Potential “Savings” of Medicare: The Analysis of Medicare Advantage and Accountable Care Organizations

Medicare faces significant financial challenges because of rising health care costs. In response, Medicare reform efforts have been testing various payment and service delivery models, including accountable care organizations (ACOs), aiming to reduce expenditures while preserving or enhancing the coordination of quality care. The idea behind ACOs is to form an organizational network to coordinate all care for Medicare beneficiaries and in so doing, at least theoretically, improve quality of care and hopefully reduce medical costs. The purpose of this research is to apply Data Envelopment Analysis (DEA) to assess the potential savings of Medicare obtainable through optimally efficient implementation of ACOs and Medicare Advantage plans. DEA comparisons across plans achieve this purpose by identifying which Medicare plans operate relatively more efficiently and which are inefficient, and additionally, for inefficient plans, the DEA analysis generates target levels of “inputs” and “outputs” required to bring the plan into efficient operation. Knowing sources of inefficiency can also provide insights into Medicare reform, such as Medicare privatization and innovation models. Our results show that Medicare Advantage plans are more efficient in reducing health expenditures but incur higher administrative costs. Health expenditure savings can also be achievable by promoting government-sponsored managed Medicare such as ACOs. Finally, compared to the profit efficiency of Medicaid managed care plans, Medicare Advantage should have the potential for more Medicare market penetration from the supply (insurer) side.     

Oil price uncertainty,workplace misconduct,and cash holding

Using a novel and comprehensive dataset on penalties imposed by several US federal agencies for workplace law violations, we find that US firms are less likely to violate employee-related laws and receive associated penalties when oil price uncertainty (OPU) increases. This evidence results from two potential channels: precautionary motive and improved board monitoring. First, firms increase discretionary safety expenditure, and second, they increase the board of directors' involvement in the safety and compliance committee. Further, the evidence is not stemmed from other alternatives, such as reduced production or employment. A firm reduces workplace misconduct more when it is financially constrained, incurs a higher cost of goods sold, and belongs to the energy industry. Our results are robust to endogeneity concerns and alternative OPU measurements. Moreover, we document that the positive effect of oil price uncertainty on cash holdings is attenuated if firms reduce workplace violations and associated penalties.     

Health insurers' use of quality improvement expenses to achieve a minimum medical loss ratio requirement

Health insurer medical loss ratios (MLRs) are the percentage of premium dollar spent on medical claims and healthcare quality improvement expenses (QIEs). QIEs include activities to improve patient health outcomes and safety, reduce medical errors, and prevent hospital readmissions. The Affordable Care Act mandates minimum MLRs in certain health insurance markets lest rebates be paid to policyholders. QIEs are reported in all markets regardless of whether that market is subject to minimum MLR requirements. Using health insurer statutory filings for a sample of group market insurers from 2010 to 2018, we employ a mixed regression discontinuity/regression kink approach to evaluate whether QIEs are used by insurers as a potential strategy for meeting the minimum MLR requirement. We show that health insurers' QIE increase in the loss ratio until meeting the minimum MLR requirement, have a significant discontinuous jump at the threshold, and decrease above the threshold after the introduction of the MLR mandate.     

大学科技城政企学研协同创新三方演化博弈研究

基于有限理性和不完全信息假设,构建大学科技城管委会、企业和学研方三方的演化博弈模型,考量三方共同作用的演化稳定策略和博弈演化过程。结果发现：大学科技城协同创新演化策略是三方主体共同作用的结果,只研究单一主体的演化决策具有局限性;学研方和企业参与协同创新的意愿与大学科技城的相关政策有关;学研方和企业参与协同创新的意愿与大学科技城主体的互信程度有关;大学科技城管委会选择监管的意愿与监管收益有关。     

Medicare in the 21st century.

The authors provide an overview of the Medicare program in terms of how the current program operates, the current issues it faces that may shape possible options for reform, and the implications of these features and issues for employment-based health plans. Current issues include adoption of a premium support model, changes in the eligibility age for Medicare benefits, Medigap insurance, benefits covered and customer service.     

Opening a dialog: communicating with retirees about Medicare+Choice.

In October 1998, the Health Care Financing Administration sent information to 38 million Medicare beneficiaries in five pilot states, consisting of a comprehensive handbook entitled Medicare and You. The purpose of the handbook is to clarify new options under Medicare+Choice to participants. Such clarification is bound to initiate contact by Medicare beneficiaries to former employers/unions. This article addresses employers' need to develop a communication strategy for beneficiaries and suggests a methodology and possible questions that may arise.     

Uncertain litigation and liability insurance

Legal penalties and liability insurance seem to have counteracting effects on the incentives of a potential injurer to take due care. However, if legal penalties are set efficiently and implemented perfectly, unrestricted access to insurance can be optimal. In contract, if the standards of guilt assessment are uncertain, the size of the legal penalties may act as a spur to litigation. Therefore, the penalties required to maintain incentives when access to insurance is unlimited may provoke too much litigation, and as a consequence, the costs of ensuring due care may decline when insurance is restricted by mandate.     

SEC enforcement: Does forthright disclosure and cooperation really matter?

This study examines the conditions under which the Securities and Exchange Commission (SEC) exercises enforcement leniency following a restatement. I explore whether cooperation with SEC staff and forthright disclosure of a restatement (e.g., disclosures reported in a timely and visible manner) reduce the likelihood of an SEC sanction or SEC monetary penalties. After controlling for restatement severity, I find that cooperation increases the likelihood of being sanctioned, perhaps because it improves the SEC's ability to build a successful case against the firm. However, cooperation and forthright disclosures are rewarded by the SEC through lower monetary penalties.     

Client Characteristics and the Negotiation Tactics of Auditors: Implications for Financial Reporting

Although the financial statements of an organization are considered a product of management, prior research suggests that a company's financial statements may be affected by the negotiation strategy employed by the auditor when resolving audit differences with management. However, little subsequent research discusses the potential strategies that auditors may employ during the negotiation process. Our study extends the literature by investigating, in a post–Sarbanes‐Oxley environment, whether auditors will employ a reciprocity‐based strategy for the resolution of audit differences and what client characteristics (client management's negotiating style and client retention risk) increase the extent to which it is utilized. Further, we explore the potential effect of a reciprocity‐based strategy on the quality of the financial statements. Such a strategy involves bringing inconsequential items to management and subsequently waiving these items in an effort to encourage management to be more cooperative in the posting of significant income‐decreasing adjustments. The results of experiment 1 indicate that client management's negotiating style and retention risk have an interactive effect on auditors' use of a reciprocity‐based strategy. Specifically, auditors are more likely to utilize a reciprocity‐based strategy when management's negotiating style is competitive and client retention risk is high. Experiment 2 findings suggest that the auditor's use of reciprocity during negotiation can actually result in more conservative financial statements by helping the auditor manage perceived client pressures to waive or reduce proposed adjustments.     

Improving workplace productivity--it isn't just about reducing absence

Employers must get more aggressive in their health and productivity strategies. A comprehensive strategy includes data analytics across health and lost-time programs, absence policies that meet today's needs for both employer and employee, health and wellness programs targeting modifiable health behaviors, and absence program administration that is aligned to operational goals. This article targets key aspects of a comprehensive long-term health and productivity strategic vision. An organization can use these aspects independently to address immediate tactical issues while it develops its broader strategy. The target areas include a view from the perspective of data management, absence program design and management, employee health and wellness, and behavioral health.     

Private monitoring,collusion, and the timing of information

When a principal's monitoring information is private (nonverifiable), the agent should be concerned that the principal could misrepresent the information to reduce the agent's wage or collect a monetary penalty. Restoring credibility may lead to an extreme waste of resources—the so‐called burning of money. A more realistic and efficient outcome is feasible when the private information arrives in time to rescale the agent's effort. Rescaling is more effective than pure monetary penalties because effort has different values to different parties whereas money is equally valuable to all parties. Furthermore, when rescaling is feasible, private monitoring is more efficient than public monitoring subject to collusion because nonmonetary penalties are ineffective to deter collusion.     

The Medicare hospice benefit: the effectiveness of price incentives in health care policy

This article examines the implications of fixed-price reimbursement of providers for access to hospice care by Medicare beneficiaries. Hospices that are offered higher reimbursement rates by Medicare are found to be more likely to become certified to provide care under the Medicare Hospice Benefit program. Each $1.00 increase in the daily routine home care rate raises the probability of certification by 1.7%. In turn, the Hospice Benefit increases access to hospice care by enabling Medicare-certified facilities to serve more patients than they would if they were noncertified. However, care must be taken to set reimbursement rates appropriately. Failure to correctly adjust reimbursement rates for the real costs of certification across different parts of the country leads to disparities in hospice certification and differential access to hospice care for Medicare beneficiaries.     

The Impact of the Inpatient Prospective Payment System and Diagnosis-Related Groups

Abstract

The outpatient prospective payment system for the Medicare program became effective Aug. 1, 2000, as mandated by the Balanced Budget Act of 1997. This outpatient program complements Medicare’s inpatient prospective payment system, which was introduced in 1983. A survey of the literature over the past 20 years is undertaken to review the effects of the inpatient prospective payment system and diagnosis-related groups (DRGs) on inpatient hospital utilization, expenditures, and outcomes. The level of the DRG payment has been questioned, as well as the process of adjusting the payment levels from one year to the next. In addition, past research has speculated that the DRG classification may not be sensitive to severity and is subject to coding ambiguities. These conclusions can be used as input to future research on the new outpatient program, as well as updating research on the inpatient program.     

Alternatives to traditional Medicare: Medicare Part C poised to prosper

Recent events indicate that Medicare Part C (Medicare Advantage) plans are poised to prosper. Yet many employers express hesitation to offer Medicare Advantage, formerly known as Medicare+Choice, plans to their retirees because they are concerned about the potential withdrawal of those plans if there is a reversal of federal funding rules. This article addresses those concerns. It provides a historical overview of Medicare Part C and describes the impact of the most recent agency guidance. The author cites plan trends, raises employer implications and concludes that Medicare Advantage plans will continue to expand, possibly facilitated by employers as they implement leading-edge retiree medical designs.     

GAME THEORY AND THE AUDITOR'S PENALTY REGIME

This paper models the audit as a cooperative game played by the auditor and auditee within a penalty regime imposed by a regulatory authority. The paper investigates the relationship between the penalties set by the regulator and the jointly agreed strategy of the auditor and auditee, and discusses how the penalty regime might be employed so as to induce a particular strategic outcome such as high effort levels on the part of the auditee and/or auditor.     

Dynamic Effects of Extending the 2001 and 2003 Income Tax Cuts

This paper focuses on the impact of permanently extending most of the provisions in EGTRRA and JGTRRA, coupled with potential legislative changes to the AMT, on the federal deficit, the distribution of after-tax income, and economic growth. The paper shows that including moderate behavioral responses offsets 16 percent of the static revenue loss estimate from 2005 to 2014. In addition, including behavioral responses implies that the percentage change in after-tax income from permanently extending the 2001 and 2003 income tax cuts would be largest for taxpayers with incomes ranging from $20,000 to $40,000. Finally, the simulation results suggest that extending the 2001 and 2003 income tax cuts and reducing the growth rate of government spending (excluding Social Security and Medicare), assuming that government expenditures are cut to avoid dramatic increases in government consumption relative to GDP in comparison to historical norms, would increase investment, employment, and output. However, postponing the implementation of tight spending controls would more than offset the positive benefits of lower tax rates on the size of the economy and leave future generations with fewer resources for private consumption and production.JEL Code: E62, H20, H30, H60The views expressed are those of the author and do not reflect those of the Baker Institute for Public Policy or any other organization. This paper was partially written while the author was employed by the Joint Committee on Taxation.     

Delegation to Encourage Communication of Problems

We study a principal's choice to centralize or delegate decisions to an agent when delegation can be used to encourage the agent to communicate potential problems. We find that the principal may choose centralization either to exercise better control over the agent's actions or to provide stronger incentives. Delegation emerges in equilibrium only if the costs of effort to acquire information for both the principal and the agent are sufficiently high. We find that increases in the principal's penalties for an incorrect decision may increase the principal's expected payoff, owing to optimal organizational responses. In addition, catastrophic risk, the risk of incorrectly accepting a defective audit (or product), may be greater under centralization than under delegation. Furthermore, catastrophic risk can be increased by well-intentioned legislative efforts to decrease such risk by, for example, increasing the agent's penalties for failing to take a corrective action, because the organizational structure may change.