defining value in health care is a complex and

controversial issue. A full discussion of this topic, however, is beyond the scope of this paper.

All payer rate setting - The authors frequently discuss the need for improved competition

in health care delivery markets as a means to reducing prices at other points in the paper,

but isn’t all payer rate setting the most draconian and non-competitive reform possible?

How can the two arguments be reconciled to maintain internal consistency?

Thank you for this comment. We argue that competition is one important consideration when

exploring how to lower prices, but our proposals exist along a spectrum of regulation-driven to

market-based, which we have now made clearer in this revision.

Bundled payments - how do bundled payments increase price and quality competition

among providers? Bundles group multiple services into a single price, but this in itself

won’t unleash price competition.

Thank you for this comment. We have included a more extended discussion of how bundled

payments may promote competition and have included several recent studies suggesting that they

may lower prices. The relevant text (page 5, paragraph 3) is copied below:

“Standardization of bundles is vital for greater competition and meaningful price shopping.

Currently, a different bundle is developed for each payer-provider dyad, reducing the ability of

patients to shop for care, but progress is being made in some regions. One successful example

comes from Arkansas’ Health Care Payment Improvement Initiative (APII) by which private

insurers and Medicaid agreed to pay for some medical episodes using bundled payments. In the

first year of the program, perinatal spending decreased by 3.8%. The decline was driven not by

changes in utilization patterns, such as cesarean section rates or length of stay, but rather by

patients being referred to lower priced facilities.19 Ultimately, if bundled payments are

standardized and well developed, new drugs and technologies could be included in the price of

the care bundle, thereby incentivizing providers to choose whether to invest in them based on

their added value. For example, recent evidence suggests that the largest savings from bundled

care for joint replacements may have resulted from providers purchasing lower-priced

implants.20”

Competitive bidding - The authors argue that competitive bidding should be extended to

Part B drugs, but many of the most expensive drugs are under patent, and so multiple

competitors do not exist for such a bidding program. Moreover, providers already

purchase their own drugs and therefore have incentive to bargain on Part B drugs, so

might this not just add administrative burden without lowering prices?

Thank you for this comment. It is true that some Part B drugs are under patent, but not all.

Furthermore, our argument is to expand competitive bidding more generally, which may include

drugs, but also other health care goods and services. The relevant text (page 6, paragraph 1) is

copied below:

“Competitive bidding could be expanded to other health care goods and services — perhaps by

awarding contracts to suppliers and providers competing on bundles — and might be effective

for reducing prices for expensive Medicare Part B drugs, equipment, and services.”

Greater price shopping through use of high-deductible health plans - The evidence to date

is fairly consistent in suggesting that consumers do not price shop, even in high deductible

plans. To this, the authors say “It is hard to imagine healthcare pricing reforms without

engaging patients”, but they should provide more evidence based arguments.

Thank you for this comment. We agree that our initial characterization of consumer shopping

did not fully make the case for this proposal. In our revision, we have included an expanded

discussion of the issue, and argue that consumer shopping paired with reference pricing may

offer a path forward. We cite several recent studies suggesting this proposal has potential. The

relevant text (page 6, paragraph 2) is copied below:











Reference pricing/Pay higher prices for drugs for first 3-5 years and pay higher prices

afterwards if they provide value - Isn’t the latter the goal of the patent system? Wouldn’t

the entry of generics theoretically lead to prices that equal marginal cost after a drug goes

off patent?

Thank you for this comment. We propose that both public and private payers take a more active

role in value-based pricing by updating their payment rates over time. This could theoretically

apply not only to drugs, but also to technologies, devices, and other therapies.

The authors should argue why the current level of prices in health care are problematic

because it is not clear that they are. Theoretically, prices reflects the willingness to pay for

a service. Moreover, who benefits from lowering prices?

Thank you for this suggestion. We note in our introduction that health care prices in the United

States are substantially higher than in other countries, and that they vary considerably across

the country without clear relation to outcomes. It is generally accepted that health care spending

in the United States is high and unsustainable, and we hope to draw attention to pricing

innovation as a mechanism to control spending (while most policy discussion has focused on

waste and utilization). A fuller discussion of whether health care prices are too high is difficult,

given space constraints.

The authors claim that most providers do not know their underlying cost structure or have

incentive to learn it, but even in a market with limited price competition, providers would

still benefit from having lower costs. This claim should be supported more.

Thank you for this suggestion. We have removed this assertion given space constraints and given

this is not central to our overall argument.

Given the focus on price, it should be defined. Specifically, it should be clarified that by

“price”, authors are referring to the sum of the price paid to providers by insurers and the

sum of the copay, deductible and coinsurance.

Thank you for this suggestion. We have now included a definition of price in the introductory

paragraphs.

The last sentence in the second to last paragraph (about bundled payments) is unrelated to

the topic of the paragraph (reference pricing). It seems out of place.

Thank you for this comment. We have removed the sentence in question.

Most of the contents in the table are not discussed or drawn upon in the text. The table and

text should cohere and complement each other more.

Thank you for this comment. We have tried to create closer links between the text and table.

However, given space constraints in the text, we believe the Table provides an opportunity to

provide added detail on some concepts.

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