Quantifying the defensive medicine contribution to primary care costs

Background:

Defensive medicine represents one cause of economic losses in healthcare. Studies that measured its cost have produced conflicting results.

Objective:

To directly measure the proportion of primary care costs attributable to defensive medicine.

Research design and methods:

Six-week prospective study of primary care physicians from four outpatient practices. On 3 distinct days, participants were asked to rate each order placed the day before on the extent to which it represented defensive medicine, using a 5-point scale from 0 (not at all defensive) to 4 (entirely defensive).

Main outcome measures:

This study calculated the order defensiveness score for each order (the defensiveness/4) and the physician defensive score (the mean of all orders defensiveness scores). Each order was assigned a weighted cost by multiplying the total cost of that order (based on Medicare reimbursement rates) by the order defensiveness score. The proportion of total cost attributable to defensive medicine was calculated by dividing the weighted cost of defensive orders by the total cost of all orders.

Results:

Of 50 eligible physicians, 23 agreed to participate; 21 returned the surveys and rated 1234 individual orders on 347 patients. Physicians wrote an average of 3.6?±?1.0 orders/visit with an associated total cost of $72.60?±?18.5 per order. Across physicians, the median physician defensive score was 0.018 (IQR?=?[0.008, 0.049]) and the proportion of costs attributable to defensive medicine was 3.1% (IQR?=?[0.5%, 7.2%]). Physicians with defensive scores above vs below the median had a similar number of orders and total costs per visit. Physicians were more likely to place defensive orders if trained in community hospitals vs academic centers (OR?=?4.29; 95% CI?=?1.55–11.86; p?=?0.01).

Conclusions:

This study describes a new method to directly quantify the cost of defensive medicine. Defensive medicine appears to have minimal impact on primary care costs.     

On the analysis of a multi-threshold Markovian risk model

We consider a class of Markovian risk models perturbed by a multiple threshold dividend strategy in which the insurer collects premiums at rate c _i whenever the surplus level resides in the i-th surplus layer, i=1, 2, …,n+1 where n<∞. We derive the Laplace-Stieltjes transform (LST) of the distribution of the time to ruin as well as the discounted joint density of the surplus prior to ruin and the deficit at ruin. By interpreting that the insurer, whose gross premium rate is c, pays dividends continuously at rate d _i =c?c _i whenever the surplus level resides in the i-th surplus layer, we also derive the expected discounted value of total dividend payments made prior to ruin. Our results are obtained via a recursive approach which makes use of an existing connection, linking an insurer's surplus process to an embedded fluid flow process.     

Monetary Regime Choice and Optimal Credit Rationing at the Official Rate: The Case of Russia

ABSTRACT

Stabilizing monetary policy in a small open economy is constrained by the open economy trilemma. In this paper, we investigate whether foreign exchange market interventions and the Central Bank’s credit rationing at the official rate (CROR) may soften this constraint and improve the results of monetary policy for different monetary regimes. We construct a dynamic stochastic general equilibrium (DSGE) model appropriate for analyzing the forward-looking behavior of households facing non-zero probabilities of losing access to financial market and CROR. We have found significant credit rationing in the quarterly Russian data of 2001:Q1–2014:Q2. The probability of losing access to financial market and the probability of CROR are estimated as 22% and 66%, respectively. Using Russian data of 2001:Q1–2014:Q2 we demonstrate that CROR provoked forward-looking activity in financial market, which led to more Ruble devaluation in the crises of 2008–2009. It improved poor countercyclical performance of two Russian monetary policy rules, whereas made small effect on welfare. Welfare maximization exercises reveal a tradeoff between low-inflation and high-welfare solutions and favor of a floating exchange rate regime. We found the optimal value of the probability of CROR in both exchange rate-based and Taylor rule-based models but resulting improvement in welfare is very small.     

Determinants of Internationalization Strategies of Emerging Market Firms: A Multilevel Approach

Recently, debates about uniqueness of emerging market firms’ (EMFs) internationalization strategies were a focus of research. Yet, findings regarding their determinants are mixed, and conclusions on how EMFs’ internationalization strategies can be theoretically explained vary greatly. This article elaborates on the underlying reasons for these inconclusive results and addresses them by the development of a multilevel theoretical framework allowing for a better understanding of integrative influence of institutional, sector, and firm-specific determinants of EMFs’ internationalization strategies. This framework is validated by evidence from Russia, and a multiple case study approach is adopted to investigate the determinants of internationalization strategies of Russian firms.     

Why does democracy need education?

Across countries, education and democracy are highly correlated. We motivate empirically and then model a causal mechanism explaining this correlation. In our model, schooling teaches people to interact with others and raises the benefits of civic participation, including voting and organizing. In the battle between democracy and dictatorship, democracy has a wide potential base of support but offers weak incentives to its defenders. Dictatorship provides stronger incentives to a narrower base. As education raises the benefits of civic engagement, it raises participation in support of a broad-based regime (democracy) relative to that in support of a narrow-based regime (dictatorship). This increases the likelihood of successful democratic revolutions against dictatorships, and reduces that of successful anti-democratic coups.     

Models of Multi-Category Choice Behavior

Given the advent of basket-level purchasing data of households, choice modelers are actively engaged in the development of statistical and econometric models of multi-category choice behavior of households. This paper reviews current developments in this area of research, discussing the modeling methodologies that have been used, the empirical findings that have emerged so far, and directions for future research. We also motivate the use of Bayesian methods to overcome the computational challenges involved in estimation.     

Bounds of ruin probabilities

Abstract

Upper and lower bounds are obtained for ruin probabilities with safety margin ρ in the case of known expectation, variance and range for the claim severity function.     

Competition and Industrial Organisation in Transition Markets: What Can We Derive from Empirical Studies?

Competition is the basic concept for both industrial organisation theory and institutional economics. Transition economies, including Russia, are natural laboratories allowing us to trace the emergence of competition, the influence of competition on the conduct of market participants, the relationship between competition and market structure and the institutional foundation of competition. This article provides a summary of the results of empirical studies in the above area. We try to explain some puzzles concerning the influence of competition on the conduct of Russian market participants and interpret the results in the framework of institutional and industrial economics. Overall, the results of empirical studies can be generalised as follows. Competition in Russian markets has been gaining momentum over the last 15 years. The results of empirical studies have confirmed the assumption that competition is an incentive for active restructuring of privatised enterprises. Many of the data collected are evidence in favour of the endogenous market structure approach. From the institutional viewpoint, the history of the evolution of Russia's transition economy shows interdependence between private property and competition: better protection of property rights is a precondition for the development of competition. At the same time, the model of corporate governance that allows the property rights of private owners to be protected in the Russian institutional environment restricts organisational diversity and therefore competition in Russian markets.     

Short-term predictability of equity returns along two style dimensions

This study uses daily return data on 20 portfolios split along two dimensions, growth/value and market size, over the period of four decades and employs over 12,000 trading rules to investigate the short-term predictability of portfolio returns. It shows that, historically, portfolios of small stocks and value stocks have been more suitable for active trading strategies since returns on value portfolios exhibit more predictability than returns on growth portfolios and returns on portfolios of large stocks appear to be less predictive than returns on portfolios of small stocks. The predictive ability of trading rules is all but gone during the 2000s. Popularization of exchange-traded funds and the introduction of quote decimalization on the exchanges are the most likely reasons behind the lack of predictability.