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PubMed1996

Market structure and the role of consumer information in the physician services industry: an empirical test.

This paper applies Panzar and Rosse's (1987) econometric test of market structure to examine two long-debated issues: What is the market structure for physician services? Do more physicians in a market area raise the search cost of obtaining consumer information and increase prices (Satterthwaite, 1979, 1985)? For primary care and general and family practice physicians, the monopolistically competitive model prevailed over the competing hypotheses--monopoly, perfect competition, and monopolistic competition characterized by consumer informational confusion. Although less conclisive, there is some evidence to support the monopolistically competitive model for surgeons and the consumer informational confusion model for internal medicine physicians.

Community Participation↗

PubMed2004

The impact of advertising on nicotine replacement therapy demand.

While much is known about the economic determinants of tobacco use, very little is known about the economic determinants of nicotine replacement therapy (NRT) use. This paper is the first econometric study to examine the impact of advertising on NRT demand. Pooled cross-sectional time-series scanner-based data for 50 major metropolitan markets in the USA covering the period between the second quarter of 1996 and the second quarter of 2002 are used in the analysis. Fixed-effects modeling is employed to estimate the NRT demand equation. The estimates indicate that increased advertising of Nicoderm CQ transdermal patches and Nicotrol transdermal patches increases per-capita sales of established Nicoderm CQ and Nicotrol products, respectively. However, increased advertising of Nicorette polacrilex (gum) was found not to significantly increase sales of established Nicorette products. Moreover, decreases in the price of NRT and increases in the price of cigarettes were found to increase per-capita sales of NRT products. Given the documented efficacy of NRT, measures to increase peoples' awareness of NRT products through advertising, measures to decrease the price of NRT, and measures to increase the price of cigarettes would be effective means to increase the use of NRT, likely leading to decreased cigarette smoking and reductions in the future public health burden caused by tobacco use.

Administration, Cutaneous↗

PubMed1996

Using physician practice cost functions in payment policy: the problem of endogeneity bias.

Empirical estimates of physician practice cost functions, especially estimates of marginal practice costs and scale economies, could assist in setting physician payment policy. This paper examines the bias that may result in these estimates from the usual approach of treating physician labor input as exogenous. Data come from 207 general surgeons included in the Physician Payment Review Commission's 1988 National Survey of Physicians. The empirical practice cost function is specified as a generalized translog. Results are compared for alternative estimation methods that treat physician labor input as exogenous and as endogenous. The findings suggest that marginal cost estimates which ignore the endogeneity of physician labor are biased downward, while estimates of economies of scale are biased upward. In particular, with physician labor exogenous, statistically significant scale economies are found over a wide range of output levels; with physician labor endogenous, constant returns to scale cannot be rejected. Applying econometric studies of physician practice costs to policy will require attention to important methodological issues and collection of high-quality data.

Bias↗

PubMed1998

Health care expenditures and GDP: panel data unit root test results.

This short paper presents unit root test results for time series on per capita national health care expenditures and gross domestic product in the OECD. Unlike the country-by-country test used by [Hansen, P., King, A., 1996. The determinants of health care expenditure: A cointegration approach. J. Health Econ, 15, 127-137], the test we employ exploits the panel nature of the OECD data. Using this approach, we are able to reject the null hypothesis that these series contain unit roots. No single test is likely to be definitive in this rapidly-evolving area of econometric research; however, our results help to mitigate concern that panel data analyses of national health care expenditures are misspecified.

Data Collection↗

PubMed2006

Estimating technical efficiency in the hospital sector with panel data: a comparison of parametric and non-parametric techniques.

BACKGROUND: Policy makers are increasingly interested in developing performance indicators that measure hospital efficiency. These indicators may give the purchasers of health services an additional regulatory tool to contain health expenditure. OBJECTIVE: Using panel data, this study compares different parametric (econometric) and non-parametric (linear programming) techniques for the measurement of a hospital's technical efficiency. METHOD: This comparison was made using a sample of 17 Italian hospitals in the years 1996-9. RESULTS: Highest correlations are found in the efficiency scores between the non-parametric data envelopment analysis under the constant returns to scale assumption (DEA-CRS) and several parametric models. Correlation reduces markedly when using more flexible non-parametric specifications such as data envelopment analysis under the variable returns to scale assumption (DEA-VRS) and the free disposal hull (FDH) model. Correlation also generally reduces when moving from one output to two-output specifications. CONCLUSIONS: This analysis suggests that there is scope for developing performance indicators at hospital level using panel data, but it is important that extensive sensitivity analysis is carried out if purchasers wish to make use of these indicators in practice.

Cost Control↗

PubMed2003

Fixed fees and physician-induced demand: a panel data study on French physicians.

This paper investigates on the existence of physician-induced demand (PID) for French physicians. The test is carried out for GPs and specialists, using a representative sample of 4500 French self-employed physicians over the 1979-1993 period. These physicians receive a fee-for-services (FFS) payment and fees are controlled. The panel structure of our data allows us to take into account unobserved heterogeneity related to the characteristics of physicians and their patients. We use generalized method of moments (GMM) estimators in order to obtain consistent and efficient estimates. We show that physicians experience a decline of the number of consultations when they face an increase in the physician:population ratio. However this decrease is very slight. In addition, physicians counterbalance the fall in the number of consultations by an increase in the volume of care delivered in each encounter. Econometric results give a strong support for the existence of PID in the French system for ambulatory care.

Cohort Studies↗

PubMed1993

Econometric analyses of national health expenditures: can positive economics help to answer normative questions?

The size of national health care expenditure is an important research and policy issue. This paper reviews theoretical and empirical analyses of an implied optimal size for a health sector. Various economic theories are explicitly or implicitly invoked, but none is fully satisfactory. Theory provides, at best, a loose justification for empirical specifications of health sector behaviour. Nevertheless, this has a large and growing empirical research industry. The complexity of the issues provides an excuse for reliance on empirical analyses using ad hoc models. The paper analyses aggregate time-series data, using the cointegration approach, on health, health care expenditures and national income. Only one national model met both statistical criteria and showed a significant relationship: between potential life years lost and health care expenditure in the UK. The case for any general relationships remains unproven. There is no objective scientific method to determine optimal health expenditure, nor should we expect one. However, positive analyses can help with normative questions. A better understanding of health expenditure determination would arise from better specification of the relationships, perhaps by analysis at a lower level of aggregation.

Bias↗

PubMed2002

Allocating physicians' overhead costs to services: an econometric/accounting-activity based-approach.

Using the optimizing properties of econometric analysis, this study analyzes how physician overhead costs (OC) can be allocated to multiple activities to maximize precision in reimbursing the costs of services. Drawing on work by Leibenstein and Friedman, the analysis also shows that allocating OC to multiple activities unbiased by revenue requires controlling for revenue when making the estimates. Further econometric analysis shows that it is possible to save about 10 percent of OC by paying only for those that are necessary.

Accounting↗

PubMed2002

Something old, something new, something borrowed, something blue: a framework for the marriage of health econometrics and cost-effectiveness analysis.

Economic evaluation is often seen as a branch of health economics divorced from mainstream econometric techniques. Instead, it is perceived as relying on statistical methods for clinical trials. Furthermore, the statistic of interest in cost-effectiveness analysis, the incremental cost-effectiveness ratio is not amenable to regression-based methods, hence the traditional reliance on comparing aggregate measures across the arms of a clinical trial. In this paper, we explore the potential for health economists undertaking cost-effectiveness analysis to exploit the plethora of established econometric techniques through the use of the net-benefit framework - a recently suggested reformulation of the cost-effectiveness problem that avoids the reliance on cost-effectiveness ratios and their associated statistical problems. This allows the formulation of the cost-effectiveness problem within a standard regression type framework. We provide an example with empirical data to illustrate how a regression type framework can enhance the net-benefit method. We go on to suggest that practical advantages of the net-benefit regression approach include being able to use established econometric techniques, adjust for imperfect randomisation, and identify important subgroups in order to estimate the marginal cost-effectiveness of an intervention.

Baltimore↗

PubMedDate not supplied

Are dental practices less productive with older patients? Comparison of alternative output measures.

This study assessed the effects of increased visits by older dental patients on alternative measures of time- and dollar-based practice productivity. The Minnesota Dental Practice Analysis System was used for analysis of data from 31 practices (12,818 patients visits) reporting increased visits by older adults between June, 1980, and December, 1984. Results suggested that the productivity effects associated with older patient visits were highly dependent on the practice output measure selected. While increased visits by patients aged 70 and over were associated with increased monetary productivity per patient visit, time and monetary productivity per practice day were found to decline. An association between increased proportions of older patients visits and increased dentist minutes per visit appeared to account for this. This econometric analysis tends to support the notion that dental practices are less productive with older patients.

Adolescent↗

PubMed2002

Cost characteristics of hospitals.

Modern hospitals are complex multi-product organisations. The analysis of a hospital's production and/or cost structure should therefore use the appropriate techniques. Flexible functional forms based on the neo-classical theory of the firm seem to be most suitable. Using neo-classical cost functions implicitly assumes minimisation of (variable) costs given that input prices and outputs are exogenous. Local and global properties of flexible functional forms and short-run versus long-run equilibrium are further issues that require thorough investigation. In order to put the results based on econometric estimations of cost functions in the right perspective, it is important to keep these considerations in mind when using flexible functional forms. The more recent studies seem to agree that hospitals generally do not operate in their long-run equilibrium (they tend to over-invest in capital (capacity and equipment)) and that it is therefore appropriate to estimate a short-run variable cost function. However, few studies explicitly take into account the implicit assumptions and restrictions embedded in the models they use. An alternative method to explain differences in costs uses management accounting techniques to identify the cost drivers of overhead costs. Related issues such as cost-shifting and cost-adjusting behaviour of hospitals and the influence of market structure on competition, prices and costs are also discussed shortly.

Capital Expenditures↗

PubMed2003

The effect of activity-based financing on hospital efficiency: a panel data analysis of DEA efficiency scores 1992-2000.

Activity-based financing (ABF) was implemented in the Norwegian hospital sector from 1 July 1997. A fraction of the block grant from the state to the county councils has been replaced by a matching grant depending upon the number and composition of hospital treatments. As a result of the reform, the majority of county councils have introduced activity-based contracts with their hospitals. This paper studies the effect of activity-based funding on hospital efficiency. We predict that hospital efficiency will increase because the benefit from cost-reducing efforts in terms of number of treated patients is increased under ABF as compared with global budgets. The prediction is tested using a panel data set from the period 1992-2000. Efficiency indicators are estimated by means of data envelopment analysis (DEA) with multiple inputs and outputs. Using a variety of econometric methods, we find that the introduction of ABF has improved efficiency when measured as technical efficiency according to DEA analysis. The result is less uniform with respect to the effect on cost-efficiency.

Cost Allocation↗

PubMed1992

Fairness in prospective payment: a clustering approach.

Problems of fairness in prospective payment have existed since the inception of this regulatory method in the early 1980s. While prospective payment ostensibly has sought to reward efficient producers and provide disincentives for inefficient producers of health care, many hospitals have been penalized financially as a consequence of facing systematic factors beyond their control. This article defines homogenous peer groups of Department of Veterans Affairs providers for the purpose of establishing competitive prospective reimbursement rates. An econometric analysis classifies hospitals into six categories: small affiliated, small general, midsize affiliated/tertiary, large affiliated/tertiary, midsize general, and psychiatric. The Department of Veterans Affairs adopted this classification to alter its prospective payment system in 1988.

Cluster Analysis↗

PubMed2003

The impact of tobacco control program expenditures on aggregate cigarette sales: 1981-2000.

Since the 1998 Master Settlement Agreement (MSA) between states and the tobacco industry, states have unprecedented resources for programs to reduce tobacco use. Decisions concerning the use of these funds will, in part, be based on the experiences of states with existing programs. We examine the experiences of several states that have adopted comprehensive tobacco control programs. We also report estimates from econometric analyses of the impact of tobacco control expenditures on aggregate tobacco use in all states and in selected states with comprehensive programs for the period from 1981 through 2000. Our analyses clearly show that increases in funding for state tobacco control programs reduce tobacco use.

Commerce↗

PubMed2002

Regulation, ownership and efficiency in the Swiss nursing home industry.

Switzerland is a federal State where policy decisions regarding long-term care regulation are by rights incumbent upon regional and local governments. This situation is in part responsible for the large number of small nursing homes operating in Switzerland. Moreover, long-term care for the elderly is supplied by public, private for-profit and non-profit nursing homes, respectively. The paper presents an econometric estimation of a stochastic cost frontier using cross-section data for a sample of 886 Swiss nursing homes operating in 1998. The results of this analysis are used to examine the relationship between cost efficiency, the alternative institutional forms and the different regulatory settings.

Aged↗

PubMed1992

Tax harmonization and the reduction of European smoking rates.

Amidst growing optimism that smoking in Europe can be greatly reduced by the year 2000, this paper simulates the possible impacts of European tax harmonization in the context of rising incomes. A range of price and income elasticities are chosen from econometric studies which use micro information. This is justified by the aggregation problems associated with studies in the smoking literature which use aggregate data. Using micro elasticities, the simulations reported in this paper show that the aims of fiscal harmonization are at variance with the aims of health promotion.

Costs and Cost Analysis↗

PubMed2004

Private medical insurance and saving: evidence from the British Household Panel Survey.

This paper uses the British Household Panel Survey for the years 1996-2000 to investigate the relationship between saving and private medical insurance in the UK. Because the National Health Service (NHS) gives comprehensive health coverage and is generally free at source, one would not expect private medical insurance to crowd-out saving. However, the NHS being characterised by long waiting lists and generally poor quality, many people prefer to use private health services. In such circumstances, those individuals who are not covered by private medical insurance, and who are therefore more exposed to facing unexpected out-of-pocket private health care expenditures or income losses while waiting for public treatment might save more for precautionary reasons than those who are covered. According to our findings, which are based on a wide range of econometric specifications, there is a positive association between insurance coverage and saving, suggesting that private medical insurance does not generally crowd-out private saving. However, we found some evidence of crowding-out in those areas where the quality of medical facilities is perceived as poor, and in rural areas, characterised by fewer NHS providers.

Cost Savings↗

PubMed2004

Innovation and risk selection in deregulated social health insurance.

One important motive for deregulating social health insurance is to encourage product innovation. For the first time, the cost savings achieved by non-US managed care plans that are attributable to product innovation are estimated, using a novel approach. Panel data from a major Swiss health insurer permits to infer health status, which can be used to predict health care expenditure. The econometric evidence suggests that the managed care plans benefit from risk selection effects. In the case of the health maintenance organization (HMO) plan, however, the pure innovation effect may account for as much as two-thirds of the cost advantage.

Actuarial Analysis↗