Advances in health economics and health services research最新文献

The second national goal for Healthy People 2010 is the elimination of health disparities related to social disadvantage in the United States. Unfortunately, progress to date has been limited. Our national strategy to achieve this goal has been too narrowly focused on public health. Success will require a broader strategy including alignment of existing national policies in non-health areas that affect the health of the socially disadvantaged such as education, health care, labor, welfare, housing, criminal justice, the environment, and taxation if it is to succeed. Key criteria are needed to begin to prioritize areas for federal investment to achieve this goal. These include the impact of the targeted condition on disparities, evidence base for the intervention, potential impact of the policy on disparities, economic impact, and federal politics. Two "big ideas" offer promise including federal investment in early child education and enhanced primary care within federally qualified community health centers. The proposed criteria are applied to each proposed policy.

We investigate whether information technology (IT) can help physicians more efficiently acquire new knowledge in a clinical environment characterized by information overload. We combine analysis of data from a randomized trial with a theoretical model of the influence that IT has on the acquisition of new medical knowledge. Although the theoretical framework we develop is conventionally microeconomic, the model highlights the non-market and non-pecuniary influence activities that have been emphasized in the sociological literature on technology diffusion. We report three findings. First, empirical evidence and theoretical reasoning suggests that computer-based decision support will speed the diffusion of new medical knowledge when physicians are coping with information overload. Second, spillover effects will likely lead to "underinvestment" in this decision support technology. Third, alternative financing strategies common to new IT, such as the use of marketing dollars to pay for the decision support systems, may lead to undesirable outcomes if physician information overload is sufficiently severe and if there is significant ambiguity in how best to respond to the clinical issues identified by the computer. This is the first paper to analyze empirically and theoretically how computer-based decision support influences the acquisition of new knowledge by physicians.

Purpose: Initial explorations in the burgeoning field of neuroeconomics have highlighted evidence supporting a potential dissociation between a fast automatic system and a slow deliberative controlled system. Growing research in the role of emotion in decision-making has attempted to draw parallels to the automatic system. This chapter will discuss a theoretical framework for understanding the role of emotion in decision-making and evidence supporting the underlying neural substrates.

Design/methodology/approach: This chapter applies a conceptual framework to understanding the role of emotion in decision-making, and emphasizes a distinction between expected and immediate emotions. Expected emotions refer to anticipated emotional states associated with a given decision that are never actually experienced. Immediate emotions, however, are experienced at the time of decision, and either can occur in response to a particular decision or merely as a result of a transitory fluctuation. This chapter will review research from the neuroeconomics literature that supports a neural dissociation between these two classes of emotion and also discuss a few interpretive caveats.

Findings: Several lines of research including regret, uncertainty, social decision-making, and moral decision-making have yielded evidence consistent with our formulization--expected and immediate emotions may invoke dissociable neural systems.

Originality/value: This chapter provides a more specific conceptualization of the mediating role of emotions in the decision-making process, which has important implications for understanding the interacting neural systems underlying the interface between emotion and cognition--a topic of immediate value to anyone investigating topics within the context of social-cognitive-affective-neuroscience.

Purpose: Responding negatively to inequity is not a uniquely human trait. Some of our closest evolutionary ancestors respond negatively when treated less well than a conspecific. Comparative work between humans and other primates can help elucidate the evolutionary underpinnings of humans' social preferences.

Methodology/approach: Results from studies of nonhuman primates, in particular chimpanzees and capuchin monkeys, are presented in comparison to human results that have been collected during economic game studies in humans, such as in the Ultimatum Game or Impunity Game.

Findings: Among nonhuman primates, a frequent behavioral reaction to inequity is to refuse to continue the interaction. While in some cases this response appears to be caused by the inequitable distribution, in others, it seems to be caused by another individual's inequitable behavior. While these reactions are similar to those of humans, this reaction does not appear to be a sense of fairness in the way that we think of it in humans. Neither nonhuman primate species alters their behavior when they are the benefited individual, and in an experimental situation, chimpanzees do not alter their behavior to obtain food for their partner as well as for themselves.

Originality/value of the chapter: Although there are differences between human and nonhuman primate responses, such studies allow us to better understand the evolution of our own responses to inequity. Given the strong behavioral reactions that even monkeys show to inequitable treatment, it is not surprising that humans are concerned with equity. Such comparisons increase understanding of issues such as healthcare disparities in humans.

Purpose: This chapter addresses the nature, formalization, and neural bases of (affective) social ties and discusses the relevance of ties for health economics. A social tie is defined as an affective weight attached by an individual to the well-being of another individual ('utility interdependence'). Ties can be positive or negative, and symmetric or asymmetric between individuals. Characteristic of a social tie, as conceived of here, is that it develops over time under the influence of interaction, in contrast with a trait like altruism. Moreover, a tie is not related to strategic behavior such as reputation formation but seen as generated by affective responses.

Methodology/approach: A formalization is presented together with some supportive evidence from behavioral experiments. This is followed by a discussion of related psychological constructs and the presentation of suggestive existing neural findings. To help prepare the grounds for a model-based neural analysis some speculations on the neural networks involved are provided, together with suggestions for future research.

Findings: Social ties are not only found to be important from an economic viewpoint, it is also shown that they can be modeled and related to neural substrates.

Originality/value of the chapter: By providing an overview of the economic research on social ties and connecting it with the broader behavioral and neuroeconomics literature, the chapter may contribute to the development of a neuroeconomics of social ties.

Purpose: We estimate national health expenditures on prevention using precise definitions, a transparent methodology, and a subdivision of the estimates into components to aid researchers in applying their own concepts of prevention activities.

Methodology/approach: We supplemented the National Health Expenditure Accounts (NHEA) with additional data to identify national spending on primary and secondary prevention for each year from 1996 to 2004 across eight spending categories.

Findings: We estimate that NHEA expenditures devoted to prevention grew from $83.2 billion in 1996 to $159.8 billion in 2004, in current dollars. As a share of NHEA, this represents an increase from 7.8 percent in 1996 to 8.6 percent in 2004. This share peaked at 9 percent in 2002 and then declined due to reductions in public health spending as a percent of NHEA between 2002 and 2004. Primary prevention represents about half the expenditures, consisting largely of public health expenditures--the largest prevention element. ORIGINALITY/VALUE OF PAPER: Our 2004 estimate that 8.6 percent of NHEA goes to prevention is nearly three times as large as the commonly cited figure of 3 percent, but depends on the definitions used: our estimate falls to 8.1 percent when the research component is excluded, 5.1 percent when consideration is limited to primary prevention plus screening, 4.2 percent for primary prevention alone, and 2.8 percent if we count only public health expenditures. These findings should contribute to a more informed discussion of our nation's allocation of health care resources to prevention.

Purpose: This experimental economics study using brain imaging techniques investigates the risk-ambiguity distinction in relation to the source preference hypothesis (Fox & Tversky, 1995) in which identically distributed risks arising from different sources of uncertainty may engender distinct preferences for the same decision maker, contrary to classical economic thinking. The use of brain imaging enables sharper testing of the implications of different models of decision-making including Chew and Sagi's (2008) axiomatization of source preference.

Methodology/approach: Using fMRI, brain activations were observed when subjects make 48 sequential binary choices among even-chance lotteries based on whether the trailing digits of a number of stock prices at market closing would be odd or even. Subsequently, subjects rate familiarity of the stock symbols.

Findings: When contrasting brain activation from more familiar sources with those from less familiar ones, regions appearing to be more active include the putamen, medial frontal cortex, and superior temporal gyrus. ROI analysis showed that the activation patterns in the familiar-unfamiliar and unfamiliar-familiar contrasts are similar to those in the risk-ambiguity and ambiguity-risk contrasts reported by Hsu et al. (2005). This supports the conjecture that the risk-ambiguity distinction can be subsumed by the source preference hypothesis.

Research limitations/implications: Our odd-even design has the advantage of inducing the same "unambiguous" probability of half for each subject in each binary comparison. Our finding supports the implications of the Chew-Sagi model and rejects models based on global probabilistic sophistication, including rank-dependent models derived from non-additive probabilities, e.g., Choquet expected utility and cumulative prospect theory, as well as those based on multiple priors, e.g., alpha-maxmin. The finding in Hsu et al. (2005) that orbitofrontal cortex lesion patients display neither ambiguity aversion nor risk aversion offers further support to the Chew-Sagi model. Our finding also supports the Levy et al. (2007) contention of a single valuation system encompassing risk and ambiguity aversion.

Originality/value of chapter: This is the first neuroimaging study of the source preference hypothesis using a design which can discriminate among decision models ranging from risk-based ones to those relying on multiple priors.