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Biomedical subjects

M V Pauly

Publications and source records attributed to M V Pauly.

At least 73 records · Page 4Linked to original sources
PubMed1991

Physician response to fee changes with multiple payers.

This paper develops a general model of physician behavior with demand inducement encompassing the two benchmark cases of profit maximization and target-income behavior. It is shown that when income effects are absent, physicians maximize profits, and when income effects are very strong, physicians seek a target income. The model is used to derive own and cross-price expressions for the response of physicians to fee changes in the realistic context of more than one payer under the alternative behavior assumptions of profit maximization and target income behavior. The implications for public and private fee policy, and empirical research on physician response to fees, are discussed.

Choice Behavior↗
PubMed1990

Benign moral hazard and the cost-effectiveness analysis of insurance coverage.

When a medical intervention is found to be cost effective, what level of insurance coverage should apply to it? The optimal level of coverage may be less than or greater than full coverage of medical care costs; a finding of cost effectiveness for a service does not necessarily imply v full coverage or coverage at the same rate as other services. If there is some imperfection in the ability to translate higher insurance benefits into higher insurer revenues, the optimal level of coverage will be greater the higher the degree of moral hazard applying to the service.

Aged↗
PubMed1990

Price of dialysis, unit staffing, and length of dialysis treatments.

We analyzed the impact of the Medicare price for outpatient maintenance dialysis on the level and composition of staffing of dialysis units, and on the length (duration) of the average hemodialysis treatment for the period 1982 to 1987. With higher prices, dialysis units employ more total staff hours per patient per week (P less than 0.01) and use a higher proportion of registered nurses (RN) compared with other staff such as technicians and licensed practical nurses (LPN). Higher Medicare prices are also associated with longer average hemodialysis treatment duration for freestanding units (P less than 0.02), but there was no statistically significant association for hospital units. The impact of the Medicare price on both staffing and average treatment duration takes into account the calendar time trend, ie, 1987 versus 1982, which has a separate impact from the price effect. For example, to avoid the complication of technology changes over calendar time, we considered the impact of the price change at one point in time. Freestanding units that had a price cut of more than +15 in 1983, reported twice the reduction in the average dialysis treatment duration (-0.38 hours) compared with -0.20 hours (P = 0.01) for units that had a cut of less than +15. An analysis of the impact of average treatment duration on patient mortality provided some evidence that shorter treatment duration in freestanding units is associated with higher mortality. This result needs further analysis. There was no statistically significant relationship between the level of staffing in the dialysis unit or the percent of staff who were RNs and 3-year patient survival. The analysis in this report was based on 1,213 and 1,058 data forms filed with Medicare by freestanding and hospital units, respectively, for 1982 and 1987. In addition, we used a Cox proportional hazards model (multivariate) for the analysis of the 3-year patient survival for 14,807 new hemodialysis patients who started dialysis in 1984.

Fees and Charges↗
PubMed1990

Managing physician incentives in managed care. The role of for-profit ownership.

The recent rapid growth of HMOs has resulted in a proliferation of contractual arrangements that offer financial incentives to induce primary care doctors to change the way they practice medicine. The impact of these incentives varies with the different incentives and with the environments in which the incentives are implemented. Although financial incentives exist in some form in the great majority of HMOs, there has been no detailed and valid information available on the way these physician incentives are managed or on the characteristics of the standard operating "climate" in which the incentives exist. This study was designed to measure a firm (organizational) characteristic hypothesized to be related to the firm's effort, ability, or desire to make financial incentives work strongly. The characteristic considered is whether the firm is a for-profit or a not-for-profit organization. The goal of this study was to provide a direct test of the relationship between HMO ownership type and the effectiveness of primary care physician incentives. Results of the study indicate that for-profit ownership does enhance the power (or the need) of management to offer effective rewards for parsimonious use of health care resources.

Capitation Fee↗
PubMed1990

Financing health care.

This article reviews the causes of growth in health care costs and concludes that only changes in the rate of growth in intensity of care are likely to be effective. It proposes a model of consumer choice (with advice) among health plans, and competition among plans on the basis of the rate at which new technology is introduced, as a solution to the problem of picking the appropriate rate. It argues that the existence of the uninsured is evidence of government failure.

Community Participation↗
PubMed1990

Toward new typologies for HMOs.

The evolution of health maintenance organizations (HMOs) has entailed changes in both their structural characteristics and incentives to attract physicians' participation. Previous classifications of HMOs have failed to capture explicitly key features of these changes. Two alternative typologies based on incentives or organizational structures may be constructed by examining precise forms of two- or three-tiered contractual arrangements, physicians' payment methods, clienteles served, and means of pooling risks. Classifications of these kinds may represent or aid in generating a valid typology to help managers, consumers, providers, and analysts understand better how HMOs operate and which factors are critical in the dynamic managed-care industry.

Capitation Fee↗
PubMed1989

How do financial incentives affect physicians' clinical decisions and the financial performance of health maintenance organizations?

It has been suggested that the use of financial incentives by health maintenance organizations (HMOs) may change physicians' behavior toward individual patients. To test this hypothesis, we used a regression analysis of data from a survey of HMOs to examine the relation between the presence of financial incentives and two measures of the use of resources (the rate of hospitalization and the rate of visits for outpatient services) and one measure of the HMOs' financial viability (the achievement of break-even status). When we controlled for the effect of market-area variables, we found that some forms of compensation were significantly associated with these indicators of decision making by physicians. Among methods of paying physicians, the use of capitation or salaries was associated with a lower rate of hospitalization than the use of fee-for-service payment; physicians in for-profit HMOs and group-model HMOs also used the hospital less often. Placing physicians at financial risk as individuals and imposing penalties for deficits in the HMO's hospital fund beyond the loss of withheld funds were associated with fewer outpatient visits per enrollee, but a higher percentage of HMO patients in a physician's caseload was associated with more frequent visits. HMOs were more likely to break even if they were larger, older, had physicians who treated more HMO patients, and placed physicians at personal financial risk for the cost of outpatient tests; break-even status was also related to the type of HMO. We conclude that the use of some, but not all, financial incentives, as well as the type of HMO, does influence the behavior of physicians toward patients. It remains to be determined how these factors affect the quality of care.

Decision Making↗
PubMed1988

Access to kidney transplantation. Has the United States eliminated income and racial differences?

We analyzed the effect of patient and dialysis unit characteristics on access to kidney transplantation using several different approaches, including an analysis of individual patient data from a systematic random sample of 2900 new dialysis patients from each year 1981 to 1985 (14721 patients total). Additional analyses focused on the composition of transplant waiting lists and aggregate data from a 1984 census of 1133 dialysis and transplant units. White, male, young, nondiabetic, high-income patients treated in smaller units are more likely to receive a cadaver transplant under Medicare than are other kidney patients. Profit status of the dialysis unit was not found to be correlated to access to transplantation, although size of the unit may be correlated to access. Future analysis should focus on whether patient access has been inappropriately compromised. Possible factors unexplored in this analysis include differential patient preferences and medical suitability, as well as differential medical access.

Adult↗
PubMed1988

Market power, monopsony, and health insurance markets.

This paper details the potential adverse welfare consequences of monopsony power in health insurance markets. It is shown that the exercise of monopsony power in the medical services market can augment the monopoly rents of an insurer with market power in the insurance market, while at the same time inefficiently reducing supplier welfare. Cost-sharing by not-for-profit firms and its welfare consequences are also analyzed.

Blue Cross Blue Shield Insurance Plans↗
PubMed1988

Is medical care different? Old questions, new answers.

This paper examines whether changes in medical markets may be making them more like other markets. The emergence of HMOs and other managed care systems appears to have increased the consumer's potential ability to make better comparative judgments about the price and quality of medical care, and also seems to have made medical care more like other goods. However, the evidence that medical care is a "reputation good" suggests that it is, in this respect, different from other goods. Finally, the social concerns about medical care use necessarily make medical care different.

Consumer Advocacy↗
PubMed1987

How will changes in physician payment by Medicare influence laboratory testing?

In-office laboratory testing offers physicians an opportunity to increase their incomes through the potential profit available from technical services. This financial incentive for in-office testing has been altered by Medicare limits on physician payment, legislative changes in physicians' ability to bill Medicare for laboratory tests, and technological advances in office laboratory equipment. While restrictions on payment may make laboratory testing relatively less profitable than other technical services offered in the physician's office, in-office laboratory testing still offers potential financial benefit to physicians, particularly if they can influence the demand for tests. Economic theory suggests that physicians may be able to increase the demand for their services, including laboratory testing, but empirical data are not conclusive. As Medicare and other third-party payers consider fundamental reform in physician payment, the effect of different payment schemes on physicians' use of laboratory tests may have important consequences for physicians' income, the quality of care, patients' access to care, and the cost of the Medicare program.

Costs and Cost Analysis↗
PubMed1987

Survival analysis of patients undergoing dialysis.

We analyzed the five-year survival of 4661 patients with end-stage renal disease whose first dialysis occurred in 1977. The analysis incorporated characteristics of patients and dialysis institutions. Results showed that mortality was positively correlated with patient age, initial conditions leading to renal failure, being male and white, open staffing, and the number of staff physicians. In addition, lower death rates were observed for patients treated in larger dialysis units and units that had been long-term reusers of dialyzers. Patients treated in for-profit and not-for-profit units appeared to have the same mortality, although patients treated in freestanding units had lower mortality. The direction of causation was not always clear in these results.

Adult↗