Measuring Selection Incentives in Managed Care: Evidence From the Massachusetts State Employee Insurance Program

Capitation gives insurers incentive to manipulate their offerings to attract the healthy and deter the sick. We calculate the incentives for such service-specific quality distortions using managed care medical and pharmacy spending data for fiscal years 2001 and 2002 from the Massachusetts State Employee Insurance Program. Services most vulnerable to stinting are cardiac care, diabetes care, and mental health and substance abuse services. Empirically, the financial temptation to distort service quality increases nonlinearly with supply-side cost sharing. Our empirical results highlight how selection incentives work at cross-purposes with efforts to reward excellent chronic disease management. Initiatives coupling pay-for-performance with risk adjustment and mixed payment hold promise for aligning incentives with quality improvement.     

The Effects of Consumer-Directed Health Plans on Health Care Spending

We use unique data from an insurer that exclusively offers high-deductible, "consumer-directed" health plans to identify the effect of plan features, notably employer contributions to the spending account, on health care spending. Our results show that the marginal dollar contributed by the employer to the spending account is entirely spent on outpatient and pharmacy services. In contrast, out-of-pocket spending was not responsive to the amount the employer contributes to the spending account. Our results represent the first plausibly causal estimates of the components of consumer-driven health plans on health spending. The magnitudes of the effects suggest important health care spending consequences to higher employer contributions to spending accounts. Our findings are most directly relevant to health reimbursement arrangement plan designs, though our results are still of value to health savings account plan designs.     

The impact of the managed care backlash on health care spending

The health spending slowdown associated with the managed care revolution in the 1990s suggests that managed care may have been successful in controlling health care spending. I exploit the passage of state regulation during the “managed care backlash” as well as geographic variation in managed care intensity to measure the impact of managed care on spending. I find that restricting managed care causes a large and significant increase in hospital spending, which cannot be explained by changes in hospital market concentration, other regulatory activity, and multiple other possible explanations. I also do not find effects of the backlash on mortality.     

How do low-income enrollees in the Affordable Care Act marketplaces respond to cost-sharing?

The Affordable Care Act requires insurers to offer cost-sharing reductions (CSRs) to low-income consumers on the marketplaces. We link 2013–2015 All-Payer Claims Data to 2004–2013 administrative hospital discharge data from Utah and exploit policy-driven differences in the actuarial value of CSR plans that are solely determined by income. This allows us to examine the effect of cost-sharing on medical spending among low-income individuals. We find that enrollees facing lower levels of cost-sharing have higher levels of healthcare spending, controlling for past healthcare use. We estimate demand elasticities of total health care spending among this low-income population of approximately −0.12, suggesting that demand-side price mechanisms in health insurance design work similarly for low-income and higher-income individuals. We also find that cost-sharing subsidies substantially lower out-of-pocket medical care spending, showing that the CSR program is a key mechanism for making health care affordable to low-income individuals.     

政府卫生支出的差异性评估:基于省际、区域和城乡的实证研究

本文聚焦政府卫生支出的差异性,运用基尼系数、泰勒指数等方法,定量研究省际、区域间和城乡间政府卫生支出的不均衡状况和程度,研究发现,经济发展水平决定了各地政府卫生支出的水平和居民医疗卫生服务的水平.医疗卫生资源的配置不当和制度缺陷是造成目前政府卫生支出不均衡的主要原因.在新医改的背景下,调整发展思路,完善相关制度有助于改善政府卫生支出不均衡的状况.但是,制度的惯性和体制的约束决定了不均衡状况的改变将是一项长期的工作.     

Health care spending accounts: a flexible solution for Canadian employers

Flexible benefits plans have grown more slowly in Canada than in the United States, largely because of certain legal and regulatory considerations. Health care spending accounts (HCSAs) provide a cost-effective way for Canadian employers to address the health care benefit needs of a diverse workforce. A flexible health care spending account is a versatile and cost-effective instrument that can be used by Canadian employers that wish to provide a full range of health care benefits to employees. The health care alternatives available through an HCSA can provide employees with an opportunity to customize and optimize their benefits program. Regulatory requirements that an HCSA must meet in order to qualify for available tax advantages are discussed, as are the range of health care services that may be covered.     

Weak Links in the Chain: A Diagnosis of Health Policy in Poor Countries

Recent empirical and theoretical literature sheds light on thedisappointing experience with implementation of primary healthcare programs in developing countries. This article focuseson the evidence showing two weak links in the chain betweengovernment spending for services to improve health and actualimprovements in health status. First, institutional capacityis a vital ingredient in providing effective services. Whenthis capacity is inadequate, health spending, even on the rightservices, may lead to little actual provision of services. Second,the net effect of government health services depends on theseverity of market failures—the more severe the marketfailures, the greater the potential for government servicesto have an impact. Evidence suggests that market failures arethe least severe for relatively inexpensive curative services,which often absorb the bulk of primary health care budgets.A companion paper, available from the authors (seep. 219), offersa perspective on how government funds can best be used to improvehealth and well-being in developing countries. It gives an alternativeview of appropriate public health policy, one that focuses onmitigating the characteristic market failures of the sectorand tailoring public health activities to the government's abilityto deliver various services.      

Editorial

This article uses international comparisons to demonstrate the UK's relatively low spending on health care services and considers why extra money is being raised from National Insurance Contributions rather than from other sources of tax revenue. It outlines various options for measuring the UK-EU health spending gap and finds that they yield substantively different estimates of the size of the spending gap to be filled. It explains why closure of that gap may be aided by enlargement of the EU. It concludes that closure of the spending gap may be as much or more the result of accident than of design.     

Financing Higher NHS Spending from Increased National Insurance

This article uses international comparisons to demonstrate the UK's relatively low spending on health care services and considers why extra money is being raised from National Insurance Contributions rather than from other sources of tax revenue. It outlines various options for measuring the UK–EU health spending gap and finds that they yield substantively different estimates of the size of the spending gap to be filled. It explains why closure of that gap may be aided by enlargement of the EU. It concludes that closure of the spending gap may be as much or more the result of accident than of design.     

The Distribution of Subsidies through Public Health Services in Indonesia, 1978-87

Indonesia has made great progress during the past fifteen yearsin enhancing the command of the poor over privately providedgoods, such as food, clothing, and housing. Has similar progressbeen made in improving their access to publicly provided socialservices? The article looks at how the use of health servicesand the incidence of subsidies in the health sector varied acrosssocioeconomic groups in Indonesia in 1987. It also examineshow the distributions of utilization and subsidies altered between1978 and 1987. The findings indicate that changes in utilizationpatterns and in the incidence of subsidies have been pro-poor.Disparities in access and utilization have diminished. However,public spending on health care is not yet well targeted.     

论保障公立医院公益性的主要条件

导致公立医院偏离公益性、出现市场化"逐利行为"的原因是多样的,办院理念的失误、管理体制和运行机制不合理、法律缺位、医德医风和医疗环境问题都是促使公立医院偏离公益性的原因。因此,在我国新时期的医疗体制改革过程中,实现国家卫生经费的大量投入是保证公立医院公益性的一项重要条件,但不是决定性条件,更不是唯一条件,要真正发挥出公立医院的公益性,必须从多方面、多角度、多环节入手,调整公立医院的办院理念、完善管理机制和运行机制、健全法律规范、倡导道德风尚、净化医疗环境,才能真正保障公立医院公益性的实现。     

The effect of management incentives and cross-listing status on the accounting treatment of R&D spending

This paper investigates the effect of management incentives and cross-listing status on the accounting treatment of research and development (R&D) spending for a sample of Canadian hi-tech and biopharmaceutical firms. U.S. GAAP adopts an immediate expensing rule for all R&D spending except for software development costs for which technological feasibility has been established. Contrary to the U.S., Canadian and international standard setters recommend capitalization if development costs meet certain criteria. Because those criteria are largely based on management judgment, capitalization of R&D spending is an accounting choice that can be used for income manipulation or signaling.Using a logit model, we examine how the decision to capitalize R&D spending is influenced by the cross-listing status and several other key firm characteristics that are well documented in the accounting literature. We find that the probability of capitalizing R&D spending increases for cross-listed and non-cross-listed firms in the software industry. The probability of capitalizing R&D spending also increases for firms that are more leveraged, more mature, and have higher level of cash flows from operations. However, the probability of capitalizing R&D spending decreases for larger corporations, firms with more concentrated ownership and highly profitable firms. Overall our results indicate a preference for Canadian firms in the software industry to emulate U.S. accounting practices for R&D spending. They also suggest that firms use the decision to capitalize or expense R&D spending as an earning management tool to either meet debt covenants or to smooth income.     

Optimum Allocations to Health Care Flexible Spending Accounts

Abstract

Models used to derive optimal contributions to health care flexible spending accounts (FSAs) typically assume an employee’s household annual out-of-pocket health care expenses are an absolutely continuously random variable. This assumption, however, ignores the fact that some employees may be able to accurately predict a portion of their household annual out-of-pocket health care expenses and often actually incur only those expenses during the plan year, implying that a mixed random variable may be more appropriate. In addition, data have shown that employees are setting contributions at lower levels than existing absolutely continuous models would suggest is optimal. Using a mixed model of household annual out-of-pocket health care expenses we prove that it is often optimal for employees to contribute an amount equal to their household annual predictable out-of-pocket expenses, thus avoiding the risk of forfeiture. We also propose a practical rule of thumb that employees may use for setting their FSA contributions. Overall, we recommend that employees use their FSAs to cover only their highly predictable out-of-pocket health care expenses rather than use their FSAs as a contingency fund to pay for unlikely or unexpected outof-pocket health care expenses.     

Will employee choice and defined contribution health plans salvage the embattled managed care system?

Defined contribution or consumer-driven health approaches will shift to employees not just the risks and rewards of the managed care system, but also decisions that will determine whether that system can survive. This article reviews the current state of the employer-sponsored health care system, describes defined contribution and consumer-driven health plan concepts, and outlines the approaches and steps employers can take to implement them. The author argues that, if fully implemented, such approaches could salvage the embattled managed care system by giving employees a financial stake in controlling medical costs while educating them to wisely take control of health plan spending decisions.     

Single-payer health care systems: the roles and responsibilities of the public and private sectors

Health care systems all over the world are experiencing some change as they look for a new balance between supply and demand. This article provides context for the U.S. health care financing debate by examining the health care systems of five other countries: Canada, the United Kingdom, Australia, China and India. The authors show that, with few exceptions, countries around the world have seen an increase in both government and private health care spending between 1998 and 2002. The authors also demonstrate that employers throughout most of the world are becoming more, rather than less, involved in the funding and delivery of health care to employees and their dependents-even among nations with so-called single-payer health systems.     

论商业保险基础风险原理对建立基本医疗保障制度的适用价值

2009年新医改重大举措不断,它对于我国相对薄弱的医疗保障体系无疑是必需和及时的。本文从理论上初步论述了商业保险基础风险原理对完善建立我国全民基本医疗保障制度的适用价值。通过总结国际医疗保障制度改革及其研究的趋势,论证以医疗保险的基础风险为依据,是实现社会医疗保险预期绩效的基本保证。同时指出定性定量分析我国全民医保的基础风险,才能从根本上找到完善建立相关制度的措施和方法,促进我国医疗保障体系的进一步科学发展。     

Dealing with Clinical Risk: Implications of the Rise of Evidence-Based Health Care

This article considers the nature of risk in health care and the use the National Health Service (NHS) makes of risk management. It explores how the concept of risk has been challenged by the rise of 'evidence-based' health care, accompanied and accelerated by a decline in professional prestige, status and mystique and much greater use of external measurement and controls as part of the New Public Management. The nature of evidence-based health care is outlined and the implications of the use of guidelines and other practice aids are explored. Finally, the article discusses how evidence-based health care is affecting our views of clinical risk.     

Analysing the Institutional Logic of Late DRG Adopters

Abstract: This study investigates how institutional logics that are prevalent in an organizational field influence change in management accounting. More precisely, we examine the institutional logics of late DRG adopters through which organizations attempt to address the pressures imposed by the institutional field of health care. Specific attention is also paid to the way in which organizations operate at different institutional levels and what kinds of interrelationships exist between these levels. Such developments may at least partially explain why the implementation and adoption of DRG–based accounting systems in Finnish health care took almost twenty years.