The changing distribution of physicians.

Over the past decade the problem of physician distribution has been the object of much research. Most past studies, however, have been cross sectional. In this study, ecological (county level) data for two decades are examined. Six consistent predictors of the physician/population ratio (PPR) were identified: the hospital bed/population ratio, per capita retail sales, percentage male professionals, per cent families with high income, the presence of a medical school and percentage of the population over 65 years of age. The percentage of physicians in group practice, recently lauded as a solution to problems of maldistribution, was found to be negatively related to change in the physician/population ratio. Predictions for more populous counties were found to be more accurate than those for less populous counties. Policy implications are discussed.     

Effects of managed care market penetration on physicians’ labor supply decisions

This paper examines data from a 1991 nationally representative survey of physicians under the age of 45 to evaluate the effects of HMO enrollment growth and the changing demographic composition of the physician work force on physicians’ choice of practice setting (employee versus self-employment) and annual hours of work. Our results indicate that HMO market penetration has a significant negative effect on the probability of self-employment for all physicians and the sub-samples of both specialists and generalists. Furthermore, increasing HMO market share has a significant negative effect on annual hours of work of all physicians and generalists but has only negligible effects on the work effort of specialists. Using these parameter estimates, we predict that a 100% increase in HMO market share decreases the probability of being self-employed by 23.5% for all physicians, 28% for specialists, and 21% among generalists. Controlling for self-employment, a doubling of the percentage of the population enrolled in HMOs reduces the annual hours of work by 4.9% for all physicians and by 6.8% among generalists. In contrast, HMO market penetration has only trivial effects on the work effort of specialists. We also find that the gender gap in hours between male and female physicians still persists. This gap is 17.7 to 19.6% for female physicians with young children, but is much smaller—5.5 to 8.5%—for women without young children.     

Determinants of the rate of home ownership of black relative to white households

This paper investigates the reasons for the lower rate of home ownership of black households compared to white households in urban areas. A model of the demand for owner-occupancy by blacks relative to the demand by whites is formulated and econometrically estimated.The principal finding is that a percentage increase in the mean level of black household incomes produces a larger increase in the relative rate of blacks' home ownership than an equivalent reduction in the price of owner-occupied housing which they face. Although significant effects of within market discrimination against blacks as reflected in higher prices of owner-occupied housing to blacks are found, attempts to associate this price premium with measures of residential segregation were unsuccessful.     

Coping with stress in emergency department physicians through improved patient-flow management

This paper provides a method for the real-time monitoring of job stress in emergency department (ED) physicians. It is implemented in a Decision Support System (DSS) designed for patient-to-physician assignment after triage. Our concept of job stress includes not only the workload but also time pressure and uncertainty. A job stress function is estimated based on the consensus views of ED physicians obtained through a novel methodology involving stress factor analysis, questionnaire design, and the statistical analysis of expert opinions. The resulting stress score enables the assessment of job stress using workload data from the ED physicians’ whiteboard. These data can be used for the real-time measurement and monitoring of ED physician job stress in a stochastic and dynamic environment, which is the main novelty of this method as compared to previous workload and stress measurement proposals. A further advantage of this methodology is that it is general enough to be adapted to physician job stress monitoring in any ED. The use of the DSS for ED patient-flow management reduces job stress and spreads it more evenly among the whole team of physicians, while also improving other important ED performance measures such as arrival-to-provider time and the percentage of compliance with patient waiting time targets. A case study illustrates the application of the methodology for the construction of a stress-score, the monitoring of physician stress levels, and ED patient-flow management.     

Advances in physician profiling: the use of DEA

Insurers, health plans, and individual physicians in the United States are facing increasing pressures to reduce costs while maintaining quality. In this study, motivated by our work with a large managed care organization, we use readily available data from its claims database with data envelopment analysis (DEA) to examine physician practices within this organization. Currently the organization evaluates primary care physicians using a profile of 16 disparate ratios involving cost, utilization, and quality. We employed these same factors along with indicators of severity to develop a single, comprehensive measure of physician efficiency through DEA. DEA enabled us to identify a reference set of “best practice” physicians tailored to each inefficient physician. This paper presents a discussion of the selection of model inputs and outputs, the development of the DEA model using a “stepwise” approach, and a sensitivity analysis using superefficiency scores. The stepwise and superefficiency analyses required little extra computation and yielded useful insights into the reasons as to why certain physicians were found to be efficient. This paper demonstrates that DEA has advantages for physician profiling and usefully augments the current ratio-based reports.     

Some thoughts on reading the physician market

Marketing to physicians is still the key to a hospital's well being. This is anything but an exact science, but it does have its roots in data collection and research. The best way to market to physicians is to meet their expectations of the hospital and seek the cooperation of the physicians in getting the word out on new programs and services to their patients. The more the hospital can promote the physician out front with his or her patients, the more likely it is that those physicians will support the promotional efforts of the hospital.     

Understanding information exchange in healthcare operations: Evidence from hospitals and patients

Coordination – or the information exchange among physicians and hospital staff – is necessary for desirable patient outcomes in healthcare delivery. However, coordination is difficult because healthcare delivery processes are information intensive, complex and require interactions of hospitals with autonomous physicians working in multiple operational systems (i.e. multiple hospitals). We examine how three important variables distinctive of the healthcare operations context – use of IT for dissemination of test results (ITDR) (i.e. electronic health records systems) by physicians and hospital staff, social interaction ties among them, and physician employment – influence information exchange and patient perceptions of their care. Drawing from the literature on process inter-dependencies and coordination, vertical integration and social exchange, we develop and test research hypotheses linking ITDR, social interaction ties and physician employment to information exchange relationship, and information exchange relationship to provider–patient communication. Using a paired sample of primary survey data and secondary archival data from CMS HCAHPS for 173 hospitals in the USA, we find that increased information exchange relationship drives provider–patient communication, and increased social interaction ties drives information exchange relationship. Social interaction ties fully mediates the relationship between ITDR and information exchange relationship. Physician employment amplifies the link between ITDR and social interaction ties, but does not have an effect on the link between ITDR and information exchange. We do not find a direct relationship between ITDR, and information exchange relationship or provider–patient communication.     

Job location and the journey-to-work: An empirical analysis

In this paper we present and estimate a single equation model designed to explain the job-location behaviour of individuals living in a multi-centered metropolitan area. We test the model separately for heads of households and non-heads of households, as well as for the total working population, in order to isolate differences in commuting behaviour between primary and secondary wage earners. The relationships are estimated from 1971 Census, cross-section data using least squares multiple regression.The results of the location equation indicate that wage gradient variables are important determinants of job location for heads of households. On the other hand, non-heads are rather insensitive to the wage gradient. Rather, contrary to the decisions of heads, the job-location choices of non-heads are strongly influenced by socio-economic attributes, notably occupation, family size and age. Clearly, job-location decisions of primary wage earners (usually the household heads) are influenced by earnings-maximizing considerations while secondary earners (non-heads in general) put more weight on other socio-economic factors. The results also suggest that there is a hidden cost associated with uneven directional growth in the Toronto CMA. It is suggestive that urban planning strategies should reflect consideration of the greater desire or need for accessibility on the part of secondary wage earners (non-heads) and the need to balance residential and job opportunities at the extending margin of the urban area.     

Owner-occupied housing in a model of exchange rate determination

This study explores the effect of owner-occupied housing asset holdings on the short and long run determination of exchange rates. In the presence of consumption goods that can simultaneously serve as investment allocation subject to capital gains—such as owner-occupied housing—the general equilibrium model, based on the Obstfeld and Rogoff Redux model, produces exchange rate overshooting both in the presence and in the absence of price rigidities in the markets for final goods. This effect depends on the size of owner-occupied housing expenditures relative to total consumption expenditures, the initial level of housing market inflation, capital gains in housing and other parameters of the model. Depending on parameter values and initial conditions, the model supports the possibility for exchange rate dynamics that include either overshooting or undershooting.     

The elasticity of substitution in urban housing production: A VES approach

Many of the models which have been developed to explain urban spatial structure and land-use patterns rest on the properties of production functions. Differing factor price ratios within urban areas, particularly land prices, result in capital-land ratios exemplified by high-rise apartments and single-family dwellings. The purpose of this paper is to explore a new functional form for the housing production function. Specifically, a variable elasticity of substitution production function is proposed and some preliminary empirical evidence is provided using data for single-family housing.     

General practitioners' choice of referral destination: A probit analysis

Following the major reforms of the UK health service in 1990, general practitioners (primary care physicians) have been able to purchase specialist care from any hospital they choose. To date, little research has been conducted with respect to the decision process by which such hospitals are chosen. Based on the results of a questionnaire survey conducted in central England and using probit analysis, the significant arguments in practitioners' decision functions are identified. Locality and clinical variables emerge as being considerably more important than price in determining referral destination.     

A model for dual health care market with congestion differentiation

The French market for specialist physician care has a dual legal structure: physicians must exclusively work in sector 1 and charge regulated fees or in sector 2, where they can freely set their fees. Patient out-of-pocket payments in sector 2 are partially covered by private insurance. The primary differentiating factor between both sectors is the number of patients per specialist, which in turn directly affects the overall quality of the service provided. We built an equilibrium model to analyze both specialists' decisions about which sector to work in, and patients' choice of physician and therefore sector. More specifically, the model allowed us to study the effect of changes in prices and economy-wide patient-to-specialist ratios on profits and patients' utility associated with the services provided in each sector.     

Physician and hospital funding options in a public system with decreasing resources

Methods of physician and hospital reimbursement have been the subject of many debates over the years. Structuring a method of payment for physicians under a publicly funded system is particularly difficult when considered in relation to methods of hospital funding. In this paper, we present a mathematical model that simulates physician and hospital behaviour in a publicly funded health care system under a variety of funding scenarios. The model assumes both doctors and hospitals are constrained profit satisficers. Given this assumption, and a reduction in funding to the institution, the model searches for a resource allocation that will achieve target incomes for both decision-making groups through changes to case mix and/or reductions in the fixed or variable costs of production.Results indicate that when physicians are funded on a fee-for-service basis, the hospital funding method in place may have little impact on resource allocation following a budget reduction. When physicians are funded via salary, conflict between the two groups is reduced, but under supply is more likely to occur. These results raise important questions regarding the type of hospital funding model that should be in place.Unlike earlier approaches, our model jointly simulates the behaviour of both hospitals and health care providers. By including both actors, it provides a mechanism for investigating the interaction between physicians and hospitals under a variety of funding scenarios. Given that hospital-physician systems respond to funding reductions by reducing the fixed costs of production or by decreasing the variable costs of production, the model can be used to identify a range of alternative case mix, case cost, and cost-sharing scenarios.     

Regional variations in hospital occupancy rates

This paper analyzes theoretically and empirically SMSA differences in occupancy rates in short-term general hospitals. Because of the randomness of shortrun demands for admission to hospitals, occupancy rates are greater, the greater the admission rate, the larger the population, and the fewer the hospitals in the SMSA. Occupancy rates are higher where a greater proportion of the population is black and where the winters are colder, both due to longer hospital stays. More beds per capita lowers the occupancy rate. The efficiency of bed use could be increased by greater coordination among hospitals.     

江阴市城镇贫困人口医疗服务利用情况调查研究

目的:了解江阴市城镇贫困人口的医疗服务利用情况,提出改善城镇贫困人口医疗服务利用情况的建议。方法:采用问卷调查的方式,对江阴市324户城镇贫困居民进行入户调查,共计925人。结果:江阴市城镇贫困人口的两周就诊率为42.2‰,未就诊比例为64.4%,年住院率为6.2%,未住院比例为29.6%。贫困居民医疗服务利用相对不足,医疗保障水平有待提高。结论:通过开展健康教育,完善医疗保障制度、医疗救助制度,深入开展社区卫生服务等方面改善贫困人口医疗服务利用情况。     

Disequilibrium models of single family housing prices and transactions: The case of Chicago, 1972–1976

This paper reports a first application of Fair-Jaffee type short-side models of disequilibrium to the intraurban single family housing market in which the housing stock is divided into distinct geographic community areas. Data on single family dwelling transactions and prices in the city of Chicago between 1972–1976 is used to estimate four versions of the Fair-Jaffee type model. The approach allows the simultaneous estimation of the price elasticity of the demand for and offer of existing single family dwellings. The demand elasticity estimate of about −0.5 agrees with other estimates in the literature obtained from equilibrium models. The price elasticity of offer has not been previously estimated for single family dwellings. It is found to be around 2.1. Elasticities are also computed with respect to the mortgage interest rate and the intensity of transactions in the dwelling's community area. The disequilibrium models appear substantially superior to equilibrium specifications. Simulations with the estimated models predict that, in the absence of external shocks, transaction prices and quantities stabilize within 2 years.     

Issues in the Industrial Organization of the Market for Physician Services

What is the nature of the industrial organization of the market for physician services? Is the market “competitive?” Are there pareto-relevant market failures, such that there is room for welfare-improving policies? Economists have devoted a great deal of attention to this market, but it remains relatively poorly understood. The key features of this market are that the product being sold is a professional service, and the pervasive presence of insurance for consumers. A professional service is inherently heterogeneous, nonretradable, and subject to an asymmetry of information between buyers and sellers. These characteristics are what bestow market power on sellers, further strengthened by the fact that consumers face only a small fraction of the price of any service due to insurance. This paper considers the implications of these characteristics for agency relationships between patients and physicians, and insurers (both private and public) and physicians. Agency relationships within physician firms are also considered. Both theoretical and empirical modeling of contracting between insurers and physicians and of the joint agency problems between patient and physician and insurer and physician are recommended as areas for future research. Because failures in this market are seen to derive largely from the structure of information, the potential gains from government intervention may be sharply circumscribed. Nonetheless, careful consideration of the competitive implications of contracting between physicians, insurers, and other health care providers is an important area for antitrust policy.     

Measuring small area variation in hospital use: site-of-care versus patient origin data.

There has been increasing attention paid to small area variation in hospital discharge rates. While there is general agreement about the importance of correcting for the migration of patients to hospitals outside their geographic area when constructing population-based hospital use rates for these small areas, there have been no studies of the sensitivity of simple correlations or multiple regression results to these adjustments. Given the paucity of patient origin data, which is needed to adjust hospital discharge rates for patient crossovers, the problems of measurement error present in the more readily available site-of-care data need to be addressed. This paper analyzes the variation in hospital discharge rates, both an unadjusted site-of-care rate and an adjusted patient origin rate, across the 68 counties in the lower peninsula of Michigan in 1980. The results indicate that both simple correlations and multiple regression results of these rates with socio-economic and health care resource characteristics of the counties are very sensitive to the specification of the discharge rate, with the analysis of the unadjusted rate potentially leading to incorrect policy recommendations. The explanatory power of the socio-economic characteristics is underestimated and that of health care resource measures most likely overestimated when the discharge rate is not adjusted for patient crossovers.     

Increasing physician supply in medically underserved areas

Physician supply in medically underserved areas has long been an interest of health and labor economists. I employ a rich database containing the location of physicians at 5-year intervals to compare the types of locations chosen by alumni and nonalumni of a United States program charged with increasing physician supply. Using a multinomial logit model with discrete unobserved heterogeneity to account for endogeneity of enrollment in the program, I find that eliminating the program would decrease the supply of physicians in medically underserved communities by roughly 10%.     

滇西南同地域佤族与傣族的民居比较研究

云南各族经过长期的迁徙后,形成了交错杂居的分布格局,民族民居在"地区性"与"民族性"共同作用下,呈现出同地域不同民族间的民居的相似与差异。以佤族干栏民居与傣族民居的对比研究为例,总结研究两个民族民居之间的异同,从而分析同地域不同民族民居的文化交融,归纳出影响住屋形式的因素。