Can a Mixed Health Care System be Desirable on Equity Grounds?*

Should health care provision be public, private, or both? We consider this question in a setting where people differ in their earnings capacity and face some illness risk. We assume that illness reduces an individual's time endowment when waiting for treatment. Treatment can be obtained in a competitive private sector (through private insurance) or in the National Health Service (NHS) where it is provided free of charge but after some (endogenous) waiting time. The equilibrium in the health care sector consists of a waiting time in the NHS such that no patient wants to switch health care provider. This equilibrium is governed by two public policies: the income tax system and the size of the NHS. We find that: (i) a mixed system with a small NHS is never desirable; (ii) actuarially fair sickness insurance is never desirable either; (iii) a mixed system with a sufficiently large NHS may improve on a pure public system if the dispersion of earnings capacities is large enough; and (iv) the welfare gains from such a mixed system are not likely to be significant.     

Navajo nation public health nurses inspire thoughts on health care reform

The wisdom and experience of pubic health nurses serving on a Navajo Reservation, who work far from the typical hospital setting, may well hold some of the keys to how we can successfully plan for and navigate the future of our shifting health care system. As more of the nursing workforce moves outside the walls of the hospital, competencies in autonomy, clinical judgment, decision making, and communication will increase in importance. long with safety and quality implications, this may also influence changes in nursing education, job requirements, hiring, and measuring performance. In addition, there may be implications around how new nurses are oriented and how they get the experience needed to function in more independent roles. Within their routine days, the conditions they work in, the situations they face, and the many ways public health nurses find to meet the needs of the people they serve, is a wealth of knowledge that may well translate into solutions for some of the challenges our nation's health care system is facing.     

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.     

The impact of patient choice and waiting time on the demand for health care: results from the London Patient Choice project

In a number of countries where health care is publicly funded, policies to introduce greater patient choice are being implemented. In most cases patient choice is seen as an instrument to reduce waiting times for elective (non-emergency) hospital services. An important issue is whether facilitating greater patient choice will increase the demand for health care and thereby undermine the achievement of reduced waiting times. A large scale pilot of choice in the London metropolitan area permits a test of the hypothesis that choice will affect demand. This paper estimates a model of the demand for elective surgery using a panel of 150 English acute hospitals over the period 1995 to 2004 for three surgical specialties. It examines whether demand shifted following the introduction of the London Patient Choice Project in 2002. The results suggest that the choice project only shifted NHS inpatient demand in orthopaedics and that this shift was inwards.     

Goal Setting,Information, and Goal Revision: A Field Experiment

People typically set goals in settings where they cannot be sure of how they will perform, but where their performance is revealed to them in parts over time. When part of the uncertainty is resolved, initial goals may have turned out to be unrealistic and hence they no longer work as a motivation device. Revising goals may increase performance by making goals realistic, but may also adversely affect performance through reduced goal commitment. We study the effects of motivating university students to set goals and inviting them to revise their goals later, using a field experiment involving nearly 2,100 students. We use courses containing two midterms and a final exam, where midterms reduce uncertainty about students’ potential performance. We find that motivating students to set goals does not affect performance on average. Students with midterm grades lower than their goal, decrease their performance. This effect is driven by students who were motivated to set goals without being made aware that they can revise their goals later. This finding may help explain why the evidence of the effectiveness of goals on study performance is mixed.     

Cronyism and education performance

Recent research suggests that some countries may be unable to use productively their schooling output because of the scope of cronyism or corruption. We investigate further and demonstrate that, in a stylised model, cronyism in the labour market, (e.g. the ability to exert influence to gain high wage positions without merit), may impact heavily on the relationship between schooling inputs and cognitive skills, due to incentive effects. We then use a two-stage DEA approach to identify factors affecting inefficiency in education performance of OECD countries, as measured by PISA scores. Along with other well known factors, a proxy measure for cronyism from the World Value Survey, explains a substantial fraction of the inefficiency. This result suggests that, as in our model, in the presence of cronyism, incentives to cognitive skills acquisition are dampened. The best way to improve education performance may be to increase transparency in labour access.     

An international comparison of hospital efficiency: does institutional environment matter?

The consensus among many health economists is that no meaningful performance differences exist among for-profit and non-profit hospitals in the US, but this topic has continued to be a matter of academic, judicial, and public policy interest. A similar debate has ensued internationally, regarding the potential efficiency gains from privatization of public enterprises. In this paper, we examine empirical evidence from the public, highly regulated Norwegian hospital sector and the private, highly competitive and unregulated California hospital sector to ascertain whether institutional environment and level of market competition significantly affect the degree of productive efficiency in hospitals. We compare and discuss the productive efficiency of four similar sets of hospitals operating in different institutional and competitive environments. The four samples are carefully matched in the dimensions of sample size, hospital size, and average lengths of stay. Heterogeneity in output definition is used to control for other dimensions (casemix, age distribution of patients). We use Data Envelopment Analysis (DEA) to estimate and compare average long-run as well as short-run efficiency measures across groups. We find that scale and scope regulation of Norwegian hospitals improves long-run efficiency, primarily due to better utilization of capital.     

The suspension of borrowing: an implicit penalty for loan default under imperfect information

A credit seeker may be suspended from borrowing for a period of time due to a previous default. Such suspension is widely used in bank lending through credit check. Our work analyses the effects of suspension on the investment choice of borrowers under uncertainty and on the lending policy of banks facing asymmetric information. We show that suspension should be tightened at low loan rates, but loosened otherwise, to improve the repayment performance of borrowers. We also show that although credit rationing may not be completely removed due to imperfect information, the excess demand for credit or transitive waiting in the market can actually be attenuated by such efficient use of suspension. Our theoretical predictions are consistent with observed cyclical patterns of changes in lendingrates and suspension severity.     

SERVICE QUALITY IN REGULATED NETWORK INDUSTRIES

ABSTRACT ** : Economic regulators provide incentives for good quality of service as well as constraints on the prices or revenue which can be charged by firms with monopoly power. Economic theory suggests that regulators should choose standards according to consumers' valuation and the marginal cost of quality improvements, and that firms respond by equalizing the marginal costs from not making improvements (i.e. the regulatory penalty plus any loss in revenue) with the marginal costs of improvement. This paper explores the evidence for such economically rational behaviour by both regulators and regulatees. We use a specially constructed data set on service quality targets and achievements across the main UK utility sectors; documentary evidence from regulators; and interviews with managers in companies subject to those regulators. We conclude that regulators are motivated by political as well as economic factors. And that companies may not respond primarily to the regulator's financial rewards or penalties for their quality targets, with a consequent danger that regulated consumers pay for marketing in unregulated markets; the resulting level of service quality may be ‘too high’ in the economic sense.     

Potential unrecognised costs of clopidogrel pretreatment in acute coronary syndrome

Abstract

Objective: To examine adherence in clinical practice to the American College of Cardiology/American Heart Association (ACC/AHA) guideline recommendations of observing a 5-day waiting period after clopidogrel administration before undergoing coronary artery bypass graft (CABG) surgery and to examine the costs of waiting.

Methods: This retrospective study used a nationwide inpatient database (Solucient ACTracker) to identify patients who were admitted for acute coronary syndrome (ACS), and who had same-stay CABG. Cost of additional days of stay was estimated using regression analysis.

Results: The recommended 5-day waiting was adhered to in 16.9% (n=3,809) of patients. The percentage of patients with ACS undergoing CABG surgery on day 0 was 14.6%. Adherence to the waiting was higher for teaching and rural hospitals; and in female and elderly patients and urgent admissions.

Conclusions: The recommended 5-day waiting for CABG surgery after clopidogrel treatment is poorly adhered to in clinical practice. This study was unable to determine specific reasons for the low adherence; however, there may be a compromise between the clinically urgent need for revascularisation and increased risk of bleeding, as well as economic costs associated with waiting. The cost of an additional hospital day in this group of patients was approximately £1,400 per day or £7,000 for 5 days. Thus, a full 5-day wait would have a significant economic impact on hospital costs.     

Medical innovation and its diffusion: Implications for economic performance and welfare

We study the impact on economic performance and welfare of medical innovations and their endogenous diffusion. We construct a general equilibrium model with a medical sector and overlapping generations subject to endogenous mortality and calibrate it to reflect the development of the US economy and health care over the cardiac revolution during the 1980s and 1990s. By counterfactual analysis we find that (i) medical innovations have increased welfare without compromising GDP growth; (ii) there is a sizeable welfare loss due to the adoption lag involved with imperfect diffusion; and (iii) there is scope for Pareto improvement by way of subsidization of innovative health care.     

The influence of black markets on a queue-rationed centrally planned economy

In centrally planned economies in which prices are fixed, and the rationing mechanism is waiting line queues, we show that an equilibrium of waiting times exists. We then introduce a “black market” in which individuals can trade commodities that they have acquired through the official economy. An equilibrium of black market prices and waiting times is shown to exist; further, the economy with a black market is “queue-efficient.”. However, the introduction of black markets is not necessarily a Pareto improvement over an economy without black markets (even when we allow winners to compensate losers).     

Performance Pay and Adverse Selection*

It is well known in personnel economics that firms may improve the quality of their workforce by offering performance pay. We analyze an equilibrium model where worker productivity is private information and show that the firms’ gain from worker self‐selection may not be matched by a corresponding social gain. In particular, the equilibrium incentive contracts are excessively high‐powered, thereby inducing the more productive workers to exert too much effort and increasing agency costs stemming from the misallocation of effort.     

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.     

Profiling hospital utilization in a mixed public–private system

While there is an extensive body of literature on the demand for hospital services, little is known about the interaction between public and private hospitals in a mixed system. In this article, we (1) apply latent class analysis to identify distinct subgroups of patients who use the hospital market differently, (2) characterize each patient type by their personal characteristics and (3) link the patient type to future hospital admissions. We apply our analysis to individual-level longitudinal patient data from Australia, focusing on three popular procedures that are performed in both public and private hospitals. We find 4–5 patient types. The most common types use either a public or a private hospital almost exclusively and absorb a moderate level of hospital resources. The severe types represent 13–17% of patients. The type which uses both sectors makes up 10–20% and tends to have private health insurance coverage. The patient types are predictive of prospective utilizations as we find that patients tend to be admitted to the sector they have used in the past. By revealing how patients use coexisting public and private hospitals, our results have direct implications on health resource financing and allocations.     

"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.     

Do Consumers Learn from Their Own Experiences?

It is natural to think that a household may learn from its own experiences and subsequently increase savings. This paper tests empirically the hypothesis that Japanese households learn from their experiences of large expenditure and increase their targets for precautionary savings after such experiences. The results imply that households raise their targets for precautionary savings by 4–5 percent of annual income in response to such experiences. Moreover, data are consistent with the argument that targets for savings affect actual savings. Assuming this holds, the results in this paper suggest that consumers may increase their actual savings following large expenditure.     

Taking action to close the nursing-finance gap: learning from success

Nurse leaders control the largest part of a hospital labor budget, in some cases the largest part of the overall budget. The effectiveness of overseeing this responsibility can mean the difference between an organization's financial stability and financial turmoil. The nursing department at Northwestern Memorial Hospital took ownership of its financial performance. Over the past 2 years, their financial performance saved $4.9 million in productivity while reducing nurses turnover costs by $7.6 million. Valuable lessons from their experience are offered for improving health care's financial and operational outlook.     

Institutional design and the closure of public facilities in transition economies

As part of the reforms of their systems for financing and delivering health care, many transition economies, particularly in central and eastern Europe, have adopted national insurance funds that are institutionally separate from ministries of health. Most of these countries have also grappled with the problem of restructuring the delivery system, especially the need to reduce hospital capacity. Although improving the performance of medical care providers through a shift from passive budgeting to explicitly incentive mechanisms is important, why this change in financial relations between the government and providers could not be implemented simply by reforming the role of health ministries is not obvious. This paper presents an explicit rationale for the separation of powers between the regulator (the ministry of health) and the financing body (the insurance fund), based on the inability of a single agency to commit to closing hospitals. JEL classification: L51, P20, P35, I18.     

Volunteering for heterogeneous tasks

We model the search for volunteers as a war of attrition. Every player is tempted to wait for someone else to volunteer for the tasks. When tasks are not equivalent, it may be optimal to volunteer quickly to perform an easy task. We analyze the trade-off between volunteering for an easy task and taking the risk of having to perform a more strenuous task in order to get the chance of avoiding all tasks. When the cost of waiting is borne by agents until every task has found a volunteer, we show that it may be optimal to volunteer for the difficult task even if an easier task is available, in order to speed up the process and reduce the costs of waiting.