Managed care and the near-elderly: effects of plan enrollment on functionality

This paper examines the effects of enrollment in a health maintenance organization (HMO) or a preferred provider organization (PPO) on the functional status of near-elderly adults (aged 55–64), compared to traditional fee-for-service (FFS) plans. A sample of 1306 near-elderly adults with employer-sponsored health insurance are drawn from the 2000–2002 waves of the Health and Retirement Study, a nationally representative panel survey of community-dwelling adults. Regression models are estimated to assess the effects of different types of insurance plans on functionality, as measured by whether or not the individual has any functional limitations. The potential influence of selection bias into alternative types of plans is addressed by limiting the sample to near-elders without a choice of health plans. The effects of HMOs on functionality are shown to be comparable to those of FFS plans among the general near-elderly population. However, significant adverse effects of HMO enrollment on functional status are observed among near-elders with chronic conditions. PPO enrollees have similar functional outcome to FFS enrollees, even among those with chronic conditions. The observed differences in functional outcome across plans have important implications for the practicality of managed care plans serving older adults.     

Does mother nature punish rotten kids?

The theory of parent-offspring conflict predicts that mothers and their offspring may not agree about how resources should be allocated among family members. An offspring, for example, may favor a later weaning date than does its mother. Despite a parent's physical superiority, it may be that offspring are able to manipulate their parents' behavior. In this paper, we investigate a two-locus population genetic model of weaning conflict in which offspring can attempt to extort resources from their parents by reducing their own chances of survival if their demands are not met. We find that the frequency of recombination between the genes controlling maternal behavior and those controlling juvenile behavior determines the evolutionary outcome of this genetic conflict. When these genes are tightly linked, the mother will be able to get her way. When they are not, offspring can successfully 'blackmail' their parents into providing additional resources.     

Negotiation versus consultation in the development of a regulation

Under negotiated regulation, stakeholders are invited to reach an agreement on a regulatory innovation. This approach might be harmful, because potential improvements might be blocked. However, negotiation can also be beneficial—eliciting information about how to improve regulations. Three reasons are identified. First, a participant might hesitate to provide information, unless she can prevent that information being used against her interests. Second, negotiation provides stronger incentives than consultation does, to suggest innovations that primarily benefit parties other than oneself. Third, if uninformed stakeholders can reduce the no-information payoff of informed parties, those parties lose the incentive to strategically withhold information.      

The financial status of the Social Security and Medicare programs (1990)

To summarize the major points I have covered: The Social Security and Medicare trust funds are carefully held and monitored by three five member boards of trustees, and each board has two members who represent the public's interest. The combined Social Security trust funds are well financed for many years into the future; however, there is reason to monitor the financing for the disability insurance trust fund; and actions will in all likelihood ultimately be required to assure the long-term financial integrity of the combined OASDI programs over the next 75 years. The Medicare trust funds are adequately financed for the short term; however, the HI program faces serious mid- and long-range financing problems that must be addressed. As a result, there is a strong need for Congress to take remedial action to improve the financing and provide an adequate contingency reserve for the program.     

An interview with Gail R. Wilensky. Interview by Carmella A. Bocchino

In this interview, conducted just 4 months after assuming her new position as Administrator of HCFA, Dr. Wilensky discusses her goals for the agency, the emergence of Medicaid as a separate bureau, Medicare reimbursement policies, and nurses' potential as recognized health care providers.     

Optimal annuitization, uncertain survival probabilities, and maxmin preferences

We consider a life-cycle model with bequest motives, and assume that the individual does not know his/her survival probability and has maxmin utility preferences; we show that it is optimal not to annuitize but to purchase pure life insurance policies instead.     

Reputation and Survival: Learning in a Dynamic Signalling Model

We consider the impact of reputation on the survival of a monopolist selling single units in discrete time periods, whose quality is learned slowly. If the seller learns her own quality at the same rate as customers, a sufficiently bad run of luck could induce her to stop selling. When she knows her quality, a good seller never stops selling though at low reputations a bad seller does with some probability. Furthermore, a seller with positive, though imperfect, information sells for the same number of periods whether her information is private or public. We further consider the robustness of the central result when the seller's opportunities for strategic behaviour are limited.     

The Hospital-Acquired Conditions (HAC) reduction program: using cranberry treatment to reduce catheter-associated urinary tract infections and avoid Medicare payment reduction penalties

Objective: The Affordable Care Act (ACA) established the Hospital-Acquired Condition (HAC) Reduction Program. The Centers for Medicare and Medicaid Services (CMS) established a total HAC scoring methodology to rank hospitals based upon their HAC performance. Hospitals that rank in the lowest quartile based on their HAC score are subject to a 1% reduction in their total Medicare reimbursements. In FY 2017, 769 hospitals incurred payment reductions totaling $430 million. This study analyzes how improvements in the rate of catheter-associated urinary tract infections (CAUTI), based on the implementation of a cranberry-treatment regimen, impact hospitals’ HAC scores and likelihood of avoiding the Medicare-reimbursement penalty.

Methods: A simulation model is developed and implemented using public data from the CMS’ Hospital Compare website to determine how hospitals’ unilateral and simultaneous adoption of cranberry to improve CAUTI outcomes can affect HAC scores and the likelihood of a hospital incurring the Medicare payment reduction, given results on cranberry effectiveness in preventing CAUTI based on scientific trials. The simulation framework can be adapted to consider other initiatives to improve hospitals’ HAC scores.

Results: Nearly all simulated hospitals improved their overall HAC score by adopting cranberry as a CAUTI preventative, assuming mean effectiveness from scientific trials. Many hospitals with HAC scores in the lowest quartile of the HAC-score distribution and subject to Medicare reimbursement reductions can improve their scores sufficiently through adopting a cranberry-treatment regimen to avoid payment reduction.

Limitations: The study was unable to replicate exactly the data used by CMS to establish HAC scores for FY 2018. The study assumes that hospitals subject to the Medicare payment reduction were not using cranberry as a prophylactic treatment for their catheterized patients, but is unable to confirm that this is true in all cases. The study also assumes that hospitalized catheter patients would be able to consume cranberry in either juice or capsule form, but this may not be true in 100% of cases.

Conclusion: Most hospitals can improve their HAC scores and many can avoid Medicare reimbursement reductions if they are able to attain a percentage reduction in CAUTI comparable to that documented for cranberry-treatment regimes in the existing literature.     

In Memoriam: Ann Chadeau (1944–2002)

Ann Chadeau died in April this year after a long illness. She was 58. Ann was an active member of our Association for many years, serving on the Editorial Board from 1985 to 1990 and on the Council from 1995 to 2000. All those who knew her will be saddened at the loss both for her warm and outgoing personality as well as for her professional abilities.     

Medicare for all or medicare for none? A macroeconomic analysis of healthcare reform

In this study, I develop a novel general equilibrium life cycle model composed of finitely-lived households that differ according to age, skill level, and access to employer-provided health insurance. After introducing a “Medicare for all” health insurance system to the model, I examine how the welfare response to this policy change will differ according to household characteristics. Then, I compare this system to a completely privatized health insurance system that achieves universal health insurance coverage through the creation of utilization-based premium subsidies. In general, both systems tend to improve the welfare of young households at the expense of old households. However, when using average value-of-life as the primary measure of welfare, Medicare for all either benefits unskilled households at the expense of skilled households, or makes both worse off. In contrast, the privatized system improves the average value-of-life of all household groups, regardless of skill level or prior access to employer-provided health insurance.     

替吉奥联合奥沙利铂在晚期结肠癌化疗中的临床效果及不良反应

目的 探讨晚期结肠癌患者应用替吉奥联合奥沙利铂化疗治疗的临床效果及不良反应发生情况.方法 选取2018年1—12月沈阳市肛肠医院收治的70例晚期结肠癌患者作为研究对象,采用随机双盲法分为观察组与对照组,各35例.观察组采用替吉奥联合奥沙利铂行化疗治疗,对照组采用奥沙利铂行化疗治疗,比较两组患者化疗期间不良反应发生率、治...     

Long‐term care and pay‐for‐performance programs

Pay‐for‐performance programs are gradually spreading across Asia. This paper builds on the longer experience in the United States to offer lessons for Asia. The Center for Medicare and Medicaid Services has introduced several pay‐for‐performance programs since 2012 to encourage hospitals to improve quality of care and reduce costs. Some state Medicaid programs have also introduced pay‐for‐performance for nursing homes. Long‐term care providers play an important role in hospital pay‐for‐performance programs because they can affect the readmission rate and also total episode payments. A good pay‐for‐performance program will focus on improving quality of care that affects health outcomes. In addition, that quality must vary across providers and be measurable. Furthermore, it is important that the measures be reported in a timely way, that both demand and supply respond to the measures, and that the measures be risk adjusted. Empirical data from Medicare beneficiaries in the state of Michigan show that mean episode payments and readmission rates in skilled nursing facilities vary widely and are sensitive to the number of observations. These practical matters create challenges for implementing pay‐for‐performance in practice. There is an extensive literature review of pay‐for‐performance in long‐term care in the United States and in Asia.     

Treatment patterns and cost-effectiveness of first line treatment of advanced non-squamous non-small cell lung cancer in Medicare patients

Aim: To assess the cost-effectiveness of first-line pemetrexed/platinum and other commonly administered regimens in a representative US elderly population with advanced non-squamous non-small cell lung cancer (NSCLC).

Materials and methods: This study utilized the Surveillance Epidemiology and End Results (SEER) cancer registry linked to Medicare claims records. The study population included all SEER-Medicare patients diagnosed in 2008–2009 with advanced non-squamous NSCLC (stages IIIB–IV) as their only primary cancer and who started chemotherapy within 90 days of diagnosis. The study evaluated the four most commonly observed first-line regimens: paclitaxel/carboplatin, platinum monotherapy, pemetrexed/platinum, and paclitaxel/carboplatin/bevacizumab. Overall survival and total healthcare cost comparisons as well as incremental cost-effectiveness ratios (ICERs) were calculated for pemetrexed/platinum vs each of the other three. Unstratified analyses and analyses stratified by initial disease stage were conducted.

Results: The final study population consisted of 2,461 patients. Greater administrative censorship of pemetrexed recipients at the end of the study period disproportionately reduced the observed mean survival for pemetrexed/platinum recipients. The disease stage-stratified ICER analysis found that the pemetrexed/platinum incurred total Medicare costs of $536,424 and $283,560 per observed additional year of life relative to platinum monotherapy and paclitaxel/carboplatin, respectively. The pemetrexed/platinum vs triplet comparator analysis indicated that pemetrexed/platinum was associated with considerably lower total Medicare costs, with no appreciable survival difference.

Limitations: Limitations included differential censorship of the study regimen recipients and differential administration of radiotherapy.

Conclusions: Pemetrexed/platinum yielded either improved survival at increased cost or similar survival at reduced cost relative to comparator regimens in the treatment of advanced non-squamous NSCLC. Limitations in the study methodology suggest that the observed pemetrexed survival benefit was likely conservative.     

Default and Renegotiation in Financial Distress in the Multiple Bank Model: An Analysis of the Main Bank System

This paper explores whether the "main bank system" in Japan can be explained by a self-enforcing mechanism that motivates delegated monitorin g creditors to be committed not to execute inefficient liquidation even though all agents are risk-neutral. Using a multiple bank model, we specify a standard debt contract equilibrium in which the delegated monitoring creditor does not care about her reputation, and a main bank contract equilibrium in which the delegated monitoring creditor will attempt to honour the loan contract so as not to destroy her reputation. The results show that, under certain conditions, any equilibrium standard debt contract is dominated by an equilibrium main bank contract in which the debtor and the delegated monitoring creditor are strictly better off. Furthermore, the equilibrium main bank contract reflects the prominent features observed in actual bank loan contracts in Japan.
JEL Classification Numbers: D82, G21, G33, G34     

A K% MONEY GROWTH LEADERSHIP RULE IN AN INTERNATIONAL MONETARY POLICY GAME

This paper examines a version of the Friedman k% money growth rule in an open economy monetary policy game. Using the two-country model proposed by Canzoneri and Henderson (1991), we show that, in response to asymmetric aggregate demand shocks, the Pareto-efficient outcome can be achieved by a policy that we call a k% money growth leadership rule. Following that rule, one country, the leader, sets her money supply growth rate, and the follower sets her money supply growth rate so as to keep the sum of nominal money supply growth at k%. We show that this policy yields the same outcome as does cooperative equilibrium. We also show that alternative policy rules, such as keeping exchange-rate adjusted money supply growth at k%, or forming a currency union, will not lead to the Pareto-efficient outcome in response to these demand shocks. ( JEL E5, F3)     

基于服务贸易拓展的服务型企业国际化战略研究

自20世纪80年代以来,随着全球经济和产业革命的发展,世界服务贸易得到了迅速发展,同时服务贸易主体逐渐由劳动密集型行业向技术和知识密集型行业转变。许多国家普遍认为,扩大国际服务贸易越来越成为发展中国家改善国际贸易地位,提高经济效率及国际竞争力,乃至增加外汇收入、扩大社会就业的重要途径。本文在探讨我国加入WTO后服务贸易发展与服务市场进一步开放的基础上,就中国服务贸易拓展的战略思路及服务型企业国际化战略进行了深入研究,并提出相应的对策建议。     

The Economic Emergence of Women: Bergmann's Six Commitments

I suggest in this essay that Barbara Bergmann's approach to the economics of women is characterized by six striking dimensions, or what I call 'commitments', namely: (1) a willingness to incorporate values into her analysis openly; (2) a commitment to applied economics - economic analysis that supports policy change that will improve women's and children's lives; (3) a commitment to empirical economics, i.e. to data collection and data-based analysis; (4) a commitment to communication with the public; (5) a commitment to the truth even if it challenges convenient orthodoxy; (6) a commitment to focus on how change can occur - to be positive not defeatist. A review of these six commitments, I demonstrate, reveals that they are held together by the first one, her willingness to incorporate values into her scholarly work openly.     

Redistributive Taxation under Ethical Behaviour*

We consider the implications of ethical behaviour on the effect of a redistributive tax‐transfer system. In choosing their labour supplies, individuals take into account whether their tax liabilities correspond to what they view as ethically acceptable. If tax liabilities are viewed as ethically acceptable, a taxpayer behaves ethically, does not distort her behaviour, and chooses to work as if she were not taxed. On the other hand, if ethical behaviour results in tax liabilities that exceed those that are ethically acceptable, she behaves egoistically (partially or fully), distorts her behaviour, and chooses her labour supply taking into account the income tax. We establish taxpayers' equilibrium behaviour and obtain that labour supply is less elastic when taxpayers may behave ethically than when they act egoistically. We characterise and compare the egoistic voting equilibrium linear tax schedules under potentially ethical and egoistic behaviour. We also compare our results to those obtained under altruism, an alternative benchmark.