"Quicker and sicker" under Medicare's prospective payment system for hospitals: new evidence on an old issue from a national longitudinal survey

Medicare's prospective payment system for hospitals (PPS), introduced in the USA in 1983, replaced cost reimbursement with a system of fixed rates which created incentives for hospitals to control costs. Previous studies found that elderly patients were discharged from hospital "quicker and sicker" under PPS and concluded that families were coping at home. We analyse a national longitudinal survey, the first National Health and Nutrition Examination Survey and its Epidemiologic Followup Study, which includes data on more outcomes over a longer period than earlier studies. We find that the rate of admission to nursing homes from the community in the first weeks after a hospital discharge more than tripled under PPS, suggesting that families were not always able to cope. As another response to sicker patients, discharges directly to nursing homes from hospitals, which jumped initially under PPS, may have risen further when payment rates were tightened in the early 1990s. Hospital readmissions fell after the first few years. Our findings are strengthened by the fact that we control for patients' health using health information collected independently of hospital admission.     

State versus private provision: How does China’s market‐oriented reform affect healthcare delivery?

The role of the government in health care provision remains a contested issue worldwide. Public hospitals dominate China’s health care industry. However, in the early 2000s, the eastern China city of Suqian privatized all its hospitals and relaxed entry barriers for private hospitals. We assess the impact of the pro‐market reform on hospital performance using a differences‐in‐differences approach. We find that the pro‐market reform decreased medical price and expenditure, improved self‐reported health outcomes, and reduced search time and cost for patients. We show that after the reform, Suqian residents had greater trust in doctors than did residents from other cities.     

Estimating the benefit of high school for university‐bound students: evidence of subject‐specific human capital accumulation

Numerous studies suggest that the value of high school education is large for potential dropouts, yet we know much less about the benefits for students who will go on to post‐secondary education. To help fill this gap I measure, using a recent Ontario high school reform, the value‐added (in terms of university grades) of an extra year of high‐school mathematics for university‐bound students. The estimated benefit is small for these students: 2.3 points on a 100‐point scale. This evidence helps to explain why the literature has found only modest effects of taking more mathematics in high school on wages.     

The effects of upcoding,cream skimming and readmissions on the Italian hospitals efficiency: A population-based investigation

In this paper we analyze the effects of some distortions induced by the prospective payment system, i.e. upcoding, cream skimming and readmissions, on hospitals' technical efficiency. We estimate a production function using a population-based dataset composed by all active hospitals in an Italian region during the period 1998–2007. We show that cream skimming and upcoding have a negative impact on hospitals' technical efficiency, while readmissions have a positive effect. Moreover, the results indicate that private hospitals engage more in cream skimming than public and not-for-profit ones, while we observe no ownership differences regarding upcoding. Not-for-profit hospitals have the highest readmission index. Last, not-for-profit and public hospitals have the same efficiency levels, while private hospitals have the lowest technical efficiency.     

Optimal Taxation: The Design of Child‐Related Cash and In‐Kind Benefits

Abstract. In this paper, we empirically derive the welfare function that guarantees that the current German tax and transfer system for single women is optimal. In particular, we compare the welfare function conditional on the presence and age of children and assess how recent reforms of in‐kind childcare transfers affect the welfare function. Our analysis is based on a discrete model of optimal taxation. We apply this framework using microsimulation and microeconometric techniques. In general, we find that marginal welfare weights are relatively high for non‐working single women. Further, we show that the reform of in‐kind childcare transfers is only optimal if society increases the marginal welfare weights for the working single women.     

Willingness‐to‐pay for parallel private health insurance: evidence from a laboratory experiment

Abstract Debate over the effects of public versus private health care finance persists in both academic and policy circles. This paper presents the results of a revealed preference laboratory experiment that tests how characteristics of the public health system affect a subject's willingness‐to‐pay (WTP) for parallel private health insurance. Consistent with the theoretical predictions of Cuff et al. (2010), subjects’ average WTP is lower and the size of the private insurance sector smaller when the public system allocates health care based on need rather than randomly and when the probability of receiving health care from the public system is high.     

Self‐rated Health Status of Japanese and Europeans in Later Life: Evidence from JSTAR and SHARE

Using panel data from two surveys in Japan and Europe, we examine the comparability of the self‐rated health of the middle‐aged and elderly across Japan and European countries and across the survey periods. We find that a person's own health is evaluated using different standards (thresholds) across the different countries and survey waves. When evaluated using common thresholds, the Japanese elderly are found to be healthier than their counterparts in the European countries. Reporting biases causing discrepancies between the changes in individuals' self‐rated health and their actual health over the survey waves are associated with education and country of residence.     

Interlinkage and Generous Tit‐for‐Tat Strategy

We investigate an infinitely‐repeated prisoners' dilemma with imperfect monitoring and consider the possibility that the interlinkage of the players' distinct activities enhances implicit collusion. We show a necessary and sufficient condition for the existence of a generous tit‐for‐tat Nash equilibrium. Such an equilibrium, if it exists, is unique. This equilibrium achieves approximate efficiency when monitoring is almost perfect, where the discount factors are fixed.     

The internal market and hospital efficiency: a stochastic distance function approach

The UK internal market was one of the first European attempts to introduce a competitive mechanism in the provision of hospital services. The assumption was that competition would have led hospitals to increase efficiency in the use of their resources. The aim of this paper is to analyse the effectiveness of this kind of reform by measuring the changes in technical efficiency of a panel of 52 acute Scottish hospitals observed from 1991/92 to 1996/97. The time period covers the whole duration of the internal market and the sample contains a different mix of both trusts and non-trusts, where the former embed the proper working of the reform. The selected model is a stochastic output distance function that includes an interaction dummy variable to allow for parameters to change over time. The results show a structural break after which hospitals change not only the way in which they provide their services, but also the kind of services they provide, favouring the quicker treatment of patients on a day basis. No significant improvement in technical efficiency is detected instead over time, nor any significant difference in efficiency between trusts and non-trusts.     

Design of reforms with time‐inconsistent voters

Widespread agreement that a political reform is necessary is no guarantee that it is actually undertaken in a timely manner. There is often a delay before action is taken and reform packages that would be most efficient to implement all at once are often done only gradually. We propose a theoretical model explaining this behavior and show that when voters have present‐biased, time‐inconsistent preferences, gradualism can arise in equilibrium and be welfare‐enhancing. This is because without the possibility for gradualism, time‐inconsistent voters would delay implementing the reform even more. Using a citizen candidate model, we allow the agenda setter, who decides which reform schedule to put to vote, to be endogenously determined. We show that voters who are aware of their own time inconsistency can use the election of the agenda setter as a commitment device and appoint an agent who is more patient than the median voter in order to avoid full procrastination and to achieve efficiency‐maximizing gradualism.     

A ‘technically level playing-field’ profit efficiency analysis of enforced competition between publicly funded institutions

The study demonstrates how recent advances in the data envelopment analysis (DEA) of profit efficiency, and in combining DEA and stochastic frontier analysis (SFA) to measure producer performance, can be used to obtain a ‘technically level playing-field’ profit efficiency performance measure. A three-stage analysis is used to provide an empirical investigation of public-sector universities facing regulatory pressures to attain both profit efficiency and output quality. Stage one employs directional distance function analysis to decompose DEA profit efficiency measures into technical and allocative components. As these performance measures incorporate the impacts of managerial inefficiency, the operating environment and luck (statistical noise), stage two applies SFA to total (radial and non-radial) slacks to obtain a degree of disentanglement from the latter two impacts. The stage-two results are used to define a common environment and common luck scenario, thus permitting university producers’ inputs to be adjusted so as to reflect operation within this more level playing-field scenario. Stage three recomputes the first-stage DEA for this scenario, to yield an (input-focused) ‘technically level playing-field’ measure of profit efficiency that unifies the regulatory financial audit and output-quality indicators in a single, best-practice-benchmarked, performance measure.     

The impact of microcredit on self‐employment profits in Vietnam

This study examines the impact of microcredit on household self‐employment profits in Vietnam. For two indicators of credit participation – a dichotomous participation dummy and the accumulated amount of microcredit received per household – the analysis reveals a positive effect on household profits. The analysis also reveals that an instrumental variable method within a fixed‐effects framework can control for the possible endogeneity of credit and thereby identify the true effect of credit.     

Measuring the Consistency of Cross‐Sectional and Longitudinal Income Information in EU‐SILC

The EU‐wide survey “Statistics on Income and Living Conditions” (EU‐SILC) is extremely important for international social science research and policy advice. It is therefore crucial to ensure that the data are of the highest quality and international comparability. This paper is aimed at identifying unexpected developments in income levels, income mobility, and inequality in the EU‐SILC data between 2005 and 2009. We examine the consistency of EU‐SILC by comparing cross‐sectional results with findings based on two‐year longitudinal samples. Although the data represent similar populations, for several countries the results of this comparison differ widely. One important outcome is the high degree of variability over time in countries that obtain their income information from register data. This suggests methodological challenges in the clear designation of new subsample members, in the reweighting of the data, in imputation of missing values, and in other areas.     

Competition and waiting times in hospital markets

This paper studies the impact of hospital competition on waiting times. We use a Salop-type model, with hospitals that differ in (geographical) location and, potentially, waiting time, and two types of patients: high-benefit patients who choose between neighbouring hospitals (competitive segment), and low-benefit patients who decide whether or not to demand treatment from the closest hospital (monopoly segment). Compared with a benchmark case of monopoly, we find that hospital competition leads to longer waiting times in equilibrium if the competitive segment is sufficiently large. Given a policy regime of hospital competition, the effect of increased competition depends on the parameter of measurement: Lower travelling costs increase waiting times, higher hospital density reduces waiting times, while the effect of a larger competitive segment is ambiguous. We also show that, if the competitive segment is large, hospital competition is socially preferable to monopoly only if the (regulated) treatment price is sufficiently high.     

Hospital Competition with Soft Budgets

We study the incentives for quality provision and cost efficiency for hospitals with soft budgets, where the payer can cover deficits or confiscate surpluses. While a higher bailout probability reduces cost efficiency, the effect on quality is ambiguous. Profit confiscation reduces both quality and cost efficiency. First‐best is achieved by a strict no‐bailout and no‐profit‐confiscation policy when the regulated price is optimally set. However, for suboptimal prices, a more lenient bailout policy can be welfare‐improving. When we allow for heterogeneity in costs and qualities, we also show that a softer budget can raise quality for high‐cost patients.     

Heroin Consumption,Prices and Addiction: Evidence from Self‐reported Panel Data*

Estimation models of drug demand should encompass the aspect of addiction. Here, we consider two static panel data regression models and two cross‐section models with lags or leads in drug consumption as additional regressors. Heroin injectors attending a needle exchange service in Oslo were interviewed twice, with a one‐year interval. Despite our relatively small sample, we obtain statistically significant price and income responses for nearly all of the models and specifications applied. The sample is split by dealing status, with dealers obtaining price elasticities in the range of [?0.15, ?1.51] and non‐dealers [?0.71, ?1.69]. Somewhat surprisingly, the estimates of the variance of the latent individual‐specific variable are rather low in the panel data models, although higher for non‐dealers than for dealers.     

A dynamic‐efficiency rationale for public investment in the health of the young

In this paper we assume away standard distributional and static‐efficiency arguments for public health and instead seek a dynamic efficiency rationale. We study a lifecycle model wherein young agents make health investments to reduce mortality risk. We identify a welfare rationale for public health under dynamic efficiency and exogenous mortality even when private and public investments are perfect substitutes. If health investment reduces mortality risk but individuals do not internalize its effect on the life‐annuity interest rate, the “Philipson‐Becker effect” emerges; when the young are net borrowers, this works together with dynamic efficiency to support a role for public health.     

A NON‐PARAMETRIC MEASURE OF POVERTY ELASTICITY

We estimate the growth elasticity of poverty (GEP) using recently developed non‐parametric panel methods and the most up‐to‐date and extensive poverty data from the World Bank, which exceeds 500 observations in size and represents more than 96 percent of the developing world's population. Unlike previous studies which rely on parametric models, we employ a non‐parametric approach which captures the non‐linearity in the relationship between growth, inequality, and poverty. We find that the growth elasticity of poverty is higher for countries with fairly equal income distributions, and declines in nations with greater income disparities. Moreover, when controlling for differences in estimation technique, we find that the reported values of the GEP in the literature (based on the World Bank's now‐defunct 1993‐PPP based poverty data) are systematically larger in magnitude than estimates based on the latest 2005‐PPP based data.     

THE MICRO‐DYNAMICS OF CATCH‐UP IN INDONESIAN PAPER MANUFACTURING

In this study we analyze the micro‐dynamics of catch‐up in Indonesian paper manufacturing, using a two‐country plant‐level dataset for the period 1975–97. We apply data envelopment analysis (DEA) to measure to what extent Indonesian paper mills are catching up with Finnish mills in terms of technical efficiency. Three questions are addressed: What is the distribution of Indonesian plant technical efficiency vis‐à‐vis the technological frontier? What is the role of entry, exit, and survival in Indonesia for catch‐up in the paper industry as a whole? In what ways do catching‐up plants in Indonesia differ from non‐catching‐up plants? We find that on average the Indonesian paper industry moved closer to the technological frontier during the 1990s. However, catch‐up has been a highly localized process in which only a few large establishments have achieved near best‐practice performance, while most other plants have stayed behind.     

GAUGING THE SOURCES OF GROWTH OF HIGH‐TECH AND LOW‐TECH INDUSTRIES: THE CASE OF KOREAN MANUFACTURING*

Literature argues that the source of growth for high‐tech industries emanates from technological progress, while that for low‐tech industries comes from technical efficiency improvement. Also, some empirical studies have shown that technological progress is often accompanied by deterioration in technical efficiency. The focus in this study is to discuss a methodology and test the above two hypotheses with regard to Korean manufacturing data from 1970 to 1997. The study found that the 2.5 per cent average annual rate of technological progress during this period was the major contributor to total factor productivity (TFP) growth in Korean manufacturing whereas technical efficiency grew by a modest 1.1 per cent per annum. The analysis also showed that technological progress was responsible for TFP growth in both high‐tech and low‐tech industries and that both technological progress and technical efficiency improvement co‐existed in the case of Korean manufacturing industries.