Health Care Payment Systems: Cost and Quality Incentives

This paper compares the cost and quality incentive effects of cost reimbursement and prospective payment systems in the health industry. When a provider cannot refuse patients who require high treatment costs or discriminate patients by qualities, optimally designed prospective payments can implement the efficient quality and cost reduction efforts, but cost reimbursement cannot induce any cost incentive. When the provider can refuse expensive patients, implementation of the first best requires a piecewise linear reimbursement rule that can be interpreted as a mixture of pure prospective payment and pure cost reimbursement, Under appropriate conditions, prospective payment can implement the first best even when the provider can use qualities to discriminate patients.     

Health-Care Payment Systems: Cost and Quality Incentives—Comment

This note analyzes the incentives for cost reduction that different payment policies provide to profit-maximizing health-care providers. Ching-to Albert Ma (1994) proposes a reimbursement mechanism that seeks to induce first-best cost reduction by using a combination of cost reimbursement and prospective payment in a model where higher effort on the part of the health-care provider reduces treatment costs. This note shows that a mechanism of this type, generally, will not result in first-best cost reduction. However, such a mechanism is optimal when the payer has efficiency and distributional concerns.     

Hospital Reimbursement Incentives: An Empirical Analysis

Reimbursement systems for health-care providers are very complex, like the production systems that they regulate. This complexity has led to some important misperceptions about the incentive consequences of major reimbursement reforms. One example is the prospective payment system (PPS), developed to provide "high-powered" incentives through fixed prices for hospital admissions for the US elderly. In fact, various features of the DRG system allow reimbursement to vary with actual treatment decisions during an admission, and so are not prospective. This paper develops a general method for measuring actual reimbursement incentives in complex regulated price systems. The method uses regression techniques with variance decompositions to quantify the effects of particular features of the payment system on prospective and retrospective cost sharing, as well as overall generosity of payments. I apply this method to microdata on 20 percent of Medicare hospital admissions in 1987 and 1990 to summarize the incentives created by PPS in practice, and how the incentives are evolving over time. I show that PPS involves limited and decreasing cost sharing with hospitals, most of which is not prospective. The reimbursement incentives vary substantially across diagnoses, demographic groups, and types of intensive treatments, possibly with important implications for hospital behavior and medical expenditure growth. The techniques developed here can be used to analyze a broad range of provider reimbursement mechanisms.     

Measuring Hospital Cost-Sharing Incentives Under Refined Prospective Payment

This paper evaluates the usefulness of a model (McClellan, 1997) that was recently proposed for measuring reimbursement incentives under ongoing refinements to the hospital prospective payment system. The model is applied to a single major disease category (HIV infection) for which the hospital reimbursement system has undergone dramatic refinements in recent years. The paper highlights a problem in the original specification, namely, the use of endogenous costs as an explanatory variable. The paper illustrates how hospital response to both marginal price incentives (e.g., a change in the supply of payment-related services) and average price incentives (e.g., a change in the supply of non-payment-related services) can cause either over-or underestimation of payer cost sharing. In the present case study, overestimation of the marginal reimbursement incentives was evidenced. Obtaining cost-sharing estimates that can be used to evaluate alternative payment classification systems requires controlling for endogenous changes in hospital behavior.     

Payer Competition and Cost Shifting in Health Care

This paper studies a model in which two payers contract with one hospital. True costs per patient are not a possible basis for payment, and contracts can only be written on the basis of allocated cost. Payers choose a contract that is fully prospective or fully based on cost allocation, or a payment scheme that would give some weight to each of these two. We characterize the payers'equilibrium contracts arid show how in equilibrium hospital input decisions are distorted by the payers' incentives to engage in cost shifting. Two cost-shifting incentives work in opposite directions, and equilibrium can be characterized by too little or too much care relative to the socially efficient level.     

Creating an efficient market for nursing home care.

This paper reviews the theoretical foundations of the common Medicaid nursing home reimbursement systems: Reasonable cost related, fixed rate and negotiated rate reimbursement. Each reimbursement system is examined in terms of the four reimbursement system design goals: allocative efficiency, appropriateness of care, quality of care and equity of economic rewards. None of the reimbursement approaches are found to be deficient on the theoretical level, but practical problems of implementation are shown to be very difficult. As an alternative, a competitive binding system is proposed which would bring competitive market efficiency to the allocation of Medicaid funds for nursing home care. A mathematical programming model is developed to process the bidding information and to allocate Medicaid funds to nursing homes.     

施工企业单项工程成本控制

本文围绕防范风险、提高效益,对单项工程项目策划、实施准备、工程实施、结算支付四个业务阶段成本控制流程进行了探讨,通过整合工程项目、业务外包、采购业务、合同管理、资产管理、资金活动等六个主要业务领域,构建单项工程成本控制框架体系。     

多渠道缴费系统设计与实现

为了满足电力用户简单、方便、快捷的电力服务需求,同时解决电力企业电费回收难,电费结零率低等问题,需要对多渠道缴费进行研究,包括从系统的需求分析、系统设计到系统实现。本文提出了多渠道缴费的目前状况、应用的意义、解决的问题,并给出了多渠道缴费系统的设计与实现。目前,该系统已经投入运行。     

A new approach to optimal selection of services in health care organizations.

A new reimbursement policy adopted by Medicare in 1983 caused financial difficulties for many hospitals and health care organizations. Several organizations responded to these difficulties by developing systems to carefully measure their costs of providing services. The purpose of such systems was to provide relevant information about the profitability of hospital services. This paper presents a new method of making hospital service selection decisions: it is based on an optimization model that avoids arbitrary cost allocations as a basis for computing the costs of offering a given service. The new method provides more reliable information about which services are profitable or unprofitable, and it provides an accurate measure of the degree to which a service is profitable or unprofitable. The new method also provides useful information about the sensitivity of the optimal decision to changes in costs and revenues. Specialized algorithms for the optimization model lead to very efficient implementation of the method, even for the largest health care organizations.     

Revision of the CPI hospital services component

Upcoming modifications are designed to capture current service delivery patterns, reimbursement methods, and payment sources for hospital visits, rather than what the hospital charges for individual treatment inputs; the result will be an index that better reflects price changes in the dynamic health care field.     

The determinants of nursing home costs in Nebraska's proprietary nursing homes.

In the past few years nursing home care expenditures in Nebraska and the U.S. have been the fastest growing component of total health care expenditures. This rate of increase is particularly alarming in view of the fact that nursing home care is financed primarily by the Medicaid program or direct out-of-pocket payments. In fact, given the cutbacks in federal and state funds for this program, consumers will be forced to allocate a larger share of their income to meet the costs of nursing home care. Although nursing home expenditures have grown at an extremely rapid rate, relatively few empirical studies exist which analyze the cost function of nursing home providers. The purpose of this study is to identify factors which have directly influenced the cost of nursing home care in Nebraska and to evaluate the current Nebraska Medicaid reimbursement system in terms of its impact upon nursing home costs. The study was limited to a sample of 40 nursing homes in Nebraska which represents 42% of the total proprietary nursing homes in the state. The sample was limited to those facilities licensed only as an Intermediate Care Facility--I and they had to be receiving some Medicaid revenue. The data were averaged over the period of 1977-79, but the year of analysis corresponded to 1978. Multiple regression analysis was used to measure the effect of the hypothesized independent variables upon two different measures of cost--the average total cost per patient day and the average variable cost per patient day. In the first regression model 76% of the variance was explained and 71% was explained in the second equation. The results of this analysis are basically consistent with the findings of other studies and indicate that the number of staffing hours, patient mix, facility age, administrator experience and administrative intensity are significant determinants of nursing home costs. The most important finding from a policy perspective is that the current retrospective cost-related Medicaid reimbursement system does not provide incentives for minimizing costs. In fact, the present system encourages administrators to overutilize resources and charge higher prices. Considerable evidence exists which suggests that a prospective system would encourage a more efficient allocation of resources without adversely affecting the quality of care. Given the increase in the state's share of the total Medicaid budget, it would appear that a change to a prospective system is critical in order to maintain the financial accessibility to nursing home care by all Nebraska residents.     

How to Regulate Heterogeneous Hospitals?

In many areas of health care financing, there is controversy over the sources of cost variability and about the respective roles of inefficiency versus legitimate heterogeneity. This paper proposes a payment system that creates incentives to increase hospital efficiency when hospitals are heterogeneous, without reducing the quality of care. We consider an extension of Shleifer's yardstick competition model and apply an econometric approach to identify and evaluate observable and unobservable sources of cost heterogeneity. Moral hazard can be seen as the result of two components: long‐term moral hazard (hospital management can be permanently inefficient) and transitory moral hazard. The latter is linked to the manager's transitory cost‐reducing effort. For instance, he or she can be more or less rigorous each year when bargaining prices for supplies delivered to the hospital by outside firms. The use of a three‐dimensional nested database makes it possible to identify transitory moral hazard and to estimate its effect on hospital cost variability. Econometric estimates are performed on a sample of 7,314 stays for acute myocardial infarction observed in 36 French public hospitals over the period 1994–1997. We obtain two alternative payment systems. The first takes all unobservable hospital heterogeneity into account, provided that it is time invariant, whereas the second ignores unobservable heterogeneity. Simulations show that substantial budget savings—at least 20%—can be expected from the implementation of such payment rules. The first method of payment has the great advantage of reimbursing high‐quality care. It leads to substantial potential savings because it provides incentives to reduce costs linked to transitory moral hazard, whose influence on cost variability is far from negligible. This payment rule could be extended to other areas of health care financing, such as Adjusted Average Per Capita Cost to calculate Medicare Managed Care reimbursements in the United States.     

Reimbursement as a tool to reduce sabotaging in rent‐seeking contests

We study standard rent‐seeking contests with reimbursement and sabotaging. This study is conducted for a symmetric model with complete information. We show that changing the contest mechanism by applying a form of reimbursement could be an effective tool against sabotaging, in addition to the fact that it increases contest designer revenue. Simple changes such as sufficient reimbursement to winners/losers might completely stop sabotaging efforts in the contest.     

Modelling the effects of price competition on the utilization of health manpower.

The introduction of diagnosis related groups (DRGs) and resource utilization groups (RUGs) for implementing prospective reimbursement is virtually certain to increase the cost-consciousness of hospital and nursing home administrators. One potential area for cost reduction is in nurse staffing. In this paper, we describe a model which identifies minimum cost nurse staffing patterns subject to constraints on patient needs, mandated staffing requirements, and labor availability, and which is also sensitive to quality considerations. We use the model to predict shifts in nursing patterns at an upstate New York nursing home. To the degree to which this model and this nursing home are typical, we foresee general reductions in the numbers of RNs and LPNs, compensated for by an increase in the number of Aides, and cost savings in the 5-10% range. We also demonstrate that the magnitudes of these changes will depend on the tradeoff between quality and cost considerations, and will certainly vary across facilities.     

Hesitation and rapid action: the new public management reforms in the Norwegian hospital sector

This paper focuses on the transition of governmental management innovations from the national, political level to the local, institutional level. In order to throw some light on the complex process of two-level reforms in public sector financial management, I discuss the case of introducing prospective payment systems in Norwegian hospitals during 1987–1999. The empirical studies are based on official documents and statistics at the national level together with surveys and case studies with a view to understand how hospitals adjust to the new payment systems. The main finding can be described in terms of slow adjustments on the institutional level, and slow and rapid action on the political level. These systemic interactions between different logics at the different levels may obstruct the implementation of reforms.     

考虑无转移支付的VMI系统Pareto改进

收益共享机制下的转移支付是影响供应商积极实施VMI的关键因素。在当前处于强势地位的下游企业不愿意提供转移支付的情况下,如何实现VMI系统的Pareto改进呢?将转移支付成本与物流供应商采用业务延伸策略为项目型企业提供终端产品所产生的成本领先优势进行比较发现,业务延伸策略下的VMI既弥补了无转移支付对供应商所造成的经济损失,又帮助项目型企业节省了实施自我服务策略时所投入的相关成本,如库存成本和加工设备成本,从而实现了VMI系统的Pareto改进。     

Using Subjective Risk Adjusting to Prevent Patient Dumping in the Health Care Industry

We examine how to procure health care services at minimum cost while preventing suppliers from refusing to care for high-cost patients. A single risk-adjusted prospective payment is optimal only when it is particularly costly for the supplier to discover likely treatment costs. Cost sharing is optimal when these screening costs are somewhat smaller. When screening costs are sufficiently small, screening is optimally accommodated and subjective risk adjusting is implemented. Under subjective risk adjusting, the supplier classifies patients according to his personal assessment of likely treatment costs, and payments are structured accordingly. Optimal procurement policies are contrasted with prevailing industry policies.     

实施国库集中支付对科研事业单位财务管理的影响与建议

实施国库集中支付改革以来,给科研事业单位的财务管理产生了多方面的正面效应,但也带来了一些新问题。本文从实施国库集中支付以来的积极作用与现存问题的改进与完善两方面提出一些建议,以求进一步加强和提高科研事业单位的财务管理水平。     

浅谈工程项目成本管理

建筑企业的成本管理控制过程是保证目标成本实现的关键,责任成本管理的关键是抓好成本形成过程的控制。在施工生产过程中,必须严格控制和监督各项成本支出,使成本支出始终置于受控状态,保证成本目标的实现。施工企业在项目施工过程中,提高管理水平,加强经济核算,努力控制成本,赢得更多的利润。     

Public good provision and the Smith Process

An existing public good provision mechanism known as the Smith Process (SP) is extended to allow for non-zero fixed cost, non-constant marginal cost and imperfectly divisible output. Two versions of SP are considered: unrestricted (USP) and restricted with a unanimity rule (RSPU). USP implements efficient choice provided the gap between marginal and average cost is sufficiently low. RSPU relaxes the conditions for efficient implementation but increases the set of equilibria involving inefficient choice. Furthermore, if weakly dominated strategies are eliminated, then non-provision is no longer an equilibrium under RSPU but continues to be one under USP.