On Labour Market Policies and Aggregate Unemployment Outflows

This paper is interested in the modelling of the relationship between active and passive labour market policies and the aggregate unemployment outflow rate. Our model is based on a matching function and includes a simple representation of the competition between various groups of job searchers. The empirical analysis uses Belgian data. Faced with variables that are often integrated of order 1 according to the usual tests but which cannot strictly speaking be integrated, we contribute to an important methodological debate by comparing the conclusions of a classical econometric analysis and a cointegration approach.     

Mergers of not-for-profit hospitals in the 1980s: Who were the most likely targets?

Proponents argue that mergers should be encouraged as a legitimate strategy to avert (presumably undesirable) hospital closures. More recently, antitrust activity directed at not-for-profit hospitals has intensified. This study attempts to shed some light on the policy debate by testing whether merger targets are indeed candidates for closure, namely hospitals with persistent losses. Acquisitions of independent not-for-profit hospitals by other hospitals and by multihospital corporations are observed from a national sample for the period 1982–1987. The likelihood of being acquired in during any year within that period is estimated using a discrete-time hazard rate model. We find no evidence to support the notion that hospitals with weak financial indicators are more likely to be acquired. Rather, we find that hospitals with high operating-margins that are located in less regulated markets, and to a certain extent in high-growth markets, are more likely to be acquired. These findings cast doubt on certain predictions found in the theoretical literature, but are in agreement with empirical studies of other industries.     

Optimal Price Rules,Administered Prices and Suboptimal Prevention: Evidence from a Medicare Program

Pricing methodologies in Medicare vary from one component of the system to another, often leading to conflicting incentives. Failure to recognize linkages may result in inefficient allocation of resources and higher overall costs. To motivate the analysis, I derive pricing rules for a welfare-maximizing regulator. I show that while optimal inpatient payments are standard Ramsey prices, optimal outpatient payments must incorporate net loss due to unnecessary hospitalizations, as well as supply elasticities. Ignoring this leads the myopic regulator to underprovide preventive services. The dialysis program is a useful case for empirical investigation, since payments for maintenance care are more rigidly determined than payments for related hospital care. Given constant prices, empirical analysis focuses on the effect of dialysis intensity on hospital use. Results indicate that greater dialysis intensity reduces hospital use, even at levels considered more than adequate. A simple cost-benefit calculation suggests that for every dollar of additional spending on outpatient intensity, about $2 in hospital expenditures can be saved. This suggests that the current pricing structure within aspects of the Medicare program is inefficient, underscoring the problem of regulatory myopia.     

Hospital performance standards and medical pricing: The impact of information disclosure in cardiac care

A policy concern is that the initiation of Hospital Compare (HC) reporting in Medicare provided leverage to insurers in price negotiations for lowering private sector prices without regard to hospital performance. Using the sequential Nash bargaining framework we provide economic intuition to the contrary: while average hospital prices decline under quality disclosures, hospitals with above‐average quality are able to exert a stronger bargaining position, consequently capturing prices above the market rate. To explore this issue empirically we estimate variants of difference‐in‐difference models, examining the effects of the three main scores (heart attack, heart failure, and combined mortalities) on transaction prices of related hospital procedures. States which had similar mandated reporting systems in place before the initiation of HC form the control group. Analyzing claims data of privately insured patients, we find that HC exerted downward pressure on prices. However, hospitals rated “above‐average” captured higher prices, thereby offsetting the overall policy effect fully or partially. Leads and lags analysis lends further support for our difference‐in‐difference approach. We find that highly ranked hospitals received a quality premium of 8–14%, comparable to price effects found in other health care markets. We conclude that HC was effective at constraining prices without penalizing high performers.     

A cost-effectiveness analysis comparing the originator follitropin alfa to its biosimilars in patients undergoing a medically assisted reproduction program from a French perspective

Objective: To assess the cost-effectiveness (CE) of the originator follitropin-α (Gonal-F) in patients undergoing a medically assisted reproduction (MAR) program in comparison to its biosimilars Bemfola and Ovaleap in a French context.

Methods: A CE model was developed for France with a National Health Service (NHS) perspective. Clinical, safety, and dosage data were derived from pivotal clinical trials that compared Gonal-F to Ovaleap and Bemfola. Costs pertaining to drugs, hospitalizations, specialist visits, and examinations were retrieved from the French Programme de Médicalisation des Systèmes d'Information (PMSI) hospital database, literature review, and French clinical experts using 2017?Euro tariffs. In order to test the robustness of results, deterministic one-way sensitivity analyses were carried out on the main variables to assess the impact of treatment cost, probability of birth, ovarian hyperstimulation syndrome (OHSS) rates, and dosage.

Results: The average incremental cost per live birth with OHSS and without OHSS was €259.56 and €278.39, respectively, for Gonal-F compared to the pooled biosimilars (i.e. Ovaleap and Bemfola). GONAL-F had an incremental efficacy of 0.06 over the pooled biosimilars. The incremental cost-effectiveness ratio for Gonal-F with OHSS ranged from €3,274.80 to €4,877.76 compared to the pooled biosimilars, owing to the additional live births reported with Gonal-F. Sensitivity analyses also supported results from the base case analyses, with Gonal-F being cost-effective or the dominant strategy in most cases.

Conclusion: Gonal-F seems to be a cost-effective strategy compared to its biosimilars Ovaleap and Bemfola, irrespective of the incidence of OHSS events, but further data are needed to confirm these results.     

Expense preference behavior and management “outsourcing”: a comparison of adopters and non-adopters of contract management in U.S. hospitals

Specialized managerial expertise, coupled with the threat of non-renewal should improve efficiency in firms that opt for contract management arrangements. To examine this we apply a generalized version of tests for expense preference behavior to U.S. hospitals in the 1990s. Extending prior literature, we create a quasi-experimental design for a comparison of adopters and non-adopters of contracts using propensity score methods. We generate the distribution of ‘expense preference’ parameters for all contract adopters in both the pre- and post-adoption states, and for a matched control group of non-adopters over the same period. Our results show that contract adoption leads to reduced expense preference behavior, but that this result depends critically on the input being examined.

Welfare Consequences of Alternative Insurance Contracts in the Mixed For-Profit/Nonprofit Hospital Market

With the advent of managed competition, contingent insurance contracts are replacing traditional fee-for-service plans that were based on pooling principles. Under contingent contracts, insurance is tied to particular providers, while under pooling contracts, insurance is provided for services rendered by all competing providers. To examine the implications of such contracts in hospital care, we model two competing hospitals, a for-profit and a nonprofit, within the framework of a two-stage game. With various assumptions concerning the objectives of the nonprofit, we are able to explore the welfare implications of different insurance contracts and the overprovision problem.     

Expense Preference Behavior and Contract-Management: Evidence from U.S. Hospitals

This paper reports on a study of expense preference behavior in a conditional sample of hospitals (before and after adoption of contract-management arrangements) using an extension of Mester's (1989) test. To identify expense preference parameters, input demand equations are considered in addition to the cost function and are estimated jointly with the cost function as a system of nonlinear equations. Based on this test, contract managers do not appear to be cost minimizers, although they tend to exhibit lower expense preference behavior than salaried managers. The importance of our results, however, goes beyond a single industry because we have shown that estimates of expense preference depend critically upon the particular input demand being studied. Studies that hitherto have relied on single input demand equations or on the cost function alone may have to be reinterpreted in this light.