This paper aims to identify selection separately from moral hazard in a mandatory health insurance market where enrollees can freely choose their deductible scheme. The empirical analysis uses a unique data set for the period 2010-2013 covering the whole population of the Netherlands at enrollee level, allowing us to use prior health expenses of the enrollees to demonstrate the selection e ect separately from the potential moral hazard e ect. Our estimates show that the enrollees who opt for deductibles are both healthier and have a higher risk-adjusted result (i.e. the di erence between the compensation from the risk-adjustment fund and the actual health care cost) under the prevailing risk-adjustment system. Compared to enrollees who have chosen the lowest available deductible level, enrollees who have chosen the highest deductible level have an average risk-adjusted result that is approximately AC450 higher per enrollee. An option that the Dutch government could consider to fully eliminate the risk-adjustment gain of the deductibles is to include the choice of a voluntary deductible in the risk-adjustment system as one of the characteristics of the consumer. Our detection of substantial selection e ect of deductibles suggests the need of further research to understand in greater detail the relationship between premium discounts and the expected gains on the risk-adjustment for enrollees with a voluntary deductible.
{"title":"Evidence of Selection in a Mandatory Health Insurance Market with Risk Adjustment","authors":"R. Croes, K. Katona, M. Mikkers, V. Shestalova","doi":"10.2139/ssrn.3157625","DOIUrl":"https://doi.org/10.2139/ssrn.3157625","url":null,"abstract":"This paper aims to identify selection separately from moral hazard in a mandatory health insurance market where enrollees can freely choose their deductible scheme. The empirical analysis uses a unique data set for the period 2010-2013 covering the whole population of the Netherlands at enrollee level, allowing us to use prior health expenses of the enrollees to demonstrate the selection e ect separately from the potential moral hazard e ect. Our estimates show that the enrollees who opt for deductibles are both healthier and have a higher risk-adjusted result (i.e. the di erence between the compensation from the risk-adjustment fund and the actual health care cost) under the prevailing risk-adjustment system. Compared to enrollees who have chosen the lowest available deductible level, enrollees who have chosen the highest deductible level have an average risk-adjusted result that is approximately AC450 higher per enrollee. An option that the Dutch government could consider to fully eliminate the risk-adjustment gain of the deductibles is to include the choice of a voluntary deductible in the risk-adjustment system as one of the characteristics of the consumer. Our detection of substantial selection e ect of deductibles suggests the need of further research to understand in greater detail the relationship between premium discounts and the expected gains on the risk-adjustment for enrollees with a voluntary deductible.","PeriodicalId":309156,"journal":{"name":"PSN: Health Care Delivery (Topic)","volume":"2 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-04-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"130397883","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Cesarean delivery for low-risk pregnancies is generally associated with worse health outcomes for infants and mothers. The interpretation of this correlation, however, is confounded by potential selectivity in the choice of birth mode. We use birth records from California, merged with hospital and emergency department (ED) visits for infants and mothers in the year after birth, to study the causal health effects of cesarean delivery for low-risk first births. Building on McClellan, McNeil, and Newhouse (1994), we use the relative distance from a mother’s home to hospitals with high and low c-section rates as an instrument for c-section. We show that relative distance is a strong predictor of c-section but is orthogonal to many observed risk factors, including birth weight and indicators of prenatal care. Our IV estimates imply that cesarean delivery causes a relatively large increase in ED visits of the infant, mainly due to acute respiratory conditions. We find no significant effects on mothers’ hospitalizations or ED use after birth, or on subsequent fertility, but we find a ripple effect on second birth outcomes arising from the high likelihood of repeat c-section. Offsetting these morbidity effects, we find that delivery at a high c-section hospital leads to a significant reduction in infant mortality, driven by lower death rates for newborns with high rates of pre-determined risk factors.
{"title":"The Health Effects of Cesarean Delivery for Low-Risk First Births","authors":"David Card, Alessandra Fenizia, D. Silver","doi":"10.3386/W24493","DOIUrl":"https://doi.org/10.3386/W24493","url":null,"abstract":"Cesarean delivery for low-risk pregnancies is generally associated with worse health outcomes for infants and mothers. The interpretation of this correlation, however, is confounded by potential selectivity in the choice of birth mode. We use birth records from California, merged with hospital and emergency department (ED) visits for infants and mothers in the year after birth, to study the causal health effects of cesarean delivery for low-risk first births. Building on McClellan, McNeil, and Newhouse (1994), we use the relative distance from a mother’s home to hospitals with high and low c-section rates as an instrument for c-section. We show that relative distance is a strong predictor of c-section but is orthogonal to many observed risk factors, including birth weight and indicators of prenatal care. Our IV estimates imply that cesarean delivery causes a relatively large increase in ED visits of the infant, mainly due to acute respiratory conditions. We find no significant effects on mothers’ hospitalizations or ED use after birth, or on subsequent fertility, but we find a ripple effect on second birth outcomes arising from the high likelihood of repeat c-section. Offsetting these morbidity effects, we find that delivery at a high c-section hospital leads to a significant reduction in infant mortality, driven by lower death rates for newborns with high rates of pre-determined risk factors.","PeriodicalId":309156,"journal":{"name":"PSN: Health Care Delivery (Topic)","volume":"51 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"129978969","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
How can public healthcare administrators predict tertiary healthcare utilization when hospitals face highly variable patient flows but large and infungible costs of specialty treatment? Using administrative claims data from a public health insurance program in India shows that utilization by social connections is associated with 26% increase in first-time utilization. The social connections model decreases root mean squared error by 11.25% compared to a baseline model. Social connections predict treatment in private rather than public facilities, but not in specialty use. The enhanced model predicts higher levels of optimum healthcare provision when the costs of undertreatment are severe.
{"title":"Social Connections and Public Healthcare Utilization","authors":"S. Debnath, Tarun Jain","doi":"10.2139/ssrn.2899976","DOIUrl":"https://doi.org/10.2139/ssrn.2899976","url":null,"abstract":"How can public healthcare administrators predict tertiary healthcare utilization when hospitals face highly variable patient flows but large and infungible costs of specialty treatment? Using administrative claims data from a public health insurance program in India shows that utilization by social connections is associated with 26% increase in first-time utilization. The social connections model decreases root mean squared error by 11.25% compared to a baseline model. Social connections predict treatment in private rather than public facilities, but not in specialty use. The enhanced model predicts higher levels of optimum healthcare provision when the costs of undertreatment are severe.","PeriodicalId":309156,"journal":{"name":"PSN: Health Care Delivery (Topic)","volume":"18 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-02-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"115374348","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
One of the most important problems in the business world is unethical behaviors by workers. Businesses lose 6% of their income with fraud and the health sector is the 5th sector among the affected sectors by fraud activities. To prevent fraud in the health sector, implementation of corporate governance principles, internal control procedures comply with international anti-fraud legislation, the disclosure of annual anti-fraud report are recommended. In this study, after a literature review, the importance of ethical behavior and institutionalization in the health sector in Turkey have been discussed and the measures which should be taken to prevent corruption in the health sector are listed.
{"title":"Fraud Prevention in Health Sector: Proposals of Solution","authors":"K. Çalıyurt","doi":"10.2139/SSRN.3121738","DOIUrl":"https://doi.org/10.2139/SSRN.3121738","url":null,"abstract":"One of the most important problems in the business world is unethical behaviors by workers. Businesses lose 6% of their income with fraud and the health sector is the 5th sector among the affected sectors by fraud activities. To prevent fraud in the health sector, implementation of corporate governance principles, internal control procedures comply with international anti-fraud legislation, the disclosure of annual anti-fraud report are recommended. In this study, after a literature review, the importance of ethical behavior and institutionalization in the health sector in Turkey have been discussed and the measures which should be taken to prevent corruption in the health sector are listed.","PeriodicalId":309156,"journal":{"name":"PSN: Health Care Delivery (Topic)","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-02-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"128422258","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
In setting prices for physician services, Medicare solicits input from a committee that evaluates proposals from industry. We investigate whether this arrangement leads to prices biased toward the interests of committee members. We find that increasing a measure of affiliation between the committee and proposers by one standard deviation increases prices by 10%, demonstrating a pathway for regulatory capture. We then evaluate the effect of affiliation on the quality of information used in price-setting. More affiliated proposals produce less hard information, measured as lower quality survey data. However, affiliation results in prices that are more closely followed by private insurers, suggesting that affiliation may increase the total information used in price-setting.
{"title":"Industry Input in Policymaking: Evidence from Medicare","authors":"David C. Chan, M. Dickstein","doi":"10.3386/W24354","DOIUrl":"https://doi.org/10.3386/W24354","url":null,"abstract":"In setting prices for physician services, Medicare solicits input from a committee that evaluates proposals from industry. We investigate whether this arrangement leads to prices biased toward the interests of committee members. We find that increasing a measure of affiliation between the committee and proposers by one standard deviation increases prices by 10%, demonstrating a pathway for regulatory capture. We then evaluate the effect of affiliation on the quality of information used in price-setting. More affiliated proposals produce less hard information, measured as lower quality survey data. However, affiliation results in prices that are more closely followed by private insurers, suggesting that affiliation may increase the total information used in price-setting.","PeriodicalId":309156,"journal":{"name":"PSN: Health Care Delivery (Topic)","volume":"31 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"123235031","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
The Hospital Readmission Reduction Program (HRRP) and the Hospital Value Based Purchasing Program (HVBP), two components of the Affordable Care Act's cost containment measures, introduced potentially sizeable penalties to underperforming hospitals across a variety of metrics. To the extent that penalized hospitals subsequently changed their processes of care, such changes may translate into higher payments from commercial insurance patients. In this paper, we estimate the effects of these pay-for-performance programs on private hospital payments using data on commercial insurance payments from a large, multi-payer database. We find that nearly 70% of the costs of the HRRP and HVBP penalties are borne by private insurance patients in the form of higher private insurance payments to hospitals. Specifically, we show that HRRP and HVBP led to increases in private payments of 1.4%, or approximately $183,700 per hospital based on an average relative penalty of $271,000. We find very limited evidence that these effects are driven by quality improvements, changes in treatment intensity, or changes in service mix.
{"title":"Who Pays in Pay for Performance? Evidence from Hospital Pricing","authors":"Michael E Darden, Ian M. McCarthy, E. Barrette","doi":"10.3386/W24304","DOIUrl":"https://doi.org/10.3386/W24304","url":null,"abstract":"The Hospital Readmission Reduction Program (HRRP) and the Hospital Value Based Purchasing Program (HVBP), two components of the Affordable Care Act's cost containment measures, introduced potentially sizeable penalties to underperforming hospitals across a variety of metrics. To the extent that penalized hospitals subsequently changed their processes of care, such changes may translate into higher payments from commercial insurance patients. In this paper, we estimate the effects of these pay-for-performance programs on private hospital payments using data on commercial insurance payments from a large, multi-payer database. We find that nearly 70% of the costs of the HRRP and HVBP penalties are borne by private insurance patients in the form of higher private insurance payments to hospitals. Specifically, we show that HRRP and HVBP led to increases in private payments of 1.4%, or approximately $183,700 per hospital based on an average relative penalty of $271,000. We find very limited evidence that these effects are driven by quality improvements, changes in treatment intensity, or changes in service mix.","PeriodicalId":309156,"journal":{"name":"PSN: Health Care Delivery (Topic)","volume":"34 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"115517482","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
In order to implement value-based concepts like Lean Management or Value Based Healthcare, hospitals should have sufficient understanding of what (potential) health care recipients value in the services that are provided to them. In this respect, in this paper, we argue that hospitals should acknowledge the multi-layered identity of the healthcare recipient. Hence, hospitals should be aware that a healthcare recipient is at the same time a patient, a person and a customer. In this paper it is shown that this Multi-layered Identity Approach (MIA) can be helpful in a better understanding of what a (potential) healthcare recipient values in the services that are provided to him and why and when certain values are of importance during his journey through the hospital.
{"title":"What a Healthcare Recipient Values in Hospital Care: A Multi-Layered Identity Approach","authors":"Dennis Moeke, Jeroen van Andel","doi":"10.2139/ssrn.3089140","DOIUrl":"https://doi.org/10.2139/ssrn.3089140","url":null,"abstract":"In order to implement value-based concepts like Lean Management or Value Based Healthcare, hospitals should have sufficient understanding of what (potential) health care recipients value in the services that are provided to them. In this respect, in this paper, we argue that hospitals should acknowledge the multi-layered identity of the healthcare recipient. Hence, hospitals should be aware that a healthcare recipient is at the same time a patient, a person and a customer. In this paper it is shown that this Multi-layered Identity Approach (MIA) can be helpful in a better understanding of what a (potential) healthcare recipient values in the services that are provided to him and why and when certain values are of importance during his journey through the hospital.","PeriodicalId":309156,"journal":{"name":"PSN: Health Care Delivery (Topic)","volume":"26 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2017-12-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"124943903","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Mariacristina De Nardi, S. Pashchenko, Ponpoje Porapakkarm
Health shocks are an important source of risk. People in bad health work less, earn less, face higher medical expenses, die earlier, and accumulate much less wealth compared to those in good health. Importantly, the dynamics of health are much richer than those implied by a low-order Markov process. We first show that these dynamics can be parsimoniously captured by a combination of some lag-dependence and ex-ante heterogeneity, or health types. We then study the effects of health shocks in a structural life-cycle model with incomplete markets. Our estimated model reproduces the observed inequality in economic outcomes by health status, including the income-health and wealth-health gradients. Our model has several implications concerning the pecuniary and non-pecuniary effects of health shocks over the life-cycle. The (monetary) lifetime costs of bad health are very concentrated and highly unequally distributed across health types, with the largest component of these costs being the loss in labor earnings. The non-pecuniary effects of health are very important along two dimensions. First, individuals value good health mostly because it extends life expectancy. Second, health uncertainty substantially increases lifetime inequality by affecting the variation in lifespans.
{"title":"The Lifetime Costs of Bad Health","authors":"Mariacristina De Nardi, S. Pashchenko, Ponpoje Porapakkarm","doi":"10.2139/ssrn.3056885","DOIUrl":"https://doi.org/10.2139/ssrn.3056885","url":null,"abstract":"Health shocks are an important source of risk. People in bad health work less, earn less, face higher medical expenses, die earlier, and accumulate much less wealth compared to those in good health. Importantly, the dynamics of health are much richer than those implied by a low-order Markov process. We first show that these dynamics can be parsimoniously captured by a combination of some lag-dependence and ex-ante heterogeneity, or health types. We then study the effects of health shocks in a structural life-cycle model with incomplete markets. Our estimated model reproduces the observed inequality in economic outcomes by health status, including the income-health and wealth-health gradients. Our model has several implications concerning the pecuniary and non-pecuniary effects of health shocks over the life-cycle. The (monetary) lifetime costs of bad health are very concentrated and highly unequally distributed across health types, with the largest component of these costs being the loss in labor earnings. The non-pecuniary effects of health are very important along two dimensions. First, individuals value good health mostly because it extends life expectancy. Second, health uncertainty substantially increases lifetime inequality by affecting the variation in lifespans.","PeriodicalId":309156,"journal":{"name":"PSN: Health Care Delivery (Topic)","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2017-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"115620069","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Michael A. Morrisey, Alice Rivlin, Richard Nathan, Mark A. Hall
This field study sought to better understand the evolution of health insurance competition in the health insurance exchange marketplaces in five states: California, Michigan, Florida, North Carolina, and Texas. This summary highlights key findings from each of the states and offers a series of testable hypotheses about the evolution of these markets. Four broad themes emerged from the analysis. First, health insurance markets are local, largely due to the necessity to establish local networks of health care providers. Second, higher than expected claims costs were the source of much of the turmoil in the marketplaces over the initial 4 years. Third, there has been a substantial shift toward narrower networks of providers, largely achieved by eliminating preferred provider plan options. Fourth, hospital and physician competition is essential for a robust and competitive insurer market.
{"title":"Five‐State Study of ACA Marketplace Competition: A Summary Report","authors":"Michael A. Morrisey, Alice Rivlin, Richard Nathan, Mark A. Hall","doi":"10.1111/rmir.12079","DOIUrl":"https://doi.org/10.1111/rmir.12079","url":null,"abstract":"This field study sought to better understand the evolution of health insurance competition in the health insurance exchange marketplaces in five states: California, Michigan, Florida, North Carolina, and Texas. This summary highlights key findings from each of the states and offers a series of testable hypotheses about the evolution of these markets. Four broad themes emerged from the analysis. First, health insurance markets are local, largely due to the necessity to establish local networks of health care providers. Second, higher than expected claims costs were the source of much of the turmoil in the marketplaces over the initial 4 years. Third, there has been a substantial shift toward narrower networks of providers, largely achieved by eliminating preferred provider plan options. Fourth, hospital and physician competition is essential for a robust and competitive insurer market.","PeriodicalId":309156,"journal":{"name":"PSN: Health Care Delivery (Topic)","volume":"66 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2017-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"123000424","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
We set out to examine the relevance of blockchain technology for healthcare management in general, and for consumer medical electronics and the portable devices connected in particular. After considering the shortcomings of private and centralized organizations for access to patient data in a fist part, we analyze the transformative role of blockchain for the management of electronic health records (EHRs). We evoke the role of public private partnerships for the design of healthcare blockchain strategies, and we address the fast-growing segment of consumer medical electronics and the Internet of Medical Things.
{"title":"Can Blockchain Improve Healthcare Management? Consumer Medical Electronics and the IoMT","authors":"M. Pilkington","doi":"10.2139/ssrn.3025393","DOIUrl":"https://doi.org/10.2139/ssrn.3025393","url":null,"abstract":"We set out to examine the relevance of blockchain technology for healthcare management in general, and for consumer medical electronics and the portable devices connected in particular. After considering the shortcomings of private and centralized organizations for access to patient data in a fist part, we analyze the transformative role of blockchain for the management of electronic health records (EHRs). We evoke the role of public private partnerships for the design of healthcare blockchain strategies, and we address the fast-growing segment of consumer medical electronics and the Internet of Medical Things.","PeriodicalId":309156,"journal":{"name":"PSN: Health Care Delivery (Topic)","volume":"18 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2017-08-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"122446696","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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