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PubMed2002

The impact of health plan report cards on managed care enrollment.

How does the release of health plan performance ratings influence employee health plan choice? A natural experiment at General Motors (GM) Corporation provides valuable evidence on this question. During the 1997 open enrollment period, GM disseminated a health plan report card for the first time. By comparing 1996 and 1997 enrollment patterns, our analysis estimates the impact of the report card information while accounting for fixed, unobserved plan traits. Results indicate that employees are less likely to enroll in plans requiring relatively high out-of-pocket contributions. Results with respect to report card ratings suggest that individuals avoid health plans with many below average ratings.

Benchmarking↗
PubMed2002

Genetic testing when there is a mix of compulsory and voluntary health insurance.

When the insurer has access to information about test status, genetic insurance can handle the negative effects of genetic testing on insurance coverage and income distribution. Hence, efficient testing is promoted. When information about prevention and test status is private, two types of social inefficiencies may occur; genetic testing may not be done when it is socially efficient and genetic testing may be done although it is socially inefficient. The first type of inefficiency is shown to be likely for consumers with compulsory insurance only, while the second type of inefficiency is more likely for those who have supplemented the compulsory insurance with substantial voluntary insurance. This second type of inefficiency is more important the less effective prevention is. It is therefore a puzzle that many countries have imposed strict regulation on the genetic information insurers have access to. A reason may be that genetic insurance is not yet a political issue, and the advantage of shared genetic information is therefore not transparent.

Access to Information↗
PubMed2002

Defining the value of a statistical life: a comment.

In a recent paper [J. Hlth. Econom. 20 (2001) 131] Per-Olov Johansson claims to demonstrate that a commonly used intuitive definition of the value of a statistical life (VSL) is wrong, and that empirical estimates of VSLs are biased estimators of what he defines as the theoretically correct concept of the value of saving a life. In this comment I first argue in favor of a theoretically correct concept that is different from Johansson's because it incorporates the risk of death into the individual's lifetime budget constraint. I then show that the common intuitive definition of a VSL in fact is consistent with the theoretically correct concept and thus, provides an appropriate empirical basis for estimating the value to society of mortality-reducing projects.

Data Interpretation, Statistical↗
PubMed2002

QALYs, standard gambles, and the expected budget constraint.

This paper shows that when quality adjustment factors for use in constructing QALY indices are established through answers to standard-gamble questions or similar methods, the assumptions that are made by respondents about the financial consequences of changing probabilities of illness and death are critically important for the use of QALYs in cost-utility analysis (CUA). It qualifies Meltzer's [Journal of Health Economics 16 (1997) 33] result that the cost per quality-adjusted life-year (QALY) for life-saving medical interventions should include the future consumption of those who would otherwise not have survived, by showing that its validity depends on how the QALY index has been established. The paper also shows that, contrary to a widely held notion, allocation of a fixed health care budget through CUA does not generally result in a second-best efficient allocation. Another finding is that failure to specify carefully what respondents to standard-gamble questions are supposed to assume about the financial consequences of ill health may result in a bias against providing care to older individuals.

Aged↗
PubMed2002

Life-cycle preferences over consumption and health: a comment on Bleichrodt and Quiggin.

In a recent issue of the Journal of Health Economics, Bleichrodt and Quiggin (1999) developed a model of life-cycle preferences over consumption and health to analyze QALY-based decision making. This analysis is critically appraised concerning issues of QALY-maximization on an individual and on an aggregate level as well as of the role of death in QALY-models. It is concluded that a more general approach might be useful for the analysis of QALYs and life-cycle preferences over consumption and health.

Attitude to Health↗
PubMed2002

Technology as a 'major driver' of health care costs: a cointegration analysis of the Newhouse conjecture.

Per capita real income on the demand-side and technological change, proxied by total R&D and health R&D spending, on the supply-side are hypothesized as major drivers of per capita real health care expenditure in the US during the 1960-1997 period. The findings are robust to a battery of unit root and cointegration tests. They support the Newhouse [Journal of Economic Perspectives 6 (1992) 3] conjecture that technological change is a major escalator of health care expenditure and confirm a significant and stable long-run relationship among per capita real health care expenditure, per capita real income and broad-based R&D expenditures. Policy implications are noted.

Biomedical Technology↗
PubMed2002

Switching costs, price sensitivity and health plan choice.

We investigate the extent to which sensitivity to health plan premiums differs across individuals according to characteristics related to the cost of switching plans. Our results indicate substantial variation in price sensitivity related to expected health care costs: younger, healthier employees are between two and four times more sensitive to price than employees who are older and who have been recently hospitalized or diagnosed with cancer. We also find evidence of status quo bias: estimated premium elasticities are significantly higher for new hires than for incumbent employees. Simulations combining our results with actuarial data illustrate the cost implications of risk-related differences in price elasticity.

Adult↗
PubMed2002

Quality information and consumer health plan choices.

This paper presents an empirical analysis of the effects of providing information about plan quality on consumers' health plan choices in a private employment setting. Analysis of plan switching behavior suggests that the provision of quality information had a small, but significant effect on consumer plan choices. Employees were more likely to switch from plans with lower reported quality. Cross-sectional analyses of plan choice indicate that reported quality played a role in plan selection even after controlling for other health plan characteristics commonly associated with plan choice. The age of the policyholder and the type of policy purchased moderated the effects of plan characteristics on plan choice in ways that may be consequential for adverse selection.

Benchmarking↗
PubMed2002

Employee demand for health insurance and employer health plan choices.

Although most private health insurance in US is employment-based, little is known about how employers choose health plans for their employees. In this paper, I examine the relationship between employee preferences for health insurance and the health plans offered by employers. I find evidence that employee characteristics affect the generosity of the health plans offered by employers and the likelihood that employers offer a choice of plans. Although the results suggest that employers do respond to employee preferences in choosing health benefits, the effects of worker characteristics on plan offerings are quantitatively small.

Commerce↗
PubMed2002

Waiting times for hospital admissions: the impact of GP fundholding.

Waiting times for hospital care are a significant issue in the UK National Health Service (NHS). The reforms of the health service in 1990 gave a subset of family doctors (GP fundholders) both the ability to choose the hospital where their patients were treated and the means to pay for some services. One of the key factors influencing family doctors' choice of hospital was patient waiting time. However, without cash inducements, hospitals would get no direct reward from giving shorter waiting times to a subset of patients. Using a unique dataset, we investigate whether GP fundholders were able to secure shorter waiting times for their patients, whether they were able to do so in cases where they had no financial rewards to offer hospitals, and whether the impact of fundholding spilled over into shorter waiting times for all patients.

Budgets↗
PubMed2002

How do doctors behave when some (but not all) of their patients are in managed care?

Most physicians today treat a variety of patients within their practices where a variety of insurance arrangements co-exist. In this paper, we propose several theoretical explanations for physician treatment patterns when the patient population is heterogeneous at the practice level. Data from the 1993-1996 National Ambulatory Medical Care Survey (NAMCS) are used to test how practice level managed care penetration affects treatment intensity. Practice composition has strong effects on treatment. Visit duration appears to be constant across patients within a practice, while medications prescribed appear to be converging as managed care penetration increases.

Ambulatory Care↗
PubMed2002

The medical treatment of depression, 1991-1996: productive inefficiency, expected outcome variations, and price indexes.

We examine the price of treating episodes of acute phase major depression over the 1991-1996 time period. We combine data from a large retrospective medical claims data base (MarketScan, from the Medstat Group) with clinical literature and expert clinical opinion elicited from a two-stage Delphi procedure. This enables us to construct a variety of treatment price indexes that include variations over time in the proportion of the "off-frontier" production, as well as the corresponding variations in expected treatment outcomes. We find that in general the incremental cost of successfully treating an episode of acute phase major depression has generally fallen over the 1991-1996 time period. Based on hedonic regression equations that account for the effects of changing patient mix, we find reductions that range from about -1.66 to -2.13% per year.

Cost of Illness↗
PubMed2002

The family as the health producer--when spouses act strategically.

The Grossman model has been extended recently in order to take account of the fact that most people lead their lives in a family--using frameworks in which family members, respectively, (a) have common preferences and (b) are Nash-bargainers. These models, however, do not consider individual incentives for behaving strategically. In the model presented in this paper, spouses interact strategically both in the production of own health and in the production of health of other family members. We analyse, inter alia, the impact on the distribution of health of changes in family policies, such as child allowance and custody rules.

Adult↗
PubMed2002

Defining health inequality: why Rawls succeeds where social welfare theory fails.

While there has been an important increase in methodological and empirical studies on health inequality, not much has been written on the theoretical foundation of health inequality measurement. We discuss several reasons why the classic welfare approach, which is the foundation of income inequality analysis, fails to provide a satisfactory foundation for health inequality analysis. We propose an alternative approach which is more closely linked to the WHO concept of equity in health and is also consistent with the ethical principles espoused by Rawls [A Theory of Justice. Harvard University Press, Cambridge, MA, 1971]. This approach in its simplest form, is shown to be closely related to the concentration curve when health and income are positively related. Thus, the criteria presented in our paper provide an important theoretical foundation for empirical analysis using the concentration curve. We explore the properties of these approaches by developing policy scenarios and examining how various ethical criteria affect government strategies for targeting health interventions.

Efficiency↗
PubMed2002

Payer type and the returns to bypass surgery: evidence from hospital entry behavior.

In this paper, we estimate the returns associated with the provision of coronary artery bypass graft (CABG) surgery, by payer type (Medicare, HMO, etc.). Because reliable measures of prices and treatment costs are often unobserved, we seek to infer returns from hospital entry behavior. We estimate a model of patient flows for CABG patients that provides inputs for an entry model. We find that FFS provides a high return throughout the study period. Medicare, which had been generous in the early 1980s, now provides a return that is close to zero. Medicaid appears to reimburse less than average variable costs. HMOs essentially pay at average variable costs, though the return varies inversely with competition.

California↗
PubMed2002

Employer investments in employee health implications for the family as health producer.

The model presented in this paper further extends the demand-for-health model in which the family is the producer of health investments, to consider the case in which an employer has incentives for investing in the health of a family member. The household and the employer are assumed to interact strategically in the production of health. The general insight provided is that the conditions which determine the nature of the relationship between the employer and the employee, for instance market conditions, production technologies, taxes, and government regulation, will also affect the allocation of health investments and health capital within the family.

Efficiency, Organizational↗
PubMed2002

Cost-minimizing risk adjustment.

Conventional risk adjustment, which sets capitation payments equal to the average cost of individuals with similar observable characteristics, is not optimal if health plans can use private information to select low-cost enrollees. "Cost-minimizing risk adjustment" minimizes the sum of capitated HMO premiums plus FFS costs by balancing the gains from HMO cost efficiency against the overpayments that result from HMO selection. Estimations using privately-insured data suggest that cost-minimizing risk adjusted premiums reduce total sponsor costs as much as 25.6% below conventional risk adjustment premiums.

Actuarial Analysis↗
PubMed2002

The structure of demand for health care: latent class versus two-part models.

We contrast the two-part model (TPM) that distinguishes between users and non-users of health care, with a latent class model (LCM) that distinguishes between infrequent and frequent users. In model comparisons using data on counts of utilization from the RAND Health Insurance Experiment (RHIE), we find strong evidence in favor of the LCM. We show that individuals in the infrequent and frequent user latent classes may be described as being healthy and ill, respectively. Although sample averages of price elasticities, conditional means and event probabilities are not statistically different, the estimates of these policy-relevant measures are substantively different when calculated for hypothetical individuals with specific characteristics.

Ambulatory Care↗