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PubMed2003

Participation and crowd-out in a Medicare drug benefit: simulation estimates.

This article provides information on likely participation in the Medicare prescription drug plan and expected crowd-out. We use a microsimulation model based on data from the MCBS to estimate the costs and benefits of a Medicare drug plan, including the benefits from reductions in risk. The simulations are repeated using different combinations of benefits and subsidies. In addition, the simulations explore the effects of different behavioral parameters for moral hazard (the extent to which participants increase drug spending in response to reduced costs) and risk aversion (the extent to which participants would be willing to pay to avoid risk) to identify the impact of these factors on participation and crowd-out.

Aged↗
PubMed2007

Investigating the quitting decision of nurses: panel data evidence from the British National Health Service.

In this paper, we provide a detailed investigation into the quitting behaviour of nurses in the British National Health Service (NHS), using a recently constructed longitudinal survey. We fit both single and competing risks duration models that enable us to establish the characteristics of those nurses who leave the public sector, distinguish the importance of pay in this decision and document the destinations that nurses move to. Contrary to expectations, we find that the hourly wage received by nurses outside of the NHS is around 20% lower than in the NHS, and that hours of work are about the same. However, while the effect of wages is found to be statistically significant, the predicted impact of an increase in nurses' pay on retention rates is small. The current nurse retention problem in the NHS is therefore unlikely to be eliminated through substantially increased pay.

Adolescent↗
PubMed2003

GPs' payment contracts and their referral practice.

This paper compares the role of general practitioners in determining access to specialists in two types of health care systems: gate-keeping systems, where a general practitioner (GP) referral is compulsory to visit a specialist, and non-gate-keeping systems, where this referral is optional. We model the dependence between the GP's diagnosis effort and her referral behaviour, and identify the optimal contracts that induce the best behaviour from a public insurer's point of view, where there is asymmetry of information between the insurer and the GP regarding diagnosis effort and referral decisions. We show that gate keeping is superior wherever GP's incentives matter.

Family Practice↗
PubMed2004

Productive efficiency and its determinants in the Finnish Public Dental Service.

OBJECTIVE: Our objective was to investigate the cost efficiency of the Public Dental Service (PDS), which, until 2000, was responsible for organising dental care for children and younger adults born in 1956 and later. METHODS: Input and output data and information on various organisational and environmental characteristics were collected from 228 municipal PDS units in Finland. First, non-parametric data envelopment analysis (DEA) was employed to assess efficiency. In the second stage, econometric Tobit analysis was used to explore various predictors of cost efficiency, technical efficiency and allocative efficiency. As input in the DEA model we used personnel full-time equivalents and material and other costs expressed in monetary terms, and as output we used the number of treated patients. RESULTS: The study showed big differences in cost efficiency between the PDS units studied. The average cost inefficiency was 30%. Approximately two-thirds of the observed cost inefficiency was because of technical inefficiency and one-third because of allocative inefficiency. High state-subsidy levels, and a high proportion of young patients predicted inefficiency, and young population and low socioeconomic conditions in the municipality predicted efficiency. The results also indicated that many PDS units could have improved allocative efficiency by increasing the relative numbers of auxiliaries in relation to dentists. On the other hand, some units were too small to employ full-time dental hygienists efficiently. CONCLUSIONS: In the Finnish PDS, there are uncommitted resources that could be reallocated so as to improve overall efficiency.

Adolescent↗
PubMed1999

An econometric analysis of smoking prevalence among lone mothers.

This paper uses panel data to examine the determinants of smoking among lone mothers over the period 1991-1996. Consideration is given to the initial conditions problem encountered when modelling dynamic panel probit models, and a recently suggested approach is applied to address this problem.

Cross-Sectional Studies↗
PubMed2004

The transition from good to poor health: an econometric study of the older population.

This is a study of the influence of socioeconomic factors on the state of health of older Canadians. Three years of panel data from the Survey of Labour and Income Dynamics are used to model the transition probabilities between good and poor health. Care is taken to avoid the problem of endogeneity of income in modelling its effects, and to adjust reported income to free it from its strong association with age at the time of the survey. Of particular note are the significant effects found for income, in spite of universal public health care coverage. Significant effects are found also for age, education, and other variables.

Age Factors↗
PubMed1994

Cost-effectiveness analysis and policy choices: investing in health systems.

The role of health systems infrastructure in studies of cost-effectiveness analysis and health resource allocation is discussed, and previous health sector cost-effectiveness analyses are cited. Two substantial difficulties concerning the nature of health system costs and the policy choices are presented. First, the issue of health system infrastructure can be addressed by use of computer models such as the Health Resource Allocation Model (HRAM) developed at Harvard, which integrates cost-effectiveness and burden of disease data. It was found that a model which allows for expansion in health infrastructure yields nearly 40% more total DALYs for a hypothetical sub-Saharan African country than a model which neglects infrastructure expansion. Widespread use of cost-effectiveness databases for resource allocations in the health sector will require the cost-effectiveness analyses shift from reporting costs to reporting production functions. Second, three distinct policy questions can be treated using these tools, each necessitating its own inputs and constraints: allocations when given a fixed budget and health infrastructure, or when given resources for marginal expansion, or when given a politically constrained situation of expanding resources. Confusion concerning which question is being addressed must be avoided through development of a consistent and rigorous approach to using cost-effectiveness data for informing resource allocations.

Computer Simulation↗
PubMed2000

Posthospitalization home health care use and changes in functional status in a Medicare population.

OBJECTIVE: The objective of this work was to estimate the effect of Medicare beneficiaries' use of home health care (HHC) for 6 months after hospital discharge on the change in functional status over a 1-year period beginning before hospitalization. DATA SOURCES AND STUDY SETTING: Data came from the Medicare Current Beneficiary Survey, which is a nationally representative sample of Medicare beneficiaries, in-person interview data, and Medicare claims for 1991 through 1994 for 2,127 nondisabled, community-dwelling, elderly Medicare beneficiaries who were hospitalized within 6 months of their annual in-person interviews. STUDY DESIGN: Econometric estimation with the instrumental variable method was used to correct for observational data bias, ie, the nonrandom allocation of discharged beneficiaries to the use of posthospitalization HHC. The analysis estimates a first-stage model of HHC use from which an instrumental variable estimate is constructed to estimate the effect on change in functional status. PRINCIPAL FINDINGS: The instrumental variable estimates suggest that HHC users experienced greater improvements in functional status than nonusers as measured by the change in a continuous scale based on the number and mix of activities of daily living and instrumental activities of daily living before and after hospitalization. The estimated improvement in functional status could be as large as 13% for a 10% increase in HHC use. In contrast, estimation with the observational data on HHC use implies that HHC users had poorer health outcomes. CONCLUSIONS: Adjusting for potential observational data bias is critical to obtaining estimates of the relationship between the use of posthospitalization HHC and the change in health before and after hospitalization. After adjustment, the results suggest that efforts to constrain Medicare's spending for HHC, as required by the Balanced Budget Act of 1997, may lead to poorer health outcomes for some beneficiaries.

Activities of Daily Living↗
PubMed2004

Impact of informal regulation of pollution on water quality in rivers in India.

In this paper an attempt is made to assess the impact of informal regulation of water pollution on water quality in Indian rivers. For this purpose, an econometric analysis of determinants of water quality in Indian rivers is carried out using water quality (water class) data for 106 monitoring points on 10 important rivers for five years, 1995-1999. To explain variations in water quality, an Ordered Probit model is estimated, in which poll percentage in parliamentary elections, a proxy for the intensity of informal regulation, is taken as one of the main explanatory variables. Rainfall, industrialization, irrigation intensity and fertilizer use are some of the other explanatory variables used in the model to control for the influence of these factors. As expected, river water quality is found to be positively related with rainfall, and negatively related with industrialization, irrigation intensity and fertilizer use. A significant positive relationship is found between poll percentage and water quality, and also between the rate of increase in literacy level in a district and the water quality in rivers flowing through the district. These results point to a significant favorable effect of informal regulation of pollution on water quality in rivers in India.

Educational Status↗
PubMedDate not supplied

Economic depression and the use of physician services in Finland.

At the start of the 1990s, the economic situation in Finland deteriorated radically. During the depression (1991-93), health care expenditure decreased by about 10%, and was associated with considerable changes in Finnish health care. This paper reports studies of the determinants of use of physician services in Finland in the 1990s. The particular aim was to evaluate how utilization altered during the economic depression and during the changes in the health care system. Using econometric methods, an attempt was made to describe the changes in structure and level of utilization. The study was based on annual computer-assisted telephone interviews made during 1991-94. Visits to a doctor were analysed using a two-part model (logit and truncated negative binomial regression). Structural changes were tested by Chow-type tests and changes in the level of utilization by chronologically defined dummy variables for each year. The most significant changes (both in structure and level) occurred in the model explaining the number of visits (negative binomial regression) of chronically ill persons. Variables describing the continuity of care seem to be more important determinants of visits to a doctor than certain other availability and socioeconomic variables.

Adult↗
PubMed2001

Econometric issues in testing the age neutrality of health care expenditure.

A recent study by Zweifel et al. (Zweifel P, Felder S, Meiers M. Ageing of the population and health care expenditure: a red herring? Health Economics 1999; 8: 485-496) suggests that age is not related to health care expenditure among the elderly once 'closeness to death' is controlled for. If correct, this finding has major policy implications, but flaws in the econometric analysis undermine its credibility. We highlight two in particular, and propose methods to deal with them.

Age Factors↗
PubMed2002

Change in determinants of use of physician services in Finland between 1987 and 1996.

The determinants of use of physician services in Finland in 1987 and 1996 were studied to evaluate how the utilisation altered over this period, which saw fairly radical changes in Finnish health care and the entire economy. We used econometric methods to describe the changes in structure and level of utilisation. The study was based on the Finnish Health Care Surveys of 1987 and 1996, which were nationally representative cross-sectional samples of the total non-institutionalised population. Visits to a doctor were analysed using a two-part model (logit +truncated negative binomial regression). Structural changes were tested by a Chow-type test and changes in utilisation level by a dummy variable indicating the year of study. Analyses were made separately for four different age groups: children aged 0-6 and 7-17, and adults aged 18-64 and over 64 years. The change in utilisation of physician services over the nine-year period was a product of both structural and level changes. Except in the youngest age group, both types of changes occurred in the second part of the utilisation model, which implies that they were more associated with supply side factors than demand factors. Among young children, the type of day-care seems to have been an important determinant of physician utilisation. Although its effect decreased considerably over the period, the total number of visits to a doctor in 1996 was still about 30% greater among children in nursery care than those at home. The rise in self-reported chronic illness was an important explanation of the increase in utilisation of doctors' services, especially among children. Among adults aged 18-64, the most important structural change was an increase of the effect of self-rated health status variables on utilisation. Inequity in utilisation of services persisted with respect to income. In conclusion it can be stated that Finland's tax-based and locally decentralised health care system adapted quite well to the radical changes experienced during the study period.

Adolescent↗
PubMed2002

Testing Gateway Theory: do cigarette prices affect illicit drug use?

We test the causal Gateway Theory of drug use dynamics by way of a natural experiment. We randomize cigarette smoking by birth cohort and cigarette prices. We use data for Israel to show that while cigarette smoking causes cannabis use, the evidence that cannabis use causes hard drug use is much weaker. These results are based on various econometric methodologies including two-stage logit (2SL), bivariate probit, and frailty analysis for survival data.

Adolescent↗