The tax implications of cost shifting in cost-benefit analysis in mental health

This paper examines the tax implications of systems of care for psychiatric patients that rely more on the provision of services in the community rather than in state hospitals. State governments pay the costs of patient care in state hospitals, but share costs with the federal government (via Medicaid) for community based care. Taxes create distortions as gauged by the marginal cost of public funds (MCF). Since state and federal governments use different tax mixes, one needs a MCF for each form of government to evaluate system changes. Separate estimates of the MCF for each state in the USA are derived. Only for Alaska is cost shifting welfare improving.     

Utilization and cost comparison of erythropoiesis-stimulating agents in inpatient and outpatient hospital settings

Abstract

Objective:

To compare utilization and associated costs of epoetin alfa (EPO) and darbepoetin alfa (DARB), two erythropoiesis-stimulating agents (ESAs), in patients with cancer undergoing chemotherapy and patients with chronic kidney disease (CKD) not on dialysis in inpatient and outpatient hospital settings.

Methods:

An analysis of medical claims recorded between January 2006 and December 2009 was conducted using the Premier Perspective Comparative Hospital database. Patients included were ≥18 years old with cancer and chemotherapy or with pre-dialysis CKD and with ≥1 claim for EPO or DARB during a hospital inpatient or outpatient treatment episode. Patients treated with both ESAs or who were receiving dialysis were excluded. Mean cumulative drug costs and dose ratios (units EPO: mcg DARB) were calculated using cumulative dose and April 2010 wholesale acquisition costs.

Results:

Cancer chemotherapy: 13,832 inpatient stays (EPO: 10,454; DARB: 3378) and 5590 outpatient treatment episodes (EPO: 2856; DARB: 2734) were identified. The inpatient and outpatient populations reported ESA dose ratios of 230:1 and 238:1 with DARB cost premiums of 42% (EPO: $948; DARB: $1348) and 38% (EPO: $3358; DARB: $4627), respectively. CKD: 148,746 hospital stays (EPO: 116,017; DARB: 32,729) and 11,012 outpatient treatment episodes (EPO: 6921; DARB 4091) were identified. The inpatient and outpatient populations reported ESA dose ratios of 251:1 and 257:1 with DARB cost premiums of 30% (EPO: $566; DARB: $738) and 27% (EPO: $2077; DARB: $2642), respectively.

Limitations:

The lack of randomization may have led to confounding by indication. In addition, statistical significance must be interpreted with caution in studies involving large samples.

Conclusions:

This study of 19,422 patients with cancer receiving chemotherapy and 159,758 patients with pre-dialysis CKD reported ESA dose ratios ranging from 230:1–257:1 (units EPO: mcg DARB) and associated cost premiums of 27–42% for DARB.     

Procedural volume,cost, and reimbursement of outpatient incisional hernia repair: implications for payers and providers

Objective: This analysis aimed to evaluate trends in volumes and costs of primary elective incisional ventral hernia repairs (IVHRs) and investigated potential cost implications of moving procedures from inpatient to outpatient settings.

Methods: A time series study was conducted using the Premier Hospital Perspective^® Database (Premier database) for elective IVHR identified by International Classification of Diseases, Ninth revision, Clinical Modification codes. IVHR procedure volumes and costs were determined for inpatient, outpatient, minimally invasive surgery (MIS), and open procedures from January 2008–June 2015. Initial visit costs were inflation-adjusted to 2015?US dollars. Median costs were used to analyze variation by site of care and payer. Quantile regression on median costs was conducted in covariate-adjusted models. Cost impact of potential outpatient migration was estimated from a Medicare perspective.

Results: During the study period, the trend for outpatient procedures in obese and non-obese populations increased. Inpatient and outpatient MIS procedures experienced a steady growth in adoption over their open counterparts. Overall median costs increased over time, and inpatient costs were often double outpatient costs. An economic model demonstrated that a 5% shift of inpatient procedures to outpatient MIS procedures can have a cost surplus of?～?US $1.8 million for provider or a cost-saving impact of US $1.7 million from the Centers for Medicare &; Medicaid Services perspective.

Limitations: The study was limited by information in the Premier database. No data were available for IVHR cases performed in free-standing ambulatory surgery centers or federal healthcare facilities.

Conclusion: Volumes and costs of outpatient IVHRs and MIS procedures increased from January 2008–June 2015. Median costs were significantly higher for inpatients than outpatients, and the difference was particularly evident for obese patients. A substantial cost difference between inpatient and outpatient MIS cases indicated a financial benefit for shifting from inpatient to outpatient MIS.     

The Commonwealth Grants Commission and Horizontal Fiscal Equalisation

The role and approach of the Commonwealth Grants Commission are outlined and put into perspective for the review of Federal financial relations being undertaken by Ross Garnaut and Vince FitzGerald.     

Debt shifting and ownership structure

Previous theoretical studies on the debt shifting behavior of multinationals have assumed affiliates of multinationals to be wholly owned. We develop a model that allows a multinational firm to determine both the leverage and ownership structure in affiliates endogenously. A main finding is that affiliates with minority owners have less debt than wholly owned affiliates and therefore a less tax-efficient financing structure. This is due to an externality that arises endogenously in our model, where costs and benefits of debt shifting are shared asymmetrically between minority and majority owners. Our findings provide a theory framework for recent empirical findings.     

控股股东、政府补助与盈余质量

本文以我国上市公司2002-2005年的数据检验了控股股东持股或实际控制人性质、政府补助以及盈余质量之间的关系.研究表明,在多数年份,控股股东持股比例与修正的盈余反应系数正相关,企业的实际控制人是国有股东时,盈余信息含量更高;控股股东在某些年份确实通过政府补助影响了盈余质量,控股股东通过政府补助提高了盈余,却降低了盈余质量,用股权的激励效应解释控股股东和盈余质量的关系并不完全合适.     

Time-driven activity-based cost analysis for outpatient anticoagulation therapy: direct costs in a primary care setting with optimal performance

Objectives: To determine how overall cost of anticoagulation therapy for warfarin compares with that of Novel Oral Anticoagulants (NOACs). Also, to demonstrate a scientific, comprehensive, and an analytical approach to estimate direct costs involved in monitoring and management of anticoagulation therapy for outpatients in an academic primary care clinic setting, post-initiation of therapy.

Methods: A population-based cross-sectional study was conducted in conjunction with observations of patient care processes between August 2014 and January 2015. The study was conducted in an academic primary care outpatient setting at Mayo Clinic’s warfarin anticoagulation clinic, Rochester, MN. The anticoagulation clinic serves patients 18?years of age or older in Warfarin therapy management, for any indication, after referral from the patient’s primary care provider. The study included anticoagulation clinic enrollment data on a population of 5,526 patients. Time-Driven Activity-Based Costing (TDABC) technique was applied. Detailed process flow maps which showed process steps for all the anticoagulation program components and care continuum phases were created. Staff roles associated with each of the process steps were identified and displayed on the maps. Process times and costs were captured and analyzed. The main outcome was direct cost of monitoring and management of anticoagulation therapy, post-initiation of therapy.

Results: The cost of warfarin management for patients who display unstable International Normalized Ratio (INR) is more than three times those who display stable INR over time. (Comparator to distinguish stability: Frequency of point-of-care visits needed by patients.) For complex anticoagulation patients, total cost of medication and monitoring for warfarin anticoagulation therapy is similar to that for NOACs.

Conclusion: Despite warfarin being significantly less expensive to purchase than NOACs, overall warfarin management incurs higher costs due to laboratory monitoring and provider time than NOACs. NOAC treatment, therefore, may not be more expensive than warfarin therapy management for complex anticoagulation patients.     

支持卓越研究的加拿大发现资助计划及其启示

本文研究分析了加拿大自然科学与工程研究理事会的发现资助计划,研究了发现资助计划的特色、预算、遴选标准。通过它对世界级最好研究人员的支持、设立“发现加速器奖”和它资助研究产生的国际影响三个方面,重点研究了该计划对卓越研究的支持。希望对我国研究计划的设立有一些启示。     

Tax enforcement and corporate profit shifting

We present empirical evidence suggesting that weak tax enforcement proxied by the extent of tax evasion in a country acts like a lower corporate tax rate in attracting profits of multinational corporations.     

Specific Purpose Payments and the Commonwealth Grants Commission*

The Commonwealth Grants Commission has, over the past ten years, been concerned with assessing the per capita relativities to be applied to the distribution of general revenue grants to the States in Australia to achieve fiscal equalization. In arriving at these assessments, the Commission has developed a number of approaches to the treatment of specific purpose payments. It is argued that one of these approaches – the inclusion approach – has an overriding effect which may place fiscal equalization in conflict with other objectives of Commonwealth policy. The nature of this conflict and its management are then explored     

Assessing the economic value of avoiding hospital admissions by shifting the management of gram+ acute bacterial skin and skin-structure infections to an outpatient care setting

Abstract

Objective:

To estimate, from a US payer perspective, the cost offsets of treating gram positive acute bacterial skin and skin-structure infections (ABSSSI) with varied hospital length of stay (LOS) followed by outpatient care, as well as the cost implications of avoiding hospital admission.     

International debt shifting and multinational firms in developing economies

We present empirical evidence suggesting that the effect of the host country corporate tax rate on the debt ratio of multinational affiliates in developing economies is positive and larger than the same effect for affiliates in developed economies.     

政府资助、现金持有与企业研发平滑研究

当前,我国政府对企业的研发资助快速增加,而在动态经济环境中,更应关注研发活动均衡健康的长期发展（研发平滑）而非短期增长变动。从政府资助视角对企业研发平滑进行重新审视,运用2007-2012年中国工业上市公司数据,采用系统GMM计量方法,对政府资助、现金持有与企业研发平滑进行了综合探析。结果发现：①我国工业上市公司普遍存在通过现金持有管理来平滑研发支出的现象;②当期政府资助对企业研发有促进作用,而持续的政府资助则会间接影响企业现金持有政策,该调节机制最终会对企业研发活动产生平滑作用。     

Economists and the ARC Large Grants Scheme: A Brief Report

We examine awards to economics in recent years under the Australian Research Council (ARC) Large Grants Scheme and speculate briefly on the effects of the new National Competitive Grants Programme. The primary determinant of number of awards by panel is number of applications. While no ARC rule guarantees panels will preserve success-to-application ratios by discipline, this seems a good approximation for economics and many other Social Science panel disciplines, though limited evidence suggests economics assessors give somewhat lower scores. Economics ARC award rates per staff member resemble those in other social sciences but are significantly smaller than those in philosophy, history, biology and chemistry.