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PubMed2001

Market restructuring and pricing in the hospital industry.

This paper examines the diagnosis related group-level (DRG) price effects of recent hospital mergers and acquisitions that occurred in Ohio and California. Empirical results indicate that hospital mergers and acquisitions increase prices at the DRG level. Further, price increases are greater in DRGs where the merging hospitals gained substantial market share compared to DRGs where the merging hospitals did not gain significant market share. These results suggest that DRG specific market share plays an important role in a hospital's post-merger pricing strategy.

California↗
PubMed2001

Risk sharing as a supplement to imperfect capitation: a tradeoff between selection and efficiency.

This paper describes forms of risk sharing between insurers and the regulator in a competitive individual health insurance market with imperfectly risk-adjusted capitation payments. Risk sharing implies a reduction of an insurer's incentives for selection as well as for efficiency. In a theoretical analysis, we show how the optimal extent of risk sharing may depend on the weights the regulator assigns to these effects. Some countries employ outlier or proportional risk sharing as a supplement to demographic capitation payments. Our empirical results strongly suggest that other forms of risk sharing yield better tradeoffs between selection and efficiency.

Capitation Fee↗
PubMed2001

Statistical inference of progressivity dominance: an application to health care financing distributions.

This paper employs a distribution-free statistical test suitable for comparisons based on dependent samples to analyse changes in health care financing distributions on Finnish data. In distinction to the more general summary index approach used in most studies of progressivity measurement, the difference between the Lorenz curve of income inequality and the concentration curves of various taxes and payments is used to evaluate progressivity dominance and changes in progressivity. Sample weights are applied to account for the effect of sampling design and non-response. The analysis demonstrates that the dominance approach can be successfully applied to various types of distributional problems besides comparisons concerning differences in income distributions. As an empirical application the paper presents estimation results for the progressivity of various health care financing sources using data from the 1987 and 1996 Finnish Health Care Surveys.

Family Characteristics↗
PubMed2001

The family as the health producer--when spouses are Nash-bargainers.

The Grossman model is extended to a situation in which the family is regarded as the producer of individual health and spouses are Nash-bargainers. The model has implications for the interaction between family structure, income and the stocks of health capital and the bargaining strength of different family members. The main insight is that the possibility of divorce affects the distribution of health capital between family members. We analyse, inter alia, the impact on the distribution of health (particularly regarding child health) of changes in family policies related to the dissolution of the family.

Adult↗
PubMed2001

Type of contract and supplier-induced demand for primary physicians in Norway.

The focus of the present study is to examine whether supplier-induced demand exists for primary care physician services in Norway. We compare how two groups of physicians, with and without incentives to induce, respond to increased competition. Contract physicians receive their income from fee-for-item payments. They have an incentive to compensate for a lack of patients by inducing demand for services. Salaried physicians receive a salary which is independent of output. Even though increased competition for patients reduces the availability of patients, they have no financial incentive to induce. Neither of the two groups of physicians increased their output as a response to an increase in physician density. This result could be expected for salaried physicians, while it provides evidence against the inducement hypothesis for contract physicians.

Contract Services↗
PubMed2001

Modeling the effects of health on economic growth.

This paper investigates the effects of health indicators such as adult survival rates (ASR) on GDP growth rates at 5-year intervals in several countries. Panel data were analyzed on GDP series based on purchasing power adjustments and on exchange rates. First, we developed a framework for modeling the inter-relationships between GDP growth rates and explanatory variables by re-examining the life expectancy-income relationship. Second, models for growth rates were estimated taking into account the interaction between ASR and lagged GDP level; issues of endogeneity and reverse causality were addressed. Lastly, we computed confidence intervals for the effect of ASR on growth rate and applied a test for parameter stability. The results showed positive effects of ASR on GDP growth rates in low-income countries.

Adult↗
PubMed2001

Dollars and performance: treating alcohol misuse in Maine.

If public funds are allocated efficiently, then an increase in funding should improve the performance of substance abuse treatment programs. In the data used in this paper, performance (measured as abstinence rates) and expenditures per patient are not positively correlated. One explanation is that funding is endogeneous, i.e. programs treating more difficult patients receive more funding. The data comes from all Maine's outpatient drug-free programs that received public funding between 1991 and 1994. After controlling for endogeneity, this paper concludes that the marginal impact of expenditures per patient on abstinence rates is small and statistically insignificantly different from zero.

Alcoholism↗
PubMed2001

Balancing incentives in the compensation contracts of nonprofit hospital CEOs.

Given the considerable insight into corporate governance achieved through studies of executive compensation in proprietary firms it is surprising that executive contracting in nonprofit organizations remains largely unexplored. In this paper, we use the multitask principal agent model of Holmström and Milgrom [The Journal of Law, Economics and Organization 7 (1991) (Suppl.) 24] to argue that nonprofit hospitals represent an optimal response to information asymmetries between managers and boards. For a board with multidimensional objectives, the agency problem is getting top executives to distribute their efforts across all dimensions of the hospital's mission. The nonprofit form is preferred because the absence of high powered incentives such as share ownership reduces executives' incentives to place undue emphasis on improving financial performance at the expense of important but less observable tasks. Using newly available compensation data we test the model by comparing the conditional distributions of earnings for industrial and nonprofit hospital CEOs in Ontario. Our best estimates are that CEOs in publicly traded firms earn twice as much on average as those in similarly sized nonprofit hospitals but bear roughly eight times the income variance. Estimates of the associated degree of risk aversion are well within conventional bounds and are consistent with the trade-off between insurance and incentives predicted by the theory.

Chief Executive Officers, Hospital↗
PubMed2001

Medical malpractice liability and its effect on prenatal care utilization and infant health.

In this paper we conduct the first national evaluation of the effect of malpractice liability pressure, as measured by malpractice premiums, on prenatal care utilization and infant health. Our results indicate that a decrease in malpractice premiums that would result from a feasible policy reform would lead to a decrease in the incidence of late prenatal care by between 3.0 and 5.9% for black women and between 2.2 and 4.7% for white women. Although, we found evidence that malpractice liability pressure was associated with greater prenatal care delay and fewer prenatal care visits, we did not find evidence that such pressure negatively affected infant health.

Black or African American↗
PubMed2001

Medicaid reimbursement and the quality of nursing home care.

An influential series of papers have found that an increase in Medicaid reimbursement decreases the level of nursing home quality in the presence of certificate-of-need (CON) and construction moratorium regulations. Using more recent national data, an outcome-oriented measure of quality, and an alternative methodology, this study finds a positive, albeit small, effect of reimbursement on quality. Although this paper does find some evidence of excess demand within the market for nursing home care, this new finding is attributed to a decline in nursing home utilization over the last two decades.

Certificate of Need↗
PubMed2002

Measuring consumer perceptions of quality differences among competing health benefit plans.

In this paper, we combine revealed preference and survey data on attribute importance to estimate parameters that represent average perceived differences in the quality and convenience of competing health benefit plans. We find that consumers do not perceive differences in provider quality across options. though they do perceive differences related to waiting time and access to specialists. In order to validate our approach, we estimate parameters representing perceived premiums and compare the estimates to actual premium differences. The results suggest that consumers correctly perceive the high-premium option to cost more than the low-premium option. These results increase our confidence in the use of stated importance data to identify and interpret parameters measuring the effect of otherwise unobservable attributes of choice alternatives.

Choice Behavior↗
PubMed2001

The incentive effects of the Medicare indirect medical education policy.

Medicare provided teaching hospitals with US$ 5.9 billion in supplemental graduate medical education (GME) payments in 1998. These payments distort input and output prices and provide teaching hospitals with incentives to hire residents, close beds, and admit more Medicare patients. The structure of the GME payment policy creates substantial variation in input and output prices between teaching hospitals. We examine the extent to which hospitals responded to these financial incentives using a panel data set of 3,900 hospitals, including over 900 teaching hospitals. We find that teaching hospitals did hire residents and close beds in response to the Medicare policy, but did not increase Medicare admissions or alter their use of registered nurses (RNs).

Aged↗
PubMed2001

Alcohol, marijuana, and American youth: the unintended consequences of government regulation.

This paper analyzes the impact of increases in the minimum drinking age on the prevalence of alcohol and marijuana use among high school seniors. The empirical analysis is based on a large sample of students from 43 states over the years 1980-1989. We find that increases in the legal minimum drinking age did slightly reduce the prevalence of alcohol consumption. We also find, however, that increased legal minimum drinking ages had the unintended consequence of slightly increasing the prevalence of marijuana consumption. Estimates from a structural model suggest that this unintended consequence is attributable to standard substitution effects.

Adolescent↗
PubMed2001

The welfare impact of HMO mergers.

This paper estimates the welfare consequences of HMO mergers using data from California's small-group market. The analysis estimates the parameters from a differentiated products demand system. The parameters are then used to simulate the effects of several HMO mergers by solving for the Nash equilibrium in prices under different ownership structures. Even small mergers in moderately concentrated markets can result in significant consumer surplus reductions. However, these welfare losses can be offset by large efficiency gains. The welfare consequences of HMO mergers turn less upon demand-side considerations than on the health plan's ability to realize efficiencies.

California↗
PubMed2001

Regulatory restrictions on selective contracting: an empirical analysis of "any-willing-provider" regulations.

"Any-willing-provider" (AWP) laws compel managed care plans to accept any provider willing to accept the plan's terms and conditions, potentially undermining managed care's ability to constrain spending. However. AWP laws potentially respond to inefficient risk-selection by providers of managed care. With risk selection, observed reductions in expenditures in the managed care sector may be offset by increases in the fee-for-service (FFS) sector, with no net decrease. This paper uses panel data on state expenditures to compare per capita spending levels in states with and without AWP laws. The results indicate that expenditures are higher when AWP laws are enacted.

Contract Services↗
PubMed2001

The demand for consumer health information.

Using data from an evaluation of a community-wide informational intervention, we modeled the demand for medical reference books, telephone advice nurses, and computers for health information. Data were gathered from random household surveys in Boise, ID (experimental site), Billings, MT, and Eugene, OR (control sites). Conditional difference-in-differences show that the intervention increased the use of medical reference books, advice nurses, and computers for health information by approximately 15, 6, and 4%. respectively. The results also suggest that the intervention was associated with a decreased reliance on health professionals for information.

Adolescent↗
PubMed2001

Screening and preventable illness.

If an agent does not discount the future at a constant rate, as in some forms of myopia, her optimal strategy is unattainable without some commitment device. We apply this familiar idea to a model of screening and disease prevention, and explore how financial incentives can correct suboptimal health choices. In general, myopia need not imply under-screening. While the optimal intervention for prevention effort is a state-invariant subsidy, the optimal intervention for screening may involve a tax or a subsidy. When screening and prevention are coincident, a simple and practical subsidy equal to one minus the discount factor to both screening and intervention is indicated.

Cost of Illness↗