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PubMed2001

Measuring competition in health care markets.

OBJECTIVE: Measuring competition is increasingly important for analysis of health care markets and policies. Measurement of competition in health care is made complex by the breadth of potential issues under study, by the lack of necessary data, and by rapid changes in health care financing and delivery. This study reviews key issues in the measurement of competition and is designed to familiarize researchers and policymakers interested in competition measurement, but not steeped in its practice, with key concepts, data sources, and ways of adapting measures to fit ongoing changes in health care markets. PRINCIPAL FINDINGS: Attention to several key issues will strengthen measurement. Important components of successful measurement are: careful identification of the products and market areas for study; selection of Herfindahl-Hirschman or other indices to fit the issues being considered; consideration of econometric problems, like endogeneity, with common measures; and attention to the ways that current marketplace changes, like growth in managed care, affect the performance of classic measures. Data needed for constructing measures are also frequently scarce, insufficient, or both. Measurement could be improved with access to better data.

Catchment Area, Health↗
PubMed2002

Migration and fishing in Indonesian coastal villages.

The coastal ecosystems in Southeast Asia are under increased pressure from local and global change. This paper examines human migration and the use of marine resources in coastal villages in the Minahasa district of North Sulawesi, Indonesia. Primary data were collected through interviews with village leaders, focus groups, and a sample survey of 600 fishing households. Migration is responsible for at least one quarter of the total growth during the past decade. All groups of fishermen report falling productivity of the nearshore fisheries. Econometric analysis is used to examine the weekly fish catch of the artisanal fishing sector. Migration status and socioeconomic variables seem to have no systematic effect, while fishing effort (labor, boat, and gear), the degree of specialization, and the remoteness of villages are found to be positively related to weekly fish catches.

Animals↗
PubMed2004

The sources of hospital cost variability.

Hospital heterogeneity is a major issue in defining a reimbursement system. If hospitals are heterogeneous, it is difficult to distinguish which part of the differences in costs is due to cost containment efforts and which part cannot be reduced, because it is due to other unobserved sources of hospital heterogeneity. In this paper, we apply an econometric approach to analyse hospital cost variability. We use a nested three-dimensional database (stays-hospitals-years) in order to explore the sources of variation in hospital costs, taking into account unobservable components of hospital cost heterogeneity. The three-dimensional structure of our data makes it possible to identify transitory and permanent components of hospital cost heterogeneity. Econometric estimates are performed on a sample of 7314 stays for acute myocardial infarction (AMI) observed in 36 French public hospitals over the period 1994-1997. Transitory unobservable hospital heterogeneity is far from negligible: its estimated standard error is about 50% of the standard error we estimate for cost variability due to permanent unobservable heterogeneity between hospitals.

Adult↗
PubMed2004

Time to include time to death? The future of health care expenditure predictions.

Government projections of future health care expenditures--a great concern given the aging baby-boom generation--are based on econometric regressions that control explicitly for age but do not control for end-of-life expenditures. Because expenditures increase dramatically on average at the end of life, predictions of future cost distributions based on regressions that omit time to death as an explanatory variable will be biased upward (or, more explicitly, the coefficients on age will be biased upward) if technology or other social factors continue to prolong life. Although health care expenditure predictions for a current sample will not be biased, predictions for future cohorts with greater longevity will be biased upwards, and the magnitude of the bias will increase as the expected longevity increases. We explore the empirical implications of incorporating time to death in longitudinal models of health expenditures for the purpose of predicting future expenditures. Predictions from a simple model that excludes time to death and uses current life tables are 9% higher than from an expanded model controlling for time to death. The bias increases to 15% when using projected life tables for 2020. The predicted differences between the models are sufficient to justify reassessment of the value of inclusion of time to death in models for predicting health care expenditures.

Aged↗
PubMed2001

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

Salas and Raftery allege that in our paper, (1) remaining life expectancy is an endogenous explanatory variable of health care expenditure and (2) the parameter designed to correct for sample selection bias in fact represents a hidden relationship between health care expenditure and age. We argue that claim (1) is not supported by the available empirical evidence, while claim (2) seems to derive from a too cursory reading of our paper.

Age Factors↗
PubMed2000

Community-level determinants of child growth in an Indonesian tea plantation.

OBJECTIVES: The paper presents the results of an ecological-economic approach to identifying community-level factors that influence the physical growth of young children. DESIGN: A cross-sectional design was used to obtain both the anthropometry and the ecological-economic data. SETTING: The sites were 24 communities located in a tea plantation near Bandung, West Java, Indonesia. SUBJECTS: 415 children between the ages of 6 and 18 months. METHODS: Epidemiological and ethnographic methods were used to measure community infrastructure and services related to child growth. Anthropometry was used to measure child growth. Econometric methods, including probit and ordinary least squares regression, were used to analyze the effect of community-level factors on child growth. RESULTS: Community vaccination programs, child care services, environmental sanitation and latrines were associated with better child growth. We concluded that community-level goods and services substantially contributed to health in early childhood.

Agriculture↗
PubMed1998

Econometrics in outcomes research: the use of instrumental variables.

We describe an econometric technique, instrumental variables, that can be useful in estimating the effectiveness of clinical treatments in situations when a controlled trial has not or cannot be done. This technique relies upon the existence of one or more variables that induce substantial variation in the treatment variable but have no direct effect on the outcome variable of interest. We illustrate the use of the technique with an application to aggressive treatment of acute myocardial infarction in the elderly.

Aged↗
PubMed2002

Computationally intensive econometrics using a distributed matrix-programming language.

This paper reviews the need for powerful computing facilities in econometrics, focusing on concrete problems which arise in financial economics and in macroeconomics. We argue that the profession is being held back by the lack of easy-to-use generic software which is able to exploit the availability of cheap clusters of distributed computers. Our response is to extend, in a number of directions, the well-known matrix-programming interpreted language Ox developed by the first author. We note three possible levels of extensions: (i) Ox with parallelization explicit in the Ox code; (ii) Ox with a parallelized run-time library; and (iii) Ox with a parallelized interpreter. This paper studies and implements the first case, emphasizing the need for deterministic computing in science. We give examples in the context of financial economics and time-series modelling.

Computer Communication Networks↗
PubMed1999

A comparison of hospital scale effects in short-run and long-run cost functions.

Numerous estimates of economies of scale in the hospital setting have been obtained since the early 1980s from both flexible long-run and short-run cost functions. Although the theoretical superiority of the latter approach is widely recognized, it has been previously suggested that the two cost specifications yield quite similar econometric findings regarding scale effects. This paper utilizes a new data set consisting of 91 Greek NHS hospitals in order to empirically examine this proposition by comparing economies of scale estimates derived from both translog total and variable cost functions. The results indicate that the use of long-run equations might seriously mislead policy makers and that constant returns to scale prevail in Greek public hospitals.

Cost-Benefit Analysis↗
PubMed1997

Research without billing data. Econometric estimation of patient-specific costs.

OBJECTIVES: This article describes a method for computing the cost of care provided to individual patients in health care systems that do not routinely generate billing data, but gather information on patient utilization and total facility costs. METHODS: Aggregate data on cost and utilization were used to estimate how costs vary with characteristics of patients and facilities of the US Department of Veterans Affairs. A set of cost functions was estimated, taking advantage of the department-level organization of the data. Casemix measures were used to determine the costs of acute hospital and long-term care. RESULTS: Hospitalization for medical conditions cost an average of $5,642 per US Health Care Financing Administration diagnosis-related group weight; surgical hospitalizations cost $11,836. Nursing home care cost $197.33 per day, intermediate care cost $280.66 per day, psychiatric care cost $307.33 per day, and domiciliary care cost $111.84 per day. Outpatient visits cost an average of $90.36. These estimates include the cost of physician services. CONCLUSIONS: The econometric method presented here accounts for variation in resource use caused by casemix that is not reflected in length of stay and for the effects of medical education, research, facility size, and wage rates. Data on non-Veteran's Affairs hospital stays suggest that the method accounts for 40% of the variation in acute hospital care costs and is superior to cost estimates based on length of stay or diagnosis-related group weight alone.

Cost Allocation↗
PubMed2003

Maternal employment and overweight children.

This paper seeks to determine whether a causal relationship exists between maternal employment and childhood weight problems. We use matched mother-child data from the National Longitudinal Survey of Youth (NLSY) and employ econometric techniques to control for observable and unobservable differences across individuals and families that may influence both children's weight and their mothers' work patterns. Our results indicate that a child is more likely to be overweight if his/her mother worked more hours per week over the child's life. Analyses by subgroups show that it is higher socioeconomic status mothers whose work intensity is particularly deleterious for their children's overweight status.

Body Mass Index↗
PubMed2005

Smooth quantile ratio estimation with regression: estimating medical expenditures for smoking-attributable diseases.

The methodological development of this paper is motivated by a common problem in econometrics where we are interested in estimating the difference in the average expenditures between two populations, say with and without a disease, as a function of the covariates. For example, let Y(1) and Y(2) be two non-negative random variables denoting the health expenditures for cases and controls. Smooth Quantile Ratio Estimation (SQUARE) is a novel approach for estimating Delta=E[Y(1)] - E[Y(2)] by smoothing across percentiles the log-transformed ratio of the two quantile functions. Dominici et al. (2005) have shown that SQUARE defines a large class of estimators of Delta, is more efficient than common parametric and nonparametric estimators of Delta, and is consistent and asymptotically normal. However, in applications it is often desirable to estimate Delta(x)=E[Y(1)|x]--E[Y(2)|x], that is, the difference in means as a function of x. In this paper we extend SQUARE to a regression model and we introduce a two-part regression SQUARE for estimating Delta(x) as a function of x. We use the first part of the model to estimate the probability of incurring any costs and the second part of the model to estimate the mean difference in health expenditures, given that a nonzero cost is observed. In the second part of the model, we apply the basic definition of SQUARE for positive costs to compare expenditures for the cases and controls having 'similar' covariate profiles. We determine strata of cases and control with 'similar' covariate profiles by the use of propensity score matching. We then apply two-part regression SQUARE to the 1987 National Medicare Expenditure Survey to estimate the difference Delta(x) between persons suffering from smoking-attributable diseases and persons without these diseases as a function of the propensity of getting the disease. Using a simulation study, we compare frequentist properties of two-part regression SQUARE with maximum likelihood estimators for the log-transformed expenditures.

Age Factors↗
PubMed2004

Evaluating the effect of care programs for elderly persons with dementia on caregiver's well-being.

This contribution provides an econometric evaluation of the impact of two innovative care programs for elderly persons with dementia (day-care centers and group-living) on the well-being of the primary caregiver of patients. For this evaluation we use data from a survey conducted in six European countries in 1998. The results show that after adjusting for selection bias day-care centers have a positive impact for a specific part of the population. They also reveal a rationing mechanism in the access to group-living.

Aged↗
PubMed2002

An econometric analysis of screening and treatment of patients with suspected Chlamydia.

Chlamydia trachomatis is probably the most common sexually transmitted disease in the Western industrialised countries with devastating consequences. However, it is an infection that can be so easily treated. There are over 50 million new cases occurring each year. In the United States chlamydia is seen as the most common and costly of the bacterial sexually transmitted diseases (STD), with approximately 4 million new cases occurring each year at an estimated total cost of $2.4 billion. The characteristic of this infection is its difficulty of detection that promotes its spread and making its prediction rather complex. Chlamydial infections are commonly asymptomatic or cause mild or non-specific symptoms and signs, which are not easily detected. Approximately 70% of women with endocervical infections and up to 50% of men with urethral infections are asymptomatic and thus not likely to seek medical care. Chlamydia has become known as the "silent epidemic". It is the more frequently identifiable single cause of pelvic inflammatory disease (PID), occurring in an estimated 15-40% of women. The primary objective of the study was to identify factors and quantify their contribution to the risk of being infected with Chlamydia and to construct an easy to use friendly method for early detection. The importance of developing some means of early detection is vital and previous studies suggest that selective screening might be one solution. A logit model was fitted to three broad variables: behavioural, patients' characteristics, and signs/symptoms noted by patient. The age of the women, the number of sexual partners over the past year, previous history of sexually transmitted disease, the use of barrier contraception and patients' and their partners' signs and symptoms were found to be among the most important variables. Such a model should allow patients who are in a high-risk category, allowing appropriate treatment.

Chlamydia Infections↗
PubMed1992

An econometric analysis of health care expenditure: a cross-section study of the OECD countries.

This paper is an empirical examination of the determinants of aggregate health care expenditure. The paper presents a systematic analysis of relationships across 19 OECD countries, showing the effects of aggregate income, institutional and socio-demographic factors on health care expenditure. The results indicate that institutional factors of the health systems, in addition to per capita Gross Domestic Product (GDP), contribute significantly to the explanation of the health care expenditure variation between countries; for example the way physicians in outpatient care are paid, and the mixture of public/private funding and inpatient/outpatient care.

Ambulatory Care↗
PubMed2001

Comparative efficiency of national health systems: cross national econometric analysis.

OBJECTIVE: To improve the evidence base for health policy by devising a method to measure and monitor the performance of health systems. DESIGN: Estimation of the relation between levels of population health and the inputs used to produce health. SETTING: 191 countries. MAIN OUTCOME MEASURE: Health system efficiency (performance). RESULTS: Estimated efficiency varied from nearly fully efficient to nearly fully inefficient. Countries with a history of civil conflict or high prevalence of HIV and AIDS were less efficient. Performance increased with health expenditure per capita. CONCLUSIONS: Increasing the resources for health systems is critical to improving health in poor countries, but important gains can be made in most countries by using existing resources more efficiently.

Delivery of Health Care↗
PubMedDate not supplied

The relationship between health expenditures and the age structure of the population in OECD countries.

The purpose of this study was to analyse national health expenditures of OECD countries relative to their age structures. Using econometric techniques designed to analyse cross-sectional time series data, the ageing of the population was found to affect health spending in several countries while having no effect in others. In addition, the effect of income on health spending was lower than that generally reported in the literature. These findings suggest that unobserved country-specific factors play a major role in determining the amount of resources allocated to health services in a country. Such factors also determine if the ageing of the population with increased health spending.

Age Factors↗
PubMed1998

An econometric study of costs of teaching and research in Finnish hospitals.

In this study we used stochastic frontier cost functions to estimate the teaching and research costs of Finnish hospitals. Average and marginal cost estimates were used to evaluate the current reimbursement system as well as to calculate the total expenditure on teaching and research in hospitals. The efficiency adjustment had significant impact on the marginal and average cost estimates of the teaching and research output. The main policy implication of this study is that university teaching hospitals are able to produce both teaching and research output at significantly lower marginal and average incremental costs than other hospitals. According to our results 55% of the total state reimbursement budget for teaching and research (FIM 665 million) should be allocated to teaching and 45% to research.

Education, Medical, Graduate↗