Substitutional effect of long-term care to hospital inpatient care?

In China, many of the top- and second-tier hospitals are overcrowded, this is partly due to the fact they are providing services which can provided by other medical facilities such as long-term care. The implementation of the Qingdao Long-term Care Medical Insurance (LTCMI) which began as a pilot in Qingdao in 2012 may alleviate the burden of overcrowding in these hospitals. In this pilot, the Qingdao government shifted patients who did not require hospital inpatient care from top- and second-tier hospitals to lower tier facilities, care homes and home care to i) reduce the expenditure of patients, ii) reduce the burden on the top- and second-tier hospitals and iii) improve delivery (from a time and geographic perspective) of long term care to those that need such attention.The purpose of this paper is to assess the impact of this policy from a burden and cost perspective. Our finding suggests that there is a reduction in costs to all stakeholders. The total cost to the government-subsidized medical insurance decreases by around $7918 RMB per recipient. The cost to the individual decreases by around $2324 RMB per recipient. Thus, netting a decrease of $10,242 RMB in total expenditure. Furthermore, we find that there is a 12% reduction in inpatient service after a recipient participates in the pilot. Given the reduction in costs and admissions, this does indicate some level of success with the program. This paper concludes by examining the policy implications of these results.     

DEA APPLIED TO A GAUTENG SAMPLE OF PUBLIC HOSPITALS1

The research presented in this paper provides an analysis of the delivery of a few health care services by the public sector in Gauteng, South Africa. The data for the study was especially difficult to collect, suggesting the need for hospital level data information systems, as well as staff who are trained to analyze the information collected. The empirical results from the analysis suggest that services provided by small‐scale medical facilities waste fewer resources, while medical centres offering more technical services, such as surgeries, also appear to deliver medical services more efficiently.     

Health care cost of floods: Evidence from Typhoon Morakot in Taiwan

Using the difference-in-difference (DID) method, this study uses Typhoon Morakot, which occurred in August 2009, as an example to estimate the effect of flooding on health care cost burden. The main data source is the medical claims records of a cohort of three million patients in Taiwan’s National Health Insurance system. By examining flood-related physiological diseases and disaster-related mental illnesses, our results indicate that the increase in outpatient health care costs resulting from the flood caused by the typhoon is approximately NTD 8.95 billion (USD 280 million), equivalent to approximately 69% of the annual special budget for flooding prevention during the period 2006–2019 in Taiwan. Moreover, the increase in outpatient expenditure for mental illnesses is nearly 10 times that of physiological diseases. An important implication of our findings is that the cost of preventing natural disasters, such as floods, can be offset by saving health care costs, particularly for mental illnesses. Our results also suggest that in addition to providing safe drinking water and indoor residual spraying, offering continuous post-disaster mental health services can further save health care expenditures caused by natural disasters.     

Public services for basic needs in Malaysia

This paper reports on results with respect to meeting basic needs from a larger study of the distribution of public expenditure in Malaysia. Both the paper and the larger study heavily rely on a household survey providing data on consumption of public services. The analysis shows that the poorest categories of Malaysians, namely the Malays, rural dwellers, and those living in the North, are the least well served by public utilities. But they are well represented in use of public medical care and primary education. What also emerges is that many of the poor are unable to avail themselves of certain services because their incomes are too low. If more of the poor are to have their children educated to higher levels, the out-of-pocket costs that constitute such a heavy burden for them probably will somehow have to be subsidized. If the poor are universally to have pure water and electricity it appears that fundamental changes will have to be made in policies for pricing the consumption of these services to reduce their rates to the poor.     

Estimating the Effect of Individual Time Preferences on the Use of Disease Screening

Economists have long been interested in evaluating the role that time preferences play in a wide range of economic decisions. In the health care arena, time preferences may be an especially important determinant of many decisions—particularly the use of preventative health care. One potential barrier to patient adoption of preventative screening regimens is that they impose current costs on consumers with the hope of lower costs in the future. Using data from a national survey, we jointly estimate latent discount rate and preventative service demand models using a limited information maximum likelihood estimator (iterated M‐estimator). The results suggest that discount rates are generally inversely related to the likelihood of most screening tests.     

The effect of HIV on health care in sub‐Saharan Africa

This article is concerned with the hitherto neglected area of the effect of HIV on the delivery of health care in sub‐Saharan Africa. The task is hampered by a lack of usable data. In most countries there have been no sentinel HIV surveys, so we have no clear idea of the magnitude of the epidemic. However, it is certain that HIV will alter the demand for health care, and the supply and quality of services.

Demand will grow as infected adults and children seek care. Most HIV‐related illness is found in people who would not normally require care, and therefore creates additional demand. Demand for care will also be determined by the availability and accessibility of services. Ironically, the middle‐income countries may face higher bills, and in this sense the effect of the HIV epidemic may be worse in the more developed world.

The supply of services will be affected by increased morbidity and mortality among health care workers. This is already happening. The generous terms and conditions of service that most governments offer to workers in the public sector will make the problem worse.

HIV has served to improve the quality of health care in most of the developed world. Patients have sought to take control over their own care, and staff have been more rigorous in taking universal precautions. But in developing countries external aid often determines how health care is organised, and money spent on AIDS is diverted from other areas. This may also be true of local funding.

The effect of HIV on health care is lamentably under‐researched. This is particularly worrying as the effects of HIV will be felt first by the health care sector. The problem must be confronted urgently from the point of view of the suppliers of health care services, the users, and the policy‐makers.     

National and International Tests of the New Drug Cost Offset Theory

The new drug cost offset theory argues that new drugs pay for themselves by keeping people out of expensive medical facilities. However, few studies have tested this theory at the macroeconomic level to determine if system‐wide savings actually accrue. This article provides two tests of the new drug cost offset theory by examining the impact of new drugs on aggregate medical care costs using time‐series data for the United States and also by using a panel data set of countries belonging to the Organization for Economic Cooperation and Development. In support of the new drug cost offset theory, the results from both tests imply the typical new drug slows the growth of overall medical care spending.     

政府补助、保险支付与老年临终照料成本——基于2002-2014年CLHLS死亡人口追踪数据的分析

为应对日益增大的老年人照料压力,我国各地试点通过政府补助或社会保险支付的方式满足老人的照料需求。基于2002-2014年CLHLS死亡人口追踪数据,文章用两部分模型、Heckman选择模型和结构方程模型,分析了政府补助、保险支付对老年临终照料直接成本和总成本的影响及其中介机制。研究发现,老年临终照料服务由保险支付的直接成本和总成本都比家庭支付明显更高,政府补助的直接成本比家庭支付更高,保险支付的直接成本比政府补助更高。保险支付和政府补助对照料成本影响的机制存在差异,保险支付主要通过收入效应对照料成本产生显著影响,但替代效应也发挥了中介作用,政府补助则主要通过替代效应对照料成本产生显著影响。文章的研究结论具有重要的政策含义。我国发展长期护理保险,应合理界定政府、市场、社会和家庭对老年人的照料责任,并明确长期护理保险的有限责任,尽量降低可能的收入效应和替代效应对照料成本的影响。     

Supply-induced demand for medical services under price regulation: Evidence from hospital expansion in China

In 2009, China launched a nationwide reform to overhaul its enormous healthcare system. Subsequently, government spending on healthcare increased significantly. Simultaneously, public hospitals experienced rapid expansion. This study empirically examines whether supply-induced demand existed for public hospitals during the expansion process, based on hospital longitudinal data from 2007 to 2016, which is matched with individual patient data. We found that medical expenditure increased rapidly, while the quality of medical services did not change significantly during the hospital expansion. In addition, due to the price regulation of medical services, public hospitals mainly passed on the costs of expansion by inducing hospitalization and diagnostic over-testing. Furthermore, supply-induced demand was more obvious in diseases for which doctors had more asymmetric information. Based on the evidence provided in this study, the expansion of public hospitals has resulted in a waste of healthcare resources and a rise in the healthcare burden on patients. This has certain implications for further deepening the reform of public hospitals.     

Inequity in inpatient healthcare utilisation 10 years after Apartheid

This paper provides evidence about socioeconomic inequity in inpatient healthcare utilisation in South Africa after 10 years of reform after Apartheid, and examines which are the contributing determinants. We use the South African sample of the World Health Survey from 2002–03 and estimate horizontal inequity in inpatient healthcare utilisation using the concentration index. We further decompose inequity in inpatient care to explore the contribution of the different determinants of use. We find that inpatient healthcare utilisation is found to be pro-rich distributed in South Africa. The rich are more likely to use inpatient healthcare than the poor, given the same level of need. In addition, race is found to be the most important contributor (42%) to socioeconomic inequity in inpatient healthcare utilisation in South Africa. Gender, education and the consumption level are also found to be important contributors, but to a lesser degree than race. Our findings provide evidence that socioeconomic inequity in inpatient healthcare utilisation still exists in post-Apartheid South Africa and that policies, regulations and research should contribute to a more equitable utilisation. The implementation of National Health Insurance could help to reduce the major problems and large (socioeconomic and racial) inequalities of the South African healthcare system.     

Poverty,HIV/AIDS and the old age pension in Bhambayi,Kwazulu-Natal,South Africa

To date the international community has tended to direct HIV prevention programmes, treatment, care and supportive services to young adults and children, with little concern about the impact on older people. Since empirical evidence on the socioeconomic impact of HIV/AIDS on households with older persons is lacking, this paper attempts to fill this gap, using data from a household-based survey conducted in Bhambayi, a mixed formal and informal settlement north of eThekwini, KwaZulu-Natal. The findings highlight the links between the uptake of the South African old age pension, poverty and HIV/AIDS in households with older persons. The paper makes recommendations for both government and non-governmental organisations in respect of community-based support systems for such households affected by HIV/AIDS.     

THE ROLE OF SOCIAL GRANTS IN MITIGATING THE SOCIO‐ECONOMIC IMPACT OF HIV/AIDS IN TWO FREE STATE COMMUNITIES1

Social grants may play an important role in mitigating the impact of HIV/AIDS. Eligibility for these grants is driven in part by the increasing burden of chronic illness, the mounting orphan crisis and the impoverishment of households associated with the epidemic. This article investigates the role of social grants in mitigating the socio‐economic impact of HIV/AIDS in South Africa, using data from a panel study on the household impact of the epidemic. Social grants reduce inequality and decrease the prevalence, depth and severity of poverty in affected households. However, these transfers also have disincentive effects on employment, while non‐uptake is in some cases higher amongst the poorest.     

Can Empirical Demand Models Assist in CON Comparative Reviews? A Case Study in Florida

Certificate‐of‐Need (CON) programs for new hospital construction are intended to foster the best selection among competing hospital applications, given demands for hospital care in the community. Yet, the merits of CON depend in part on the quality of the comparative review process. This article examines a case study in Florida to illustrate the utility of empirical evaluations using patient choice models. I estimate such models to show how patients would respond to a change in hospital choices. By simulating the welfare effects of the proposed hospitals, I can further predict how prices of hospital care differ by applicant. Results suggest that empirical analysis using data on patient choice of hospitals may better inform the review process. At the same time, however, it may not give a unique ranking without additional analysis of the fixed costs of proposed services in the context of existing marketwide capacity.     

Restless worlds of work,health and migration: domestic workers in Johannesburg

The lives of migrant women have generally received far less attention than those of their male counterparts. Similarly, male migrants have been the focus of research on the relationship between migration and HIV/AIDS. Little attention has been paid to the vulnerability of female migrants themselves to HIV infection and their access to health care and treatment. Domestic work is the second largest sector of employment for black women in South Africa, and the largest for black women in Johannesburg and, as this article shows, most of these workers are migrants. Based on a survey of 1100 domestic workers in Johannesburg, the article explores the lives of domestic workers, focusing on their experience as migrants, their working conditions, use of health-care services and knowledge of and possible vulnerability to HIV/AIDS.     

公共服务设施步行可达性对住宅价格的影响——基于累积机会的可达性度量方法

构建节能环保低碳的“绿色交通体系”是目前解决城市交通及其一系列衍生问题的重要举措。“将生活与服务混在一起”对于提升步行效能、促进步行和降低机动交通需求有重要的现实意义。公共服务设施步行可达性,反映居民获取公共服务设施的难易程度,对住宅价格具有资本化效应。文章以厦门岛1840个普通多/高层住宅为样本,通过累积机会法评价教育、商业、医疗和文体4种公共服务设施的步行可达性,并构建特征价格方程来检验公共品在住宅市场的资本化方向与程度。研究发现,教育、医疗和商业3类公共服务设施的规划布局已资本化入住宅价格：教育和商业服务步行可达性对住宅价格有正向影响,而二/三甲医院步行可达性有负向影响;省示范小学步行可达性对房价的正向影响大于重点中学;市区级文化体育中心对房价的影响不显著;此外,建筑面积、小区内部环境、商业中心距离等因素对房价都有显著的影响。特征价格模型也实证估计了各特征变量对住宅价格的影响程度。     

The Effect of Service Capability on Operating Costs: An Empirical Study of Ontario Hospitals*

Abstract. We examine variations in the relation between a hospital's level of service capability and the operating costs of its departments and activities (e.g., surgery, laboratory, laundry). We propose a model of the hospital as a set of concentric, interrelated services organized around a core mission to provide patient care. We hypothesize that increases in service capability (i.e., complexity of operations) will increase overall operating costs. At the departmental level, we expect variations in service capability to have a greater cost impact in departments that are closer to the patient. We examine these issues using 1986 data from 154 acute-care hospitals. We disaggregate total operating costs into 18 pools that together account for 84 percent of all operating costs. We find that models with aggregate drivers explain about 90 percent of the variance in overall hospital costs. Complexity is found to be a significant determinant of overall operating costs. At the departmental level, models with department-specific drivers dominate models that employ aggregate drivers. We find that approximately 45 percent of hospital operating costs are significantly associated with the complexity of care provided. There is only limited support for the claim that the effect of the complexity of care provided on operating costs increases as the extent of a department's direct contact with the patient increases. Hence, although our results suggest that the complexity of care should be accounted for in any cost allocation and reimbursement scheme, they also suggest that finding the “right” level of adjustment is a difficult task because complexity differentially affects costs in the various departments. Résumé. Les auteurs examinent les variations observées dans la relation entre le niveau de la capacité de service d'un hôpital, d'une part, et les coûts d'exploitation de ses services et de ses activités (chirurgie, laboratoire, blanchisserie, par exemple), d'autre part. Dans le modèle qu'ils proposent, l'hôpital est une organisation de services concentriques reliés entre eux et qui s'articulent autour d'une mission principale, celle de la prestation de soins aux patients. Ils posent l'hypothèse selon laquelle l'augmentation de la capacité de service (c'est-à-dire de la complexité de l'exploitation) entraîne une hausse des coûts d'exploitation globaux. À l'échelon des services, les variations dans la capacité de service devraient, selon les auteurs, avoir une incidence plus marquée sur les coûts des services qui sont plus près des patients. Ces questions sont analysées à l'aide de données de 1986 relatives à 154 hôpitaux de soins actifs. Les auteurs procèdent à la désagrégation des coûts totaux d'exploitation en 18 groupes de coûts qui, ensemble, représentent 84 pour cent du total des coûts d'exploitation. Ils constatent que les modèles dont les inducteurs de volume sont agrégés expliquent environ 90 pour cent de l'écart dans les coûts globaux des hôpitaux. La complexité, concluent-ils, est un déterminant majeur des coûts globaux d'exploitation. À l'échelon des services, les modèles dont les inducteurs de volume sont propres aux services ont préséance sur les modèles qui font appel à des inducteurs agrégés. Les auteurs constatent qu'environ 45 pour cent des coûts d'exploitation des hôpitaux présentent un lien marqué avec la complexité des soins dispensés. L'affirmation selon laquelle l'incidence de la complexité des soins dispensés sur les coûts d'exploitation augmente avec l'intensité du contact du service avec les patients n'est que faiblement étayée. En conséquence, bien que les résultats obtenus par les auteurs donnent à penser que la complexité des soins doit être prise en compte dans tout plan de répartition et de remboursement des coûts, ces résultats indiquent également que la détermination du niveau approprié d'ajustement est une tâche difficile, étant donné que l'influence de la complexité sur les coûts varie selon les services.     

The role of direct flights in trade costs

Effects of direct flights on trade costs are investigated using micro price data at the city level. After controlling for local retail/distribution costs, traded input prices are obtained to be further used in the measurement of trade costs across cities through arbitrage conditions. The existence of a direct flight enters trade costs regressions negatively and significantly. The results are shown to be robust to the consideration of many control variables, nonlinearities in the effects of distance on trade costs, possible endogeneity of having direct flights between cities and alternative definitions of the data. The direct flights that are shown to be determined by bilateral air services agreements are further shown to reduce trade costs through an endogeneity analysis; the main policy implications are twofold: (i) international trade policies through aviation services, such as Open Skies Agreements of the US, are alternative trade policy tools to reduce international trade barriers; (ii) direct flights facilitate the integration of internal markets as in the case of European Union.     

The economic survival of black physicians: Swimming in turbulent waters

This article presents an analysis of the effects restructuring in the health care sector is likely to have on the economic conditions of black physicians. The model presented of the physicians’ services market is one in which black physicians, because of perceived quality differences and patient preferences, are relegated to servicing the lowest income clients and those with the lowest quality insurance. It is argued that the physician surplus, the growth in the uninsured, and the increasing competition by large group practices, outpatient-care facilities, and HMOs will place additional pressure on black physicians.     

Gatekeeper incentives and demand inducement: An empirical analysis of care managers in the Japanese long-term care insurance program

This study analyzes the incentives and supplier-induced demand of care managers, who are intermediaries between consumers and service providers in the Japanese social insurance program for long-term care. Care managers can be considered as pure gatekeepers, in that their function is limited to referral people to specialists and they themselves do not provide care. Care managers are rewarded by capitation, which is considered as a cost-effective payment mechanism for insurers. However, many care managers actually work for firms that also operate as service providers. Service providers are rewarded by a fee-for-service payment and can have a motivation to induce excess consumer demand. The violation of the neutrality of care managers might result in a financial burden on social insurance. In this study, we empirically test whether there is a positive correlation between care manager density and care costs, which might imply the existence of supplier-induced demand. Our results show a positive correlation, particularly in the case of care managers who work for firms that jointly operate in service provision sectors. Based on these results, we conduct a quantitative analysis, and show that the demand induced by care managers might produce a considerable financial burden on social insurance.