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PubMed2003

How important are economic factors in choice of medical specialty?

An ongoing debate exists among health care researchers about the mechanism that allocates physicians across medical specialties, and appropriate policy measures to correct imbalances that may arise from time to time. Most researchers believe that choice of residency program by medical school graduates is key to understanding how physicians are distributed across specialties, but there is much disagreement about whether economic or non-economic factors are most influential in determining this choice. We undertake an empirical investigation of two potentially important economic factors: income and leisure. To do so, we specify a two way error component regression model to estimate the effects of expected earnings and available leisure time, and uncertainty of earnings and leisure, on specialty choices of medical residents. Our findings indicate that economic factors are an important influence in the specialty choice process; in particular, medical residents are attracted to specialties that offer the prospect of longer and more certain annual vacations, higher earnings, shorter residency programs, and more certain work schedules. Our results suggest that employment contracts that provide generous annual vacation time and promise regular weekly work schedules may be more effective than increased earnings in correcting the current perceived shortage of primary care physicians.

Career Choice↗
PubMed2002

Reflections on and alternatives to WHO's fairness of financial contribution index.

In its 2000 World Health Report (WHR), the World Health Organization argues that a key dimension of a health system's performance is the fairness of its financing system. This paper provides a critical assessment of the index of fairness of financial contribution (FFC) proposed in the WHR. It shows that the index cannot discriminate between health financing systems that are regressive and those that are progressive, and cannot discriminate between horizontal inequity on the one hand, and progressivity and regressivity on the other. The paper compares the WHO index to an alternative and more illuminating approach developed in the income redistribution literature in the early 1990s and used in the late 1990s to study the fairness of various OECD countries' health financing systems. It ends with an illustrative empirical comparison of the two approaches using data on out-of-pocket payments for health services in Vietnam for two years - 1993 and 1998. This analysis is of some interest in its own right, given the large share of health spending from out-of-pocket payments in Vietnam, and the changes in fees and drug prices over the 1990s.

Abstracting and Indexing↗
PubMed2002

Willingness to pay for health risk reduction in the context of altruism.

This paper presents results on the valuation of health risks in the presence of altruism. The contingent valuation method is utilised in a split sample experiment for estimating the private and public values in reducing the risk of flu. Data modelling for the dichotomous choice method follows a Bayesian approach, which accounts for zero responses and is adequate for the comparison of small sample results. The results of the experiment suggest that altruism is a positive component in the value of reducing the probability of flu, which depends positively on the number of days involved, the health status and the personal income of the subject. The marginal value of risk is found to be a decreasing function of the reduction in the probability of becoming ill.

Altruism↗
PubMed2002

Social risk management options for medical care in Indonesia.

This paper investigates the extent to which price subsidies for medical care are a suitable instrument to reduce household's exposure to catastrophic financial risks associated with ill-health in Indonesia. Using the 1995 SUSENAS household survey, the observed distribution of user fees and health expenditures is used to derive a distribution of 'needed' medical expenditures. The trade-off between the tax burden and effectiveness in reducing the exposure to catastrophic risk is analyzed for two existing price regimes along with a number of hypothetical regimes. We find that the existing regimes significantly reduce the exposure to catastrophic shocks but do not eliminate them. Simulations suggest that further reductions could be achieved if a larger proportion of government subsidies were directed to inpatient care. Subsidizing outpatient treatment is a cost effective policy to reduce exposure to catastrophic risks only for the very poor.

Adult↗
PubMed2002

Reducing avoidable inequalities in health: a new criterion for setting health care capitation payments.

Traditionally, most health care systems which pretend to any sort of rationality and cost control have sought to allocate their limited funds in order to secure equal opportunity of access for equal need. The UK government is implementing a fundamental change of resource allocation philosophy towards 'contributing to the reduction of avoidable health inequalities'. The purpose of this essay is to explore some of the economic issues that arise when seeking to allocate health care resources according to the new criterion. It indicates that health inequalities might arise because of variations in the quality of health services, variations in access to those services, or variations in the way people produce health, and that the resource allocation consequences differ depending on which source is being addressed. The paper shows that an objective of reducing health inequalities is not necessarily compatible with an objective of equity of access, nor with the objective of maximising health gain. The results have profound consequences for approaches towards economic evaluation, the role of clinical guidelines and performance management, as well as for resource allocation methods.

Capitation Fee↗
PubMed2002

The subjective costs of health losses due to chronic diseases. An alternative model for monetary appraisal.

This paper proposes a method to evaluate health losses or gains by looking at the impact on well-being of a change in health status. The paper presents estimates of the equivalent income change that would be necessary to change general satisfaction with life to the same extent as a change in health satisfaction would do. In other words, the income equivalent of health satisfaction changes is estimated. Next, this health satisfaction changes are linked to specific diseases in order to estimate the income equivalent for these diseases. This method uses answers to well-being and health satisfaction questions as posed in a large German data set, distinguishing between workers and non-workers and between East and West Germans. It is found, for instance, that for West-German workers hearing impediments are on average equivalent to an income reduction of about 20%, and that heart or blood difficulties are for the same group equivalent to a 47% income reduction.

Adult↗
PubMed2003

A utility-theoretic model for QALYs and willingness to pay.

Despite the widespread use of quality-adjusted life years (QALY) in economic evaluation studies, their utility-theoretic foundation remains unclear. A model for preferences over health, money, and time is presented in this paper. Under the usual assumptions of the original QALY-model, an additive separable presentation of the utilities in different periods exists. In contrast to the usual assumption that QALY-weights do solely depend on aspects of health-related quality of life, wealth-standardized QALY-weights might vary with the wealth level in the presented extension of the original QALY-model resulting in an inconsistent measurement of QALYs. Further assumptions are presented to make the measurement of QALYs consistent with lifetime preferences over health and money. Even under these strict assumptions, QALYs and WTP (which also can be defined in this utility-theoretic model) are not equivalent preference-based measures of the effects of health technologies on an individual level. The results suggest that the individual WTP per QALY can depend on the magnitude of the QALY-gain as well as on the disease burden, when health influences the marginal utility of wealth. Further research seems to be indicated on this structural aspect of preferences over health and wealth and to quantify its impact.

Attitude to Health↗
PubMed2003

Assessing and comparing costs: how robust are the bootstrap and methods based on asymptotic normality?

This article addresses and challenges some common perceptions in the statistical assessment of costs and cost-effectiveness in health economics. Cost data typically exhibit highly skew distributions. Two techniques whose validity does not depend on any specific form of underlying distribution are the bootstrap and methods based on asymptotic normality of sample means. These methods are generally thought to be appropriate for the analysis of cost data. We argue that, even when these methods are technically valid, they may often lead to inefficient and even misleading inferences. It is important to apply methods that recognise the skewness in cost data. We further demonstrate that it may also be important to incorporate relevant prior information in a Bayesian analysis.

Bayes Theorem↗
PubMed2003

The determinants of health care expenditure: testing pooling restrictions in small samples.

Health care expenditure has increased substantially in all Western industrialized countries in the last decades. The necessity to contain the increase in health care expenditure has motivated the analysis of its determinants to explain differences across countries and health systems. However, recent studies have questioned the use of cross section data arguing that health systems are too different to allow for such comparisons. In this paper we investigate whether this criticism is really justified. We analyze the variations of health care expenditure in OECD countries relative to income, population aging and technological change. Our analysis is based on pooled cross section data and time series. Firstly, formulating error correction models for individual countries we demonstrate that in almost all cases the investigated variables are cointegrated. Secondly, we use a bootstrap framework for inference and examine whether the influence of explanatory variables is unique across countries. Applying recursive estimation procedures we find evidence for cross country homogeneity during the period 1961-1979. In the last two decades health care dynamics become more and more country specific thus indicating divergence of health systems and the growing importance of country-specific effects in the explanation of differences in health care expenditure.

Analysis of Variance↗
PubMed2003

Medical student indebtedness and the propensity to enter academic medicine.

This paper considers the potential impact of medical school indebtedness and other variables on the propensity of US doctors to enter academic medicine. Probit models provide some evidence that indebtedness reduces the likelihood that physicians will choose academic medicine as their primary activity. Nevertheless, the magnitude of this effect is not large. As indebtedness may be endogenous, the probits are rerun using an instrumental variables approach. These estimates imply that over time indebtedness may have an important impact on the propensity of physicians to enter academic medicine.

Academic Medical Centers↗
PubMed2003

Deadweight loss of bacterial resistance due to overtreatment.

Widespread use of antibiotics is considered the major driving force behind the development of antibiotic resistance. The benefits of exceeding the welfare-maximizing level of antibiotic use are below the costs of resistance created by this excess quantity of antibiotics used, thereby resulting in a welfare deadweight loss. This paper uses a simple economic model to examine the theoretical and empirical aspects of the welfare loss generated by resistance and analyzes its policy implications. The annual deadweight loss associated with outpatient prescriptions for amoxicillin in the United States is estimated at US dollars 225 million.

Amoxicillin↗
PubMed2002

A theoretical model of adolescent suicide and some evidence from US data.

Suicide rates for adolescents have doubled since 1970 and tripled since 1960, even as rates for other age groups have declined. Using a Becker-type model of household production and consumption, we demonstrate conditions under which utility maximizing parents allocate time away from time-intensive commodities like children's well-being, and towards market work and less time-intensive consumption commodities. This reallocation of time towards market work has mixed effects on children' mental health: higher money income tends to improve family and children's well-being, but the loss of parental time has an opposite effect on children's mental health and increases the risk of adolescent suicide. Empirical evidence using state panel regressions of adolescent suicide rates on economic, social and demographic variables is consistent with predictions based on our model; our results indicate that the favorable effect of higher incomes has more than offset the negative effect of lost parental time.

Adolescent↗
PubMed2003

The interaction between cost-management and learning for major surgical procedures - lessons from asymmetric information.

The theory of the learning curve states that learning effects are of particular importance in industries, where human skills play an important role. Consequently, one would expect to find large learning effects for surgical procedures because the physician's experience is quite important for this type of work. For hospitals, there exists indeed a well-documented effect that shows a positive relationship between the number of a certain type of surgery being performed and its resulting quality (volume-outcome relationship). Empirical analyses of the impact of learning on the average cost of a procedure, however, have noted a conspicuous absence of learning effects. Using a mechanism design approach, the paper analyzes a model of quality and cost-management for a hospital, where learning effects are included into the cost function and asymmetric information exists between management and physician. It seeks to answer the question, whether recommendations from a symmetric information scenario with respect to learning carry over to a health care setting, where informational problems tend to be pronounced and severe. If surgery volume interacts with physicians' informational rents, an optimal management reaction to the presence of learning may result in a policy, which is the exact opposite of the one under symmetric information.

Clinical Competence↗
PubMed2003

The effect of cigarette prices on youth smoking.

Prior economic research provides mixed evidence on the impact of cigarette prices on youth smoking. This paper empirically tests the effects of various price measures on youth demand for cigarettes using data collected in a recent nationally representative survey of 17 287 high school students. In addition to commonly used cigarette price measures, the study also examined the effect of price as perceived by the students. This unique information permits the study of the effect of teen-specific price on cigarette demand. The analysis employed a two-part model of cigarette demand based on a model developed by Cragg (1971) in which the propensity to smoke and the intensity of the smoking habit are modeled separately. The results confirm that higher cigarette prices, irrespective of the way they are measured, reduce probability of youth cigarette smoking. There is also some evidence of negative price effect on smoking intensity, but it is sensitive to the price measure used in the model. The largest impact on cigarette demand has the teen-specific, perceived price of cigarettes.

Adolescent↗
PubMed2003

Medical care use and selection in a social health insurance with an equalization fund: evidence from Colombia.

This paper studies the relationship between health status and insurance participation, and between insurance status and medical use in the context of a social health insurance with an equalization fund (SHIEF). Under this system, revenues from a mandatory payroll tax are collected into a single pool (equalization fund) that reimburses for-profit insurance companies according to a capitated formula. Although competition should induce insurers to control costs without reducing the quality of service necessary to attract consumers, limitations in the capitation formula might induce insurers to select against bad risks, and limitations in the contribution system might induce more healthy individuals to evade enrollment. A three-equation model having social health insurance, private health insurance, and using medical services is estimated using a 1997 Colombian household survey. Consistent with similar studies, participation in SHIEF increases medical care use. On the other hand, the evidence on selection is somewhat mixed: individuals who report good health status are more likely to participate in SHIEF, while those without a chronic condition are less likely to participate in SHIEF.

Capitation Fee↗
PubMed2003

Managed care and technical efficiency.

By focusing exclusively on consumer benefit, previous studies of the effects of managed care have ignored important hospital efficiency gains. This study uses the HCUP sample of hospitals for 1992-1996 to estimate a stochastic frontier model of hospital technical efficiency. After controlling for hospital and market area variables, the study finds strong evidence that increased managed care insurance in a given market is associated with improved technical efficiency in the area's hospitals, especially in tertiary cases. Using Battese and Coelli's one-stage method (1995), the coefficients estimates are more efficient than for two-stage methods found in the literature.

Efficiency, Organizational↗
PubMed2003

Double discounting of QALYs.

Quality-adjusted life-years (QALYs) calculated from time tradeoff (TTO) based preferences have a time preference component. To impose a conventional discount rate on these implicitly discounted QALYs introduces some degree of double discounting. The purpose of this study was to determine the magnitude of the double discounting effect and the effectiveness of a suggested method for avoiding double discounting in a TTO-based QALY model. Our analysis used holistic and composite preference scores obtained with the TTO technique in a prior study of four hypothetical treatment paths in type 2 diabetes. Discounted composite preference scores were significantly discrepant from holistic preference scores. Adjusting TTO-based quality weights prior to external discounting reduced the discrepancy only slightly. Since time preference effects may vary with health state context, the double discounting effect needs further investigation.

Attitude to Health↗