[A model contract for ambulatory nursing services].
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Ambulatory Care↗
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Patient choice of physician: do health insurance and physician characteristics matter?
Generous health insurance coverage is widely believed to have contributed to both high and rising health care costs. This paper tests the hypothesis that better insured patients will demand higher "quality" by choosing more often to visit specialists rather than generalist physicians. We model the conditional decision to seek care from a specialist physician as a function of health insurance status, physician characteristics, and other socioeconomic factors. Analysis of data from the 1987 National Medical Expenditure Survey and the American Medical Association suggests that the presence of insurance coverage does not affect choice of physician. The results do show that people enrolled in health maintenance organizations (HMOs) see specialists less often than other patients.
Adolescent↗
Cost analysis of hospital material management systems.
Integrated healthcare material management begins with manufactures of medical/surgical supplies, uses distributors and ends at the point of use at hospitals. Recent material management philosophies in the healthcare industry, such as just-in-time and stockless systems, are yet to be fully evaluated. In order to evaluate the cost effectiveness of each type of material management technique, a cost model for hospital materials management has been designed. Several case scenarios are analyzed and results are reported.
Cost Savings↗
Econometric critique of the economic change model of mortality.
The application of time-series data and analysis to study the effects of changes in unemployment rates on mortality rates has been a controversial issue in health-unemployment research for many years. This article presents new criticism against previous aggregate time-series regression models and concludes that these models are misspecified in functional form, and the t-ratios used in significance tests are grossly overstated. Future empirical analysis of the Economic Change Model of Mortality, i.e. the aggregate, time-series relationship between mortality rates and economic variables must pay more attention to the salient characteristics of time-series data and implications for regression results.
Bias↗
Financial incentives and productive efficiency in Finnish health centres.
This paper examines the productive efficiency of Finnish health centres by applying data envelopment analysis (DEA) and econometric methods. The Tobit model was used in an attempt to find out how various economic, structural and demographic factors affect efficiency. The dependent variable of the model, the coefficient of inefficiency, was obtained by deducting the DEA efficiency score from one. According to the results, a high percentage of funding coming from central government matching grants and high taxable income per inhabitant are significant predictors of inefficiency. The results suggest that more generous resources tend to increase inefficiency since they may lessen incentives for tight cost and performance control. A high share of doctors and a low share of administrative, maintenance and support personnel promote efficiency. A low population share of the elderly and a long distance to the nearest hospital are positively associated with inefficiency.
Community Health Centers↗
Health, health care, and the environment. Econometric evidence from German micro data.
The paper develops and applies a Grossman-style health production model set up in discrete time to explain the impact of environmental pollution on the demand for both health and health care. In order to introduce the environment, our analysis takes changes in environmental conditions to influence the rate at which an individual's stock of health depreciates. While the theoretical part of our paper also contains a discussion of the full model, we restrict our empirical analysis to a submodel which is known as the pure investment model. This is because the other submodel, the pure consumption model, implies a rather implausible case of satiation with respect to the individual's preferences. Our empirical findings are based on data taken from the German Socio-economic Panel. The stock of health capital and environmental pollution are treated as latent variables and estimated using a Linear Covariance Structures model. The quality of the environment turns out to be an important determinant of health capital. From the point of view of health economics, improvements in environmental conditions can be interpreted as preventive measures. In terms of prevention, public policies designed to protect the environment also yield significant health effects. As regards health care demand the influence is not clearcut, i.e., one cannot necessarily expect a reduction in resource use.
Data Interpretation, Statistical↗
Consolidations and closures: an empirical analysis of exits from the hospital industry.
This paper investigates the pre-exit characteristics of hospital mergers, acquisitions, and closures. We estimate competing risk hazard models using an 18-year national data set that spans the wave of closures in the 1980s and of mergers in the 1990s. Evidence shows that weak productivity of the hospital is a strong determinant for closures while competitive pressures are more influential in the decision to consolidate. Thus, increased market power, relative to cost reductions, appears to play a larger role in the merger decision. Our results also provide insight into possible correlations between mergers and closures.
Efficiency, Organizational↗
The relationship between health care expenditure and health outcomes. Evidence and caveats for a causal link.
The relationship between health care expenditure and health outcomes is of interest to policy makers in the light of steady increases in health care spending for most industrialised countries. However, establishing causal relationships is complex because, firstly, health care expenditure is only one of many quantitative and qualitative factors that contribute to health outcomes, and, secondly, measurement of health status is an imperfect process. This study reviews key findings and methodological approaches in this field and reports the results of our own empirical study of countries of the European Union. Our analysis examines life expectancy and infant mortality as the 'output' of the health care system, and various life-style, environmental and occupational factors as 'inputs'. Econometric analyses using a fixed effects model are conducted on a panel data set for the former 15 members of the European Union over the period 1980-1995. The findings show that increases in health care expenditure are significantly associated with large improvements in infant mortality but only marginally in relation to life expectancy. The findings are generally consistent with those of several previous studies. Caveats and improvements for future research are presented.
Causality↗
Nursing home care in The Netherlands: a nonparametric efficiency analysis.
This paper analyzes the technical efficiency of Dutch nursing homes with respect to the use of labor inputs by means of Data Envelopment Analysis (DEA). In addition, the determinants of the efficiency scores are investigated using censored regression analysis. Special attention is paid to checking the robustness of the results to using different versions of DEA and to the econometric specification of the censored regression models. Fifty percent of the nursing homes are fully efficient, according to the theoretically preferred frontier with constant or decreasing returns to scale. There is some evidence of a trade-off between labor input efficiency and the quality of care.
Data Collection↗
Estimating the quality of care in hospitals using instrumental variables.
Mortality rates are a widely used measure of hospital quality. A central problem with this measure is selection bias: simply put, severely ill patients may choose high quality hospitals. We control for severity of illness with an instrumental variables (IV) framework using geographic location data. We use IV to examine the quality of pneumonia care in Southern California from 1989 to 1994. We find that the IV quality estimates are markedly different from traditional GLS estimates, and that IV reveals different determinants of quality. Econometric tests suggest that the IV model is appropriately specified, that the GLS model is inconsistent.
California↗
The protracted demise of medical technology. The case of intermittent positive pressure breathing.
In this study, the effects of hospital, staff, and patient characteristics on the rates of use and abandonment of an outmoded medical technology, intermittent positive pressure breathing (IPPB) are analyzed. The study focuses specifically on the use of IPPB to treat inpatients with chronic obstructive pulmonary disease in a national sample of more than 500 community hospitals from 1980 to 1987. Cross-sectionally, hospitals with shorter case-mix-adjusted lengths of stay, private nonprofit or investor-owned hospitals, and hospitals located outside of the north central United States were more likely to abandon IPPB by 1980. Teaching status, location, ownership, volume, and source of payment all appeared to affect rates of IPPB use in 1980. The longitudinal analysis examines both the probability a hospital abandoned IPPB and declines in rates of IPPB use over the study period, conditioned on the availability of IPPB in 1980. The results show that changes in the characteristics of hospitals, patients, and physicians all help to explain variations in the abandonment of IPPB. These findings contrast with previous studies of technological change, which find hospital size to be the most important variable. Size is important in explaining the rate of use in 1980, but it has no effect on the rate of decline in use or abandonment after 1980. In general, the analysis demonstrates that a combination of factors, economic incentives as well as information, contribute to the abandonment of outmoded medical technologies. Given the surprisingly long time periods required for this process to occur, the analysis underscores the need to strengthen financial incentives that encourage appropriate medical decisions and to disseminate information about the efficacy of specific procedures more widely and effectively.
Cross-Sectional Studies↗
Cost-effectiveness of male circumcision for HIV prevention in a South African setting.
BACKGROUND: Consistent with observational studies, a randomized controlled intervention trial of adult male circumcision (MC) conducted in the general population in Orange Farm (OF) (Gauteng Province, South Africa) demonstrated a protective effect against HIV acquisition of 60%. The objective of this study is to present the first cost-effectiveness analysis of the use of MC as an intervention to reduce the spread of HIV in sub-Saharan Africa. METHODS AND FINDINGS: Cost-effectiveness was modeled for 1,000 MCs done within a general adult male population. Intervention costs included performing MC and treatment of adverse events. HIV prevalence was estimated from published estimates and incidence among susceptible subjects calculated assuming a steady-state epidemic. Effectiveness was defined as the number of HIV infections averted (HIA), which was estimated by dynamically projecting over 20 years the reduction in HIV incidence observed in the OF trial, including secondary transmission to women. Net savings were calculated with adjustment for the averted lifetime duration cost of HIV treatment. Sensitivity analyses examined the effects of input uncertainty and program coverage. All results were discounted to the present at 3% per year. For Gauteng Province, assuming full coverage of the MC intervention, with a 2005 adult male prevalence of 25.6%, 1,000 circumcisions would avert an estimated 308 (80% CI 189-428) infections over 20 years. The cost is 181 dollars (80% CI 117-306 dollars) per HIA, and net savings are 2.4 million dollars (80% CI 1.3 million to 3.6 million dollars). Cost-effectiveness is sensitive to the costs of MC and of averted HIV treatment, the protective effect of MC, and HIV prevalence. With an HIV prevalence of 8.4%, the cost per HIA is 551 dollars (80% CI 344-1,071 dollars) and net savings are 753,000 (80% CI 0.3 million to 1.2 million dollars). Cost-effectiveness improves by less than 10% when MC intervention coverage is 50% of full coverage. CONCLUSIONS: In settings in sub-Saharan Africa with high or moderate HIV prevalence among the general population, adult MC is likely to be a cost-effective HIV prevention strategy, even when it has a low coverage. MC generates large net savings after adjustment for averted HIV medical costs.
Adolescent↗
Health plan disenrollment in a choice-based Medicaid managed care program.
Consumer decisions to switch health plans have implications for quality of care and risk selection. We examine factors related to time to disenrollment in a Medicaid managed care program where beneficiaries face a menu of plans and can change plans every month. Several findings have direct policy relevance. Families and individuals who make active choices upon entering the program are at substantially lower risk of disenrollment than those who are auto-assigned. Interactions between enrollee ethnicity and provider language proficiency suggest that enrollee satisfaction depends on the cultural competence of providers. Differential disenrollment by risk status results in adverse retention for certain types of plans.
Adult↗
Premarital cohabitation and subsequent marital dissolution: a matter of self-selection?
Married couples who began their relationship by cohabiting appear to face an increased risk of marital dissolution, which may be due to self-selection of more dissolution-prone individuals into cohabitation before marriage. This paper uses newly developed econometric methods to explicitly address the endogeneity of cohabitation before marriage in the hazard of marital disruption by allowing the unobserved heterogeneity components to be correlated across the decisions to cohabit and to end a marriage. These methods are applied to data from the National Longitudinal Study of the High School Class of 1972. We find significant heterogeneity in both cohabitation and marriage disruption, and discover evidence of self-selection into cohabitation.
Adult↗
Poverty, health infrastructure and the nutrition of Peruvian children.
This paper offers empirical evidence on the impact of the expansion in health infrastructure of the 1990s upon child nutrition in Peru, as measured by the height for age z-score. Using a pooled sample of three rounds of the Peruvian DHS, I have controlled for biases in the allocation of public investments by using a district fixed effects model. The econometric analysis shows a positive effect of the expansion of the last decade in urban areas, but not in rural areas. Furthermore, the effect for urban children is highly non-linear and has a pro-poor bias, in the sense that the estimated effect is larger for children of less educated mothers. These findings support the idea that reducing distance and waiting time barriers is necessary to improve child health and nutrition in developing countries, but that we need more explicitly inclusive policies to improve the health of the rural poor, especially indigenous groups, that are caught in this type of poverty trap.
Child Nutritional Physiological Phenomena↗
Public policy and smoking cessation among young adults in the United States.
In the wake of significant budget shortfalls, numerous states have increased cigarette excise taxes to boost revenues. This study examines whether or not increasing the price of cigarettes, which will occur as a consequence of cigarette excise tax increases, and implementing stronger restrictions on smoking in private worksites and other public places have an impact on smoking cessation decisions of young adults, thereby influencing public health in the United States (US). This paper employs longitudinal data on young adults from the Monitoring the Future Surveys matched with information on site-specific prices and measures of clean indoor air restrictions. A Cox regression is employed to estimate the smoking cessation equations. The estimates clearly indicate that increasing the price of cigarettes increases the number of young adults who quit smoking. The average price elasticity of cessation is 0.35. In addition, stronger restrictions on smoking in private worksites and public places other than restaurants increase the probability of young adult smoking cessation. Given the well-documented benefits of smoking cessation, a significant increase in cigarette excises taxes may be one of the most effective means to reduce premature death and disease in the United States.
Adolescent↗
A pint a day raises a man's pay; but smoking blows that gain away.
This paper studies the wage effects of the use of alcohol and tobacco. The analysis based on a recent survey in The Netherlands shows that for males the use of tobacco has a negative wage effect of about 10% while the use of alcohol has a positive wage effect of about the same size. The wages of females are not affected by smoking and drinking.
Adolescent↗
A quality-adjusted cost function in a regulated industry: the case of Dutch nursing homes.
The primary objective of this paper is to examine the cost structure of the Dutch nursing home industry, using econometric techniques. In this paper we present a model that combines economic behaviour and quality of services measured by a latent variable. We propose a simple method for identifying and estimating cost functions in the presence of endogenous, unobserved quality. Estimating this quality-adjusted cost function and the corresponding cost share equations indicates that quality is negatively related to the input prices of nurses and other personnel, indicating that nursing homes have a preference for labour. We also show that the quality-adjusted model is superior to a model with exogenous quality.
Aged↗