Int J Health Care Finance Econ
· 2004 Dec · PMID 15467407
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In response to the introduction of global budgets, dentists might alter their supply behaviour, changing the number of visits, the amount of expenditure, and the type of services provided. We develop two-way fixed effect...In response to the introduction of global budgets, dentists might alter their supply behaviour, changing the number of visits, the amount of expenditure, and the type of services provided. We develop two-way fixed effects models to estimate these effects using a panel data constructed from outpatient dental care expenditures claims from the Taiwanese National Health Insurance system. The availability of a long panel allows us to estimate a "policy effect" for each dentist in the panel. The overall effect of global budgets is to constrain costs but there is evidence of a change in the mix of services. Male and younger dentists have higher policy effects than female and older dentists. Global budgets favour dentists in deprived areas and there is some evidence of increases in the expenditure per visit and the volume of composite resin fillings.
Int J Health Care Finance Econ
· 2004 Dec · PMID 15467406
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OBJECTIVE: To estimate the price sensitivity of demand for health care by analysing the relation between deductibles and expenditures found in an administrative database. DATA: Data are from 100,048 privately insured in...OBJECTIVE: To estimate the price sensitivity of demand for health care by analysing the relation between deductibles and expenditures found in an administrative database. DATA: Data are from 100,048 privately insured in the Netherlands. Information is available on expenditures in 1996, demographic variables, deductibles, and both diagnoses from hospitalisations and pharmacy costs for the years 1993-1995. The data are unique because prior pharmacy costs are good predictors of future expenditures while in the three years concerned these costs were covered by a separate national, mandatory insurance scheme. Therefore, these costs are not affected by deductibles and can be seen as excellent proxies for health status, which this study uses to correct for the existing adverse selection with respect to the choice of deductible. METHODS: For the group of insured without deductibles an expenditure model is estimated which is subsequently used to estimate expected expenditures for insurance policies with various levels of deductible. From the difference between actual and expected expenditures the impact of deductibles on expenditures is estimated, and from this price sensitivity. RESULTS: The principal finding is an estimated price elasticity of -0.14. The highest price sensitivity is found for GP care (-0.40) and physiotherapy (-0.32), and the lowest for specialist care (-0.12) and prescription drugs (-0.08); hospital care was hardly affected.
Int J Health Care Finance Econ
· 2004 Dec · PMID 15467405
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This paper considers how the decision to enter advanced practice nursing (e.g., the occupations of nurse practitioner, certified nurse-midwife, nurse anesthetist, and clinical nurse specialist) is affected by State laws...This paper considers how the decision to enter advanced practice nursing (e.g., the occupations of nurse practitioner, certified nurse-midwife, nurse anesthetist, and clinical nurse specialist) is affected by State laws on the scope of practice of APNs. We find that enrollments in APN programs are 30 percent higher in States where APNs have a high level of professional independence. Our work differs from previous studies by estimating a fixed effects model on cross-sectional and time series data, to avoid problems of endogeneity of State laws.
Int J Health Care Finance Econ
· 2004 Sep · PMID 15277781
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This study examines the effect of multiple prior years of health expenditures on the probability of enrollment in a Medicare HMO. Beneficiaries may require more than one year of prior expenditure data to form a reliable...This study examines the effect of multiple prior years of health expenditures on the probability of enrollment in a Medicare HMO. Beneficiaries may require more than one year of prior expenditure data to form a reliable estimate of future expenditures if health expenditures have a significant transitory component. We used a logit model to estimate the influence of 1991-1993 Part A expenditures and demographic data on the choice of health plans in 1994. The results indicate that beneficiaries use multiple years of expenditures in their choice of health plan and the effect of prior spending declined with time.
Friedman B, Sood N, Engstrom K
… +1 more, McKenzie D
Int J Health Care Finance Econ
· 2004 Sep · PMID 15277780
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This study provides (a) new estimates of U.S. hospital profitability by payer group, controlling for hospital characteristics, and (b) evidence about the intensity of care for particular diseases associated with the gene...This study provides (a) new estimates of U.S. hospital profitability by payer group, controlling for hospital characteristics, and (b) evidence about the intensity of care for particular diseases associated with the generosity of the patient's payer and other payers at the same hospital. The conceptual framework is a variant of the well-known model of a local monopolist selling in a segmented market. Effects of two kinds of regulation are considered. The data are taken from hospital accounting reports in four states in FY2000, and detailed discharge summaries from the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality. The profitability of inpatient care for privately insured patients was found to be about 4% less than for Medicare, but 14% higher than for Medicaid and only 9% higher than for self-pay patients. We found significant direct associations but not external effects of payer generosity on the intensity of care.
Int J Health Care Finance Econ
· 2004 Sep · PMID 15277779
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This paper examines the effects of conversions between For-Profit and Not-For-Profit forms on quality of medical care in California hospitals. The sample includes elderly patients treated in California's private hospital...This paper examines the effects of conversions between For-Profit and Not-For-Profit forms on quality of medical care in California hospitals. The sample includes elderly patients treated in California's private hospitals from 1990 to 1998 for Acute Myocardial Infarction and Congestive Heart Failure. The results suggest that converted hospitals have experienced quality changes before conversion and that ignoring these changes may bias the estimates of conversion effects. Both conversions are found to have some adverse consequences: Hospitals that converted to FP form show an increase in AMI mortality rates, while those converted to NFP status indicate an increase in CHF mortality outcomes.
Int J Health Care Finance Econ
· 2004 Sep · PMID 15277778
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The league table approach to rank ordering health care programs according to the incremental cost-effectiveness ratio is a common method to guide policy makers in setting priorities for resource allocation. In the presen...The league table approach to rank ordering health care programs according to the incremental cost-effectiveness ratio is a common method to guide policy makers in setting priorities for resource allocation. In the presence of uncertainty, however, ranking programs is complicated by the degree of variability associated with each program. Confidence intervals for cost-effectiveness ratios may be overlapping. Moreover, confidence intervals may include negative ratios and the interpretation of negative cost-effectiveness ratios is ambiguous. We suggest to rank mutually exclusive health care programs according to their rate of return which is defined as the net monetary benefit over the costs of the program. However, how does a program with a higher expected return but higher uncertainty compare to a program with a lower expected return but lower risk? In the present paper we propose a risk-adjusted measure to compare the return on investment in health care programs. Financing a health care program is treated as an investment in a risky asset. The risky asset is combined with a risk-free asset in order to construct a combined portfolio. The weights attributed to the risk-free and risky assets are chosen in such a manner that all programs under consideration exhibit the same degree of uncertainty. We can then compare the performance of the individual programs by constructing a risk-adjusted league table of expected returns.
Int J Health Care Finance Econ
· 2004 Jun · PMID 15211105
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The market for employment-related coverage contains public transfers through the tax system and private transfers across workers with predictably different risks. We examine both transfers across a wide range of employee...The market for employment-related coverage contains public transfers through the tax system and private transfers across workers with predictably different risks. We examine both transfers across a wide range of employee characteristics, including age, race, ethnicity, family size, poverty level, and health risk. To resolve longstanding questions regarding the incidence of employer contributions, we simulate a range of alternative incidence scenarios in which (i) all employees offered coverage in a firm share equally in the employer's costs, (ii) burdens are narrowly targeted according to employee-specific health risks, and (iii) intermediate cases with burdens targeted by job characteristics, age, sex, race, ethnicity, and family size. Our results provide evidence regarding the distribution of tax subsidies and net benefits under a range of scenarios that we believe bound the true incidence of employer premium contributions.
Int J Health Care Finance Econ
· 2004 Jun · PMID 15211104
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Research on health care quality has become increasingly sophisticated, but the research has not had a major impact on competition law and policy. Five specific translational barriers (relevance/litigation dynamics, compl...Research on health care quality has become increasingly sophisticated, but the research has not had a major impact on competition law and policy. Five specific translational barriers (relevance/litigation dynamics, complexity, framing, judicial and administrative skepticism, and inadequate demand) are identified. If researchers on health care quality want to have an impact on competition law and policy they must confront and overcome these translational barriers.
Int J Health Care Finance Econ
· 2004 Jun · PMID 15211103
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The literature on hospital competition and quality is young; most empirical studies have focused on few conditions and outcomes. Measures of in-hospital mortality and complications are susceptible to bias from unmeasured...The literature on hospital competition and quality is young; most empirical studies have focused on few conditions and outcomes. Measures of in-hospital mortality and complications are susceptible to bias from unmeasured severity and transfer/discharge practices. Only one research team has evaluated related process and outcome measures, and none has exploited chart-review or patient survey-based data. Prior studies have generated inconsistent findings, suggesting the need for additional research. We describe the strengths and limitations of various approaches to quality measurement, summarize how quality has been operationalized in studies of hospital competition, outline three mechanisms by which competition may affect hospital quality, and propose measures appropriate for testing each mechanism.
Int J Health Care Finance Econ
· 2004 Jun · PMID 15211102
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This paper reviews the concept of optimal quality in medical care from an economic viewpoint. It also provides some data on recent trends in competition in the health care sector. Economically optimal quality reflects a...This paper reviews the concept of optimal quality in medical care from an economic viewpoint. It also provides some data on recent trends in competition in the health care sector. Economically optimal quality reflects a tradeoff of marginal benefits against (minimized) marginal cost. Actual quality may be suboptimal either because of technical inefficiency in the production of quality or because consumers fail to make proper choices. In concept, competition, if supplemented by adequate information, can help. Overall competition in the hospital industry has declined modestly in recent years, but competition in markets for more generously reimbursed specific services, such as coronary artery bypass grafting, has increased.
Int J Health Care Finance Econ
· 2004 Jun · PMID 15211101
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On May 28, 2003, the Agency for Healthcare Research and Quality and the Federal Trade Commission co-sponsored an invitational conference entitled, "Provider Competition and Quality: Latest Findings and Implications for t...On May 28, 2003, the Agency for Healthcare Research and Quality and the Federal Trade Commission co-sponsored an invitational conference entitled, "Provider Competition and Quality: Latest Findings and Implications for the Next Generation of Research." The main objectives of this conference were to share and discuss the latest findings on provider competition and quality, to identify implications for antitrust policy, and to develop an agenda for further research in this area. While it is impossible to completely capture the rich exchange of ideas and perspectives that transpired at the conference, we highlight several key themes that emerged and present a research agenda to guide future investigations.
Int J Health Care Finance Econ
· 2004 Mar · PMID 15170965
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This paper study labour market responses to hospital mergers. The market consists of two hospitals providing horizontally and vertically differentiated services. Hospitals compete either in price and quality or just in q...This paper study labour market responses to hospital mergers. The market consists of two hospitals providing horizontally and vertically differentiated services. Hospitals compete either in price and quality or just in quality (non-price competition). To provide medical care, hospitals employ health care workers (e.g., physicians, nurses). The workers collectively bargain wages either at a central level, firm level or plant level. Anticipating wage responses, hospitals decide whether or not to merge. The main finding is that the bargaining structure, the nature of competition and the patient copayment rate have a crucial impact on the profitability of hospital mergers.
Int J Health Care Finance Econ
· 2004 Mar · PMID 15170964
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We use a longitudinal national sample of Medicare claims linked to the National Long-Term Care Survey (NLTCS) to assess the productivity of routine eye examinations. Although such exams are widely recommended by professi...We use a longitudinal national sample of Medicare claims linked to the National Long-Term Care Survey (NLTCS) to assess the productivity of routine eye examinations. Although such exams are widely recommended by professional organizations for certain populations, there is limited empirical evidence on the productivity of such care. We measure two outcomes, the ability to continue reading, and no onset of blindness or low vision, accounting for potential endogeneity of frequency of eye exams. Using instrumental variables, we find a statistically significant and beneficial effect of routine eye exams for both outcomes. Marginal effects for reading ability are large, but decline in the number of years with eye exams. Effects for blindness/low vision are smaller for the general elderly population, but larger for persons with diabetes. Instrumental variables provide a useful approach for assessing the productivity of particular interventions, particularly in situations in which randomized controlled trials are expensive or perhaps unethical and difficult to conduct over a lengthy time period.
Int J Health Care Finance Econ
· 2004 Mar · PMID 15170963
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The theory of wage differentials argues that workers must pay for employer-provided group health insurance coverage through lower wages or reductions in other fringe benefits. This paper uses data from the 1988-90 Consum...The theory of wage differentials argues that workers must pay for employer-provided group health insurance coverage through lower wages or reductions in other fringe benefits. This paper uses data from the 1988-90 Consumer Expenditure Survey (CEX) to estimate the wage-health insurance trade-off for male workers between the ages of 25 and 55. A fixed-effects model, which takes advantage of the rotating panel design of the CEX, is used to control for unobservable worker characteristics that are positively related with all forms of compensation, including wage earnings and health insurance coverage. I find a compensating differential for health insurance equal to roughly 10 to 11 percent of wages. Some caution is advised here due to the fact that I was unable to control for other fringe benefits, the most important being paid vacation and sick leave.
Int J Health Care Finance Econ
· 2004 Mar · PMID 15170962
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Quality of care problems have persisted for decades within U.S. nursing homes. A potential state-level policy towards addressing this concern is the level of Medicaid payment. However, a number of studies have found that...Quality of care problems have persisted for decades within U.S. nursing homes. A potential state-level policy towards addressing this concern is the level of Medicaid payment. However, a number of studies have found that an increase in Medicaid payment is associated with lower quality in the presence of certificate-of-need (CON) laws and bed construction moratorium regulations, which serve as barriers to entry within the nursing home industry. Instead of relying on potentially confounded cross-sectional comparisons, this study presents novel, panel-based evidence that incorporates aggregate private-pay price data. These estimates almost uniformly indicate that an increase in the Medicaid payment rate raises nursing home quality. When compared to the earlier literature, these new findings are attributed to changes over time in the market for nursing home care related to the growth in nursing home substitutes.
Dervaux B, Leleu H, Valdmanis V
… +1 more, Walker D
Int J Health Care Finance Econ
· 2003 Dec · PMID 14650081
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An aim of vaccination programs is near-complete coverage. One method for achieving this is for health facilities providing these services to operate frequently and for many hours during each session. However, if vaccine...An aim of vaccination programs is near-complete coverage. One method for achieving this is for health facilities providing these services to operate frequently and for many hours during each session. However, if vaccine vials are not fully used, the remainder is often discarded, considered as waste. Without an active appointment schedule process, there is no way for facility staff to control the stochastic demand of potential patients, and hence reduce waste. And yet reducing the hours of operation or number of sessions per week could hinder access to vaccination services. In lieu of any formal system of controlling demand, we propose to model the optimal number of hours and sessions in order to maximize outputs, the number and type of vaccines provided given inputs, using Data Envelopment Analysis (DEA). Inputs are defined as the amount of vaccine wastage and the number of full-time equivalent staff, size of the facility, number of hours of operation and the number of sessions. Outputs are defined as the number and type of vaccines aimed at children and pregnant women. This analysis requires two models: one DEA model with possible reallocations between the number of hours and the number of sessions but with the total amount of time fixed and one model without this kind of reallocation in scheduling. Comparing these two scores we can identify the "gain" that would be possible were the scheduling of hours and sessions modified while controlling for all other types of inefficiency. By modeling an output-based model, we maintain the objective of increasing coverage while assisting decision-makers determining optimal operating processes.
Int J Health Care Finance Econ
· 2003 Dec · PMID 14650080
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Finland's 1993 state subsidy reform encouraged hospital districts to determine their services as products and change their pricing from bed-day to case-based and fee-for-service types. The economic incentive in hospital...Finland's 1993 state subsidy reform encouraged hospital districts to determine their services as products and change their pricing from bed-day to case-based and fee-for-service types. The economic incentive in hospital production was investigated by exploring how different price types affected the use of lumbar discectomies, and hip and knee replacements. Procedure rates, pricing, need, demand and supply variables in 1991-1998 were analysed using panel data methods. Case-based prices increased lumbar discectomies about 8%. In hip replacement the effect was opposite (-11%). Only for knee replacements (1995-1998) did mixed fee-for-service and bed-day prices significantly increase production (21%).
Int J Health Care Finance Econ
· 2003 Dec · PMID 14650079
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We study a health-insurance market where individuals are offered coverage against both medical expenditures and losses in income due to illness. Individuals vary in their level of innate ability and their probability of...We study a health-insurance market where individuals are offered coverage against both medical expenditures and losses in income due to illness. Individuals vary in their level of innate ability and their probability of falling ill. If there is private information about the probability of illness and an individual's innate ability is sufficiently low, we find that competitive insurance contracts yield screening partly in the form of co-payment, i.e., a deductible in pay, and partly in the form of reduced medical treatment, i.e., a deductible in pain.
Int J Health Care Finance Econ
· 2003 Dec · PMID 14650078
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In Norway, a new system of Activity Based Financing (ABF) for general hospitals was introduced on a comprehensive basis in July 1997. The main purpose of the reform was to increase activity so that more patients could re...In Norway, a new system of Activity Based Financing (ABF) for general hospitals was introduced on a comprehensive basis in July 1997. The main purpose of the reform was to increase activity so that more patients could receive treatment more quickly without reducing the quality of care. In this paper we analyse whether the reform has had any significant effect using two different performance indicators: number of patients treated and production of DRG points (Diagnosis Related Group). We divide the hospitals into two groups: hospitals owned by counties that have adopted the ABF system, and hospitals owned by counties using other funding systems. The first group then becomes the experiment group, while the second serves as a comparison group. It is argued that fixed-effect models are suitable specifications for this evaluation study, handling selection bias and the influence of unobservable explanatory variables in a consistent manner. We find that the reform has had a significant effect on the number of patients treated and DRG points produced. The results are sensitive as to how the experiment and the comparison group are determined.