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Effects of the Medicaid coverage cliff on low-income elderly Medicare beneficiaries 医疗补助覆盖悬崖对低收入老年医疗保险受益人的影响。
IF 2 3区 医学 Q2 ECONOMICS Pub Date : 2024-09-28 DOI: 10.1002/hec.4902
Kanghyock Koh, Sungchul Park

The Medicaid coverage “cliff” occurs when Medicare beneficiaries with household income exceeding 100% of the federal poverty level lose eligibility for supplemental Medicaid coverage. Using a regression discontinuity design with data from Medical Expenditure Panel Survey and National Health and Nutrition Examination Survey for 2007–2019, we demonstrate that the cliff increases out-of-pocket spending by 25% and the probability of experiencing problems paying medical bills by 44.4% without decreases in overall health care spending. However, there is evidence that near-poor Medicare beneficiaries changed behavior in response to the cliff, increasing the use of high-value diagnostic and preventive testing by 8.8% and enrollment in a more affordable plan by 12.2%. The cliff does not encourage healthy behavior.

当医疗保险受益人的家庭收入超过联邦贫困线的 100%时,就会出现医疗补助保险 "悬崖",失去享受医疗补助补充保险的资格。我们利用 2007-2019 年医疗支出面板调查和全国健康与营养调查的数据,采用回归不连续设计,证明悬崖会使自付支出增加 25%,支付医疗账单出现问题的概率增加 44.4%,而总体医疗支出并未减少。然而,有证据表明,近乎贫困的医疗保险受益人因悬崖而改变了行为,增加了 8.8%的高价值诊断和预防性测试的使用,并加入了 12.2%的更实惠的计划。悬崖并不鼓励健康行为。
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引用次数: 0
Going beyond randomised controlled trials to assess treatment effect heterogeneity across target populations 超越随机对照试验,评估不同目标人群的治疗效果异质性。
IF 2 3区 医学 Q2 ECONOMICS Pub Date : 2024-09-26 DOI: 10.1002/hec.4903
David G. Lugo-Palacios, Patrick Bidulka, Stephen O’Neill, Orlagh Carroll, Anirban Basu, Amanda Adler, Karla DíazOrdaz, Andrew Briggs, Richard Grieve

Methods have been developed for transporting evidence from randomised controlled trials (RCTs) to target populations. However, these approaches allow only for differences in characteristics observed in the RCT and real-world data (overt heterogeneity). These approaches do not recognise heterogeneity of treatment effects (HTE) according to unmeasured characteristics (essential heterogeneity). We use a target trial design and apply a local instrumental variable (LIV) approach to electronic health records from the Clinical Practice Research Datalink, and examine both forms of heterogeneity in assessing the comparative effectiveness of two second-line treatments for type 2 diabetes mellitus. We first estimate individualised estimates of HTE across the entire target population defined by applying eligibility criteria from national guidelines (n = 13,240) within an overall target trial framework. We define a subpopulation who meet a published RCT's eligibility criteria (‘RCT-eligible’, n = 6497), and a subpopulation who do not (‘RCT-ineligible’, n = 6743). We compare average treatment effects for pre-specified subgroups within the RCT-eligible subpopulation, the RCT-ineligible subpopulation, and within the overall target population. We find differences across these subpopulations in the magnitude of subgroup-level treatment effects, but that the direction of estimated effects is stable. Our results highlight that LIV methods can provide useful evidence about treatment effect heterogeneity including for those subpopulations excluded from RCTs.

目前已开发出将证据从随机对照试验(RCT)转移到目标人群的方法。然而,这些方法只考虑到随机对照试验和真实世界数据中观察到的特征差异(明显异质性)。这些方法无法识别根据未测量特征而产生的治疗效果异质性(HTE)(基本异质性)。我们采用目标试验设计,将局部工具变量(LIV)方法应用于临床实践研究数据链(Clinical Practice Research Datalink)的电子健康记录,并在评估 2 型糖尿病两种二线治疗方法的比较效果时考察了这两种形式的异质性。我们首先在总体目标试验框架内,通过应用国家指南中的资格标准(n = 13,240)来估算整个目标人群的 HTE 个性化估算值。我们定义了符合已发表 RCT 资格标准的子人群("符合 RCT 标准",n = 6497)和不符合 RCT 标准的子人群("不符合 RCT 标准",n = 6743)。我们比较了符合 RCT 条件的亚群、不符合 RCT 条件的亚群以及总体目标人群中预先指定的亚群的平均治疗效果。我们发现,在这些亚群中,亚群级治疗效果的大小存在差异,但估计效果的方向是稳定的。我们的结果突出表明,LIV 方法可以为治疗效果的异质性提供有用的证据,包括那些被排除在 RCT 之外的亚人群。
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引用次数: 0
Externality and policy intervention in interregional travel with infectious diseases 传染病区域间旅行的外部性和政策干预。
IF 2 3区 医学 Q2 ECONOMICS Pub Date : 2024-09-24 DOI: 10.1002/hec.4900
Naoshi Doi, Shingo Yamazaki

This paper theoretically investigates externalities and policy interventions in travel during a pandemic. We develop a tractable static model of two regions from a short-run perspective. The model shows that the externalities can be both negative and positive, depending on regional asymmetry. Thus, even when infectious diseases are widespread, travel restrictions do not necessarily reduce infections and do not necessarily improve social welfare. A formula for the optimal policy intervention is derived and shown to be the weighted average of four types of externalities defined by the direction of travel and the epidemiological status of a traveler.

本文从理论上研究了大流行病期间旅行的外部性和政策干预。我们从短期角度建立了一个两个地区的可操作静态模型。模型显示,外部性既可能是负的,也可能是正的,这取决于地区的不对称性。因此,即使在传染病广泛传播的情况下,旅行限制也不一定能减少感染,也不一定能提高社会福利。最佳政策干预的公式是由旅行方向和旅行者的流行病学状况决定的四种外部性的加权平均值。
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引用次数: 0
Income effect of prenatal sunlight exposure: Empirical evidence from China 产前阳光照射对收入的影响:来自中国的经验证据。
IF 2 3区 医学 Q2 ECONOMICS Pub Date : 2024-09-24 DOI: 10.1002/hec.4892
Guanghua Wan, Tongjin Zhang, Xiaoshan Hu

Despite a growing interest in the impacts of prenatal factors on adulthood quality of life, economists have not estimated the income effects of sunlight exposures by mothers during pregnancy. This paper estimates such effects using data from China General Social Survey and China National Meteorological Data Service Center. The results show that the income effects of prenatal sunlight exposure in the second trimester are significantly positive. The effects differ for individuals born in different months and the effects are larger for female employees, older employees, those born in rural areas, in the pre-reform period, or whose mothers are less-educated. Finally, we investigate the possible mechanisms via the human capital pathway, discovering that fetuses with longer sunlight exposure in the second trimester are healthier and do more exercises in adulthood. It is suggested that families, communities, policymakers should pay attention to prenatal sunlight exposure, especially for pregnant women in the developing world who are less educated or live in rural areas.

尽管人们越来越关注产前因素对成年后生活质量的影响,但经济学家尚未估算过母亲在怀孕期间接触阳光对收入的影响。本文利用中国社会综合调查和中国国家气象数据服务中心的数据估算了这种影响。结果表明,产前第二孕期日照的收入效应显著为正。不同月份出生的个体所受影响不同,女性雇员、年龄较大的雇员、出生在农村地区、出生在改革前时期或母亲受教育程度较低的个体所受影响更大。最后,我们通过人力资本途径对可能的机制进行了研究,发现在怀孕后三个月接触阳光时间较长的胎儿更健康,成年后做的运动也更多。我们建议家庭、社区和政策制定者关注产前的日光照射,尤其是发展中国家受教育程度较低或生活在农村地区的孕妇。
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引用次数: 0
Pathways from education to mortality, mediated through income 以收入为中介,从教育到死亡的路径。
IF 2 3区 医学 Q2 ECONOMICS Pub Date : 2024-09-19 DOI: 10.1002/hec.4894
Govert E. Bijwaard, Kieron J. Barclay

Lower levels of education are associated with higher mortality. Lower levels of education are also associated with lower income, which is also associated with higher mortality. We investigate the impact of education on mortality and the extent to which this is mediated through income over the life course. We account for both selective educational attainment and selective income over the life course, through inverse propensity weighting (IPW) of the mortality hazard. We decompose the educational gain, that is, the decrease in mortality from more education, in the hazard into an indirect effect of education, running through changes in income and a direct effect of education, running through other factors. We use Swedish conscription data (men only), linked to parental information and individual annual income for the period 1968 till 2012. Our empirical results indicate large educational gains in mortality. We also find that this educational gradient runs through changes in income, especially for the more educated, and does not run through other factors related to education. We conduct several robustness and sensitivity checks that indicate that the results are robust.

教育水平越低,死亡率越高。较低的教育水平也与较低的收入有关,而较低的收入也与较高的死亡率有关。我们研究了教育对死亡率的影响,以及这种影响在多大程度上是通过生命过程中的收入来调节的。我们通过死亡率危险的反倾向加权(IPW),对生命过程中教育程度的选择性和收入的选择性进行了考虑。我们将危险中的教育收益(即教育程度越高死亡率越低)分解为教育的间接效应(通过收入变化产生)和教育的直接效应(通过其他因素产生)。我们使用了瑞典征兵数据(仅限男性),这些数据与 1968 年至 2012 年期间的父母信息和个人年收入相关联。我们的实证结果表明,教育对死亡率的影响很大。我们还发现,这种教育梯度与收入变化有关,尤其是对受教育程度较高的人而言,而与教育相关的其他因素无关。我们进行了多项稳健性和敏感性检验,结果表明这些检验结果是稳健的。
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引用次数: 0
The effect of a minor health shock on labor market outcomes: The case of concussions 轻微健康冲击对劳动力市场结果的影响:脑震荡案例。
IF 2 3区 医学 Q2 ECONOMICS Pub Date : 2024-09-18 DOI: 10.1002/hec.4897
Florian Fouquet, Lisa Meehan, Gail Pacheco, Alice Theadom

The literature on health shocks finds that minor injuries have only short-term labor market impacts. However, mild traumatic brain injuries (mTBIs, commonly referred to as concussions) may be different as the medical literature highlights that they can have longer-term health and cognitive effects. Moreover, TBIs are one of the most common causes of disability globally, with the vast majority being mild. Thus, it is important to understand the impact of mTBIs on labor market outcomes. We use administrative data on all medically-diagnosed mild traumatic brain injuries (mTBIs) in New Zealand linked to monthly tax records to examine the labor market effects of a mTBI. We use a comparison group of those who suffer a mTBI at a later date to overcome potential endogeneity issues, and employ a doubly-robust difference-in-differences method. We find that suffering a mTBI has negative labor market effects. Rather than dissipating over time, these negative effects grow, representing a decrease in employment of 20 percentage points and earning losses of about a third after 48 months. Our results highlight the need for timely diagnosis and treatment to mitigate the effect of mTBIs to reduce economic and social costs.

有关健康冲击的文献发现,轻伤只会对劳动力市场产生短期影响。然而,轻度脑外伤(mTBIs,通常称为脑震荡)可能有所不同,因为医学文献强调,轻度脑外伤可能对健康和认知能力产生较长期的影响。此外,创伤性脑损伤是全球最常见的致残原因之一,其中绝大多数为轻度创伤性脑损伤。因此,了解轻度创伤性脑损伤对劳动力市场结果的影响非常重要。我们利用新西兰所有经医疗诊断为轻度创伤性脑损伤(mTBI)的行政数据,并将其与每月的纳税记录联系起来,来研究轻度创伤性脑损伤对劳动力市场的影响。为了克服潜在的内生性问题,我们使用了稍后发生的轻度脑损伤患者作为对比组,并采用了双重稳健差分法。我们发现,创伤后应激障碍会对劳动力市场产生负面影响。这些负面影响非但不会随着时间的推移而消失,反而会越来越大,48 个月后,就业率会下降 20 个百分点,收入损失约三分之一。我们的研究结果凸显了及时诊断和治疗的必要性,以减轻创伤后应激障碍的影响,从而降低经济和社会成本。
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引用次数: 0
Effect of age-related premium readjustment on health insurance cancellation in Brazil: Regression discontinuity approach 与年龄相关的保费调整对巴西取消医疗保险的影响:回归不连续法。
IF 2 3区 医学 Q2 ECONOMICS Pub Date : 2024-09-18 DOI: 10.1002/hec.4898
Aline de Souza, Mônica Viegas Andrade, Kenya Valéria Micaela de Souza Noronha, Igor Viveiros Melo Souza

Age is one of the most relevant observable risk attributes in determining the value of health insurance premiums. Empirical evidence indicates that the cost of health insurance is the leading cause of contract switching, which can compromise access to healthcare services and potentially result in treatment discontinuities. Using data from a Health Maintenance Organization in the Southern region of Brazil, we examined the effect of health plan price readjustment resulting from changes in the beneficiary's age group on disenrollment or switches to a more limited coverage plan. The estimates were obtained using the method of regression discontinuity. The main findings indicate that for age group transitions at 59 years old, the price readjustment effect led to an increase in contract cancellations and switching to cheaper plans. These findings highlight that an important consequence of the difference in premium sensitivity among age groups is that the exit of individuals from the health insurance sector is selective in age. The results of this paper can support policymaking to improve access to health insurance.

年龄是决定医疗保险费价值的最相关的可观察风险属性之一。经验证据表明,医疗保险费用是导致合同转换的主要原因,这会影响医疗服务的获取,并可能导致治疗中断。我们利用巴西南部地区一家健康维护组织的数据,研究了因受益人年龄组变化而导致的健康计划价格调整对退保或转投更有限的保险计划的影响。我们使用回归非连续性方法进行了估算。主要研究结果表明,对于 59 岁年龄组的转变,价格调整效应导致合同取消和转投更便宜计划的情况增加。这些研究结果突出表明,不同年龄组对保费敏感度的差异所带来的一个重要结果是,个人退出医疗保险领域在年龄上是有选择性的。本文的研究结果可以为改善医疗保险的政策制定提供支持。
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引用次数: 0
The effect of parental health shocks on living arrangements and employment 父母健康冲击对生活安排和就业的影响。
IF 2 3区 医学 Q2 ECONOMICS Pub Date : 2024-09-16 DOI: 10.1002/hec.4893
Julien Bergeot, Irene Ferrari, Ya Gao

This study investigates the impacts of health shocks among older individuals on the dynamics of their living arrangements in Europe and the United States. Exploiting unpredicted health shocks, we use an event-study difference-in-differences approach to demonstrate that health shocks increase difficulties with activities of daily living and instrumental activities of daily living, thereby increasing the need for care. Our findings indicate that health shocks raise the probability of nursing home residency and co-residence with adult children by 0.7 and 1.4 percentage points in Europe, and by 2.1 and 1.8 percentage points in the U.S., respectively. Further analyses reveal that more generous long-term care public policies correlate with a higher probability of nursing home residency and a lower probability of co-residing with adult children, highlighting the significant role of public policies in household responses to health shocks. Additionally, we find that health shocks negatively impact adult children's labor supply, particularly in the U.S.

本研究调查了欧洲和美国老年人的健康冲击对其生活安排动态的影响。利用未预测的健康冲击,我们采用事件研究差分法来证明健康冲击会增加日常生活活动和工具性日常生活活动的困难,从而增加对护理的需求。我们的研究结果表明,在欧洲,健康冲击会将入住养老院和与成年子女共同居住的概率分别提高 0.7 和 1.4 个百分点,在美国则分别提高 2.1 和 1.8 个百分点。进一步的分析表明,更慷慨的长期护理公共政策与更高的养老院居住概率和更低的与成年子女共同居住概率相关,这凸显了公共政策在家庭应对健康冲击中的重要作用。此外,我们还发现健康冲击会对成年子女的劳动力供给产生负面影响,尤其是在美国。
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引用次数: 0
The impact of long-term care insurance on the utilization of inpatient service: Evidence and mechanisms in China 长期护理保险对住院服务使用的影响:中国的证据与机制。
IF 2 3区 医学 Q2 ECONOMICS Pub Date : 2024-09-13 DOI: 10.1002/hec.4896
Xiao Han, Hanyang Wang, Xia Du

This paper empirically investigates the impact of public long-term care insurance (LTCI) on the utilization of inpatient services and associated expenditures among disabled Chinese individuals, using data from the China Health and Retirement Longitudinal Study from 2011 to 2018. Employing a staggered difference-in-difference approach within a propensity score matching framework (PSM-DID), the study finds that the introduction of LTCI significantly reduces the likelihood of inpatient service usage by 4.2%, the annual number of inpatient admissions by 10.2%, the annual inpatient cost by 16.2%, the out-of-pocket expenses by 20.7%, and the reimbursement expenditure by the public medical insurer by 9.9%. The study further explores the mechanisms underlying these effects and identifies that the Substitution Effect, where care services in community healthcare centers and nursing homes replace hospitalizations, outweighs the Income Effect generated by LTCI benefits. By leveraging the quasi-natural experimental setting of diverse LTCI policies across cities, the study also examines the heterogeneous impacts of LTCI based on household income, eligibility criteria, and reimbursement methods. The findings underscore the positive role of LTCI in controlling medical expenses and alleviating congestion in urban hospitals, offering valuable insights for promoting “Healthy Aging”.

本文利用中国健康与养老纵向研究(China Health and Retirement Longitudinal Study)2011-2018年的数据,实证研究了公共长期护理保险(LTCI)对中国失能人员住院服务使用及相关支出的影响。研究采用倾向得分匹配框架下的交错差分法(PSM-DID),发现引入长护险后,住院服务使用的可能性显著降低了4.2%,年住院人数显著降低了10.2%,年住院费用显著降低了16.2%,自付费用显著降低了20.7%,公费医疗保险报销支出显著降低了9.9%。研究进一步探讨了这些效应的内在机制,发现社区保健中心和疗养院的护理服务取代住院治疗的替代效应超过了长寿保险福利产生的收入效应。通过利用各城市不同的长期护理保险政策这一准自然实验环境,本研究还考察了长期护理保险对家庭收入、资格标准和报销方法的不同影响。研究结果强调了长期护理保险在控制医疗费用和缓解城市医院拥挤方面的积极作用,为促进 "健康老龄化 "提供了有价值的见解。
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引用次数: 0
Comparing methods for estimating causal treatment effects of administrative health data: A plasmode simulation study 比较估算行政健康数据因果治疗效果的方法:质谱模拟研究
IF 2 3区 医学 Q2 ECONOMICS Pub Date : 2024-09-10 DOI: 10.1002/hec.4891
Vanessa Ress, Eva-Maria Wild

Estimating the causal effects of health policy interventions is crucial for policymaking but is challenging when using real-world administrative health care data due to a lack of methodological guidance. To help fill this gap, we conducted a plasmode simulation using such data from a recent policy initiative launched in a deprived urban area in Germany. Our aim was to evaluate and compare the following methods for estimating causal effects: propensity score matching, inverse probability of treatment weighting, and entropy balancing, all combined with difference-in-differences analysis, augmented inverse probability weighting, and targeted maximum likelihood estimation. Additionally, we estimated nuisance parameters using regression models and an ensemble learner called superlearner. We focused on treatment effects related to the number of physician visits, total health care cost, and hospitalization. While each approach has its strengths and weaknesses, our results demonstrate that the superlearner generally worked well for handling nuisance terms in large covariate sets when combined with doubly robust estimation methods to estimate the causal contrast of interest. In contrast, regression-based nuisance parameter estimation worked best in small covariate sets when combined with singly robust methods.

估算医疗政策干预措施的因果效应对政策制定至关重要,但由于缺乏方法指导,在使用真实世界的行政医疗数据时却面临挑战。为了填补这一空白,我们利用最近在德国一个贫困城市地区推出的一项政策措施中的此类数据进行了质谱模拟。我们的目的是评估和比较以下几种估算因果效应的方法:倾向得分匹配法、逆概率治疗加权法和熵平衡法,所有这些方法都与差异分析、增强逆概率加权法和目标最大似然估算相结合。此外,我们还使用回归模型和称为超级学习器的集合学习器估算了干扰参数。我们重点研究了与就诊次数、总医疗费用和住院治疗相关的治疗效果。虽然每种方法都有其优缺点,但我们的结果表明,当结合双重稳健估计方法来估计感兴趣的因果对比时,超级学习器通常能很好地处理大型协变量集中的滋扰项。相比之下,基于回归的滋扰参数估计与单稳健方法相结合时,在小型协变量集中效果最佳。
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引用次数: 0
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Health economics
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