How do Hospitals Respond to Price Changes? Evidence from Norway

Many publicly funded health systems use activity‐based financing to increase hospital production and efficiency. The aim of this study is to investigate whether price changes for different treatments affect the number of patients treated and the mix of activity provided by hospitals. We exploit the variations in prices created by the changes in the national average treatment cost per diagnosis‐related group (DRG) offered to Norwegian hospitals over a period of 5 years (2003–2007). We use the data from Norwegian Patient Register, containing individual‐level information on age, gender, type of treatment, diagnosis, number of co‐morbidities and the national average treatment costs per DRG. We employ fixed‐effect models to examine the changes in the number of patients treated within the DRGs over time. The results suggest that a 10% increase in price leads to about 0.8–1.3% increase in the number of patients treated for DRGs, which are medical (for both emergency and elective patients). In contrast, we find no price effect for DRGs that are surgical (for both emergency and elective patients). Moreover, we find evidence of upcoding. A 10% increase in the ratio of prices between patients with and without complications increases the proportion of patients coded with complications by 0.3–0.4 percentage points. Copyright © 2015 John Wiley & Sons, Ltd.     

How Do Hospitals Respond to Market Entry? Evidence from a Deregulated Market for Cardiac Revascularization

Regulatory entry barriers to hospital service markets, namely Certificate of Need (CON) regulations, are enforced in many US states. Policy makers in other states are considering reinstating CON policies in tandem with service expansions mandated under the Affordable Care Act. Although previous studies examined the volume effects of CON, demand responses to actual entry into local hospital markets are not well understood. In this paper, we empirically examine the demand‐augmenting, demand‐redistribution, and risk‐allocation effects of hospital entry by studying the cardiac revascularization markets in Pennsylvania, a state in which dynamic market entry occurred after repeal of CON in 1996. Results from interrupted time‐series analyses indicate demand‐augmenting effects for coronary artery bypass graft (CABG) and business‐stealing effects for percutaneous coronary intervention (PCI) procedures: high entrant market share mitigated the declining incidence of CABG, but it had no significant effect on the rising trend in PCI use, among patients with coronary artery disease. We further find evidence that entry by new cardiac surgery centers tended to sort high‐severity patients into the more invasive CABG procedure and low‐severity patients into the less invasive PCI procedures. These findings underscore the importance of considering market‐level strategic responses by hospitals when regulatory barriers are rescinded. Copyright © 2014 John Wiley & Sons, Ltd.     

Cigarette Taxes,Smoking—and Exercise?

This research provides the first in‐depth analysis of the effect that increased cigarette taxes have on exercise behavior. Smoking may diminish the ability to exercise; individuals may also use exercise to compensate for the harmful health effects of smoking or to avoid gaining weight if they cut back. Our conceptual model highlights these and several other avenues for effect and reveals that the predicted effect of cigarette costs on exercise behavior is theoretically ambiguous. To investigate the relationship empirically, 1994–2012 data from the behavioral risk factor surveillance system are combined with state level cigarette tax rates and other state level variables. Several measures of both smoking and exercise behavior are created and estimated in reduced form models. Our results suggest that both smoking and exercise are reduced by cigarette taxes. However, the effects on exercise may be more complicated as we find that certain groups, such as young adults or those who have recently quit smoking, are affected differently. Our analyses also show that the responsiveness of both smoking and exercise behavior to cigarette costs is much smaller in the 2000s, an era of high‐tax increases. Copyright © 2016 John Wiley & Sons, Ltd.     

How Well Do Perceptions of Family Planning Service Quality Correspond to Objective Measures? Evidence from Tanzania

This study examines the relationship between common objective measures of quality and perceptions of the quality of family planning facilities. Results of prior research indicate that such perceptions are an important determinant of contraceptive use in rural Tanzania. The data for this study are drawn from two surveys conducted in rural Tanzania. Three models are tested separately for women and for men. The important determinants of perceptions of quality among women and men are: perceived travel time to the facility, availability of immunizations, and availability of maternal and child health services. Additionally, the ratio of the number of staff to outpatients is important to men. The data explain a moderate amount of the variance in the quality measures, indicating that perceived quality is not fully predicted by common objective measures of quality. Future surveys of facility quality should develop objective measures to better predict the perceived quality, with the underlying goal of increasing contraceptive use.     

Do only children have poor vision? Evidence from China's One‐Child Policy

This paper examines whether only children have poor vision by exploiting the quasinatural experiment generated by the Chinese One‐Child Policy. The results suggest that being an only child increases the incidence of myopia by 9.1 percentage points. We further investigate the mechanisms through which being an only child affects the myopia and find that only children, as the only hope in a household, receive higher expectations in terms of academic performance and future educational attainment and pressure to succeed in life from parents, which contribute to the increased myopia. We also find that the school quality of only children is significantly higher than that of non‐only children. This study provides new insights into an important health consequence of One‐Child Policy in China.     

Do consumers respond to publicly reported quality information? Evidence from nursing homes

Public reporting of quality information is designed to address information asymmetry in health care markets. Without public reporting, consumers may have little information to help them differentiate quality among providers, giving providers little incentive to compete on quality. Public reporting enables consumers to choose highly ranked providers. Using a four-year (2000-2003) panel dataset, we examine the relationship between report card scores and patient choice of nursing home after the Centers for Medicare and Medicaid Services began publicly reporting nursing home quality information on post-acute care in 2002. We find that the relationship between reported quality and nursing home choice is positive and statistically significant suggesting that patients were more likely to choose facilities with higher reported post-acute care quality after public reporting was initiated. However, the magnitude of the effect was small. We conclude that there has been minimal consumer response to information in the post-acute care market.     

Do Fertility Control Policies Affect Health in Old Age? Evidence from China's One‐Child Experiment

How do fertility control policies contribute to the welfare of women, and their husbands, particularly as they get older? We consider whether the reduction in fertility resulting from population control policies has had any effect on the health of elderly parents in China. In particular, we examine the influence of this fertility decline, experienced due to China's one‐child policy, on several measures of the health of parents in middle and old age. Overall, our results suggest that having fewer children has a positive effect on self‐reported parental health but generally no effect on other measures of health. The results also suggest that upstream financial transfers have a positive effect on several measures of parental health. Copyright © 2014 John Wiley & Sons, Ltd.     

How to distinguish medicalization from over-medicalization?

Is medicalization always harmful? When does medicine overstep its proper boundaries? The aim of this article is to outline the pragmatic criteria for distinguishing between medicalization and over-medicalization. The consequences of considering a phenomenon to be a medical problem may take radically different forms depending on whether the problem in question is correctly or incorrectly perceived as a medical issue. Neither indiscriminate acceptance of medicalization of subsequent areas of human existence, nor criticizing new medicalization cases just because they are medicalization can be justified. The article: (i) identifies various consequences of both well-founded medicalization and over-medicalization; (ii) demonstrates that the issue of defining appropriate limits of medicine cannot be solved by creating an optimum model of health; (iii) proposes four guiding questions to help distinguish medicalization from over-medicalization. The article should foster a normative analysis of the phenomenon of medicalization and contribute to the bioethical reflection on the boundaries of medicine.

     

Price Changes in Regulated Healthcare Markets: Do Public Hospitals Respond and How?

This paper examines the behaviour of public hospitals in response to the average payment incentives created by price changes for patients classified in different diagnosis‐related groups (DRGs). Using panel data on public hospitals located within the Italian region of Emilia‐Romagna, we test whether a 1‐year increase in DRG prices induced public hospitals to increase their volume of activity and whether a potential response is associated with changes in waiting times and/or length of stay. We find that public hospitals reacted to the policy change by increasing the number of patients with surgical treatments. This effect was smaller in the 2 years after the policy change than in later years, and for providers with a lower excess capacity in the pre‐policy period, whereas it did not vary significantly across hospitals according to their degree of financial and administrative autonomy. For patients with medical DRGs, instead, there appeared to be no effect on inpatient volumes. Our estimates also suggest that an increase in DRG prices had no impact on the proportion of patients waiting more than 6 months. Finally, we find no evidence of a significant effect on patients' average length of stay. Copyright © 2016 John Wiley & Sons, Ltd.     

Do regionally targeted lockdowns alter movement to non-lockdown regions? Evidence from Ontario,Canada

Regionally targeted interventions are being used by governments to slow the spread of COVID-19. In areas where free movement is not being actively restricted, there is uncertainty about how effective such regionally targeted interventions are due to the free movement of people between regions. We use mobile-phone network mobility data to test two hypotheses: 1) do regions targeted by exhibit increased outflows into other regions and 2) do regions targeted by interventions increase outflows specifically into areas with lesser restrictions. Our analysis focuses on two well-defined regionally targeted interventions in Ontario, Canada the first intervention as the first wave subsided (July 17, 2020) and the second intervention as we entered into new restrictions during the onset of the second wave (November 23, 2020). We use a difference-in-difference model to investigate hypothesis 1 and an interrupted time series model to investigate hypothesis 2, controlling for spatial effects (using a spatial-error model) in both cases. Our findings suggest that there that the regionally targeted interventions had a neutral effect (or no effect) on inter-regional mobility, with no significant differences associated with the interventions. We also found that overall inter-regional mobility was associated with socio-economic factors and the distance to the boundary of the intervention region. These findings are important as they should guide how governments design regionally targeted interventions (from a geographical perspective) considering observed patterns of mobility.     

Do food stamps cause obesity? Evidence from immigrant experience

I use changes in immigrant eligibility for food stamps under the 1996 federal law and heterogeneous state responses to set up a natural experiment research design to study the effect of food stamps on Body Mass Index (BMI) of adults in immigrant families. I find that in the post-1996 period food stamps use by foreign-born unmarried mothers with a high school or lower education was 10 percentage points higher in states with substitute programs than in states that implemented the federal ban. However, this increase in FSP participation was not associated with any statistically significant difference in BMI. I find that FSP participation was associated a statistically insignificant 0.3% increase in BMI among low-educated unmarried mothers.     

Do Health Insurance Mandates Spillover to Education? Evidence from Michigan’s Autism Insurance Mandate

Social programs and mandates are usually studied in isolation, but unintended spillovers to other areas can impact individual behavior and social welfare. We examine the presence of spillovers from health care policy to the education sector by studying how health insurance coverage affects the education of students with Autism Spectrum Disorder (ASD). We leverage a state mandate that increased insurance coverage of ASD-related services, which often are provided by both the private sector and within public schools. The mandate primarily affected coverage for children with private health insurance, so we proxy for private insurance coverage with students’ economic disadvantage status and estimate effects via triple-differences. While we find little change in ASD identification, the mandate crowds-out special education supports for students with ASD. A lack of short-run impact on achievement supports our crowd-out interpretation and indicates that the mandate had little net effect on the academic achievement of ASD students.     

Do hospitals respond to changing incentive structures? Evidence from Medicare’s 2007 DRG restructuring

In 2007, the Centers for Medicare and Medicaid restructured the diagnosis related group (DRG) system by expanding the number of categories within a DRG to account for complications present within certain conditions. This change allows for differential reimbursement depending on the severity of the case. We examine whether this change incentivized hospitals to upcode patients as sicker to increase their reimbursements. Using the National Inpatient Survey data from HCUP from 2005 to 2010 and three methods to detect the presence of upcoding, our most conservative estimate is an additional three percent of reimbursement is attributable to upcoding. We find evidence of upcoding in government, non-profit, and for-profit hospitals. We find spillover effects of upcoding impacting not only Medicare payers, but also private insurance companies as well.     

Do health changes affect smoking? Evidence from British panel data

This paper uses seven waves of British Household Panel Survey (BHPS) data to examine the link between health developments while smoking (both one's own and those of other smokers in the same household) and future cigarette consumption. We find those whose health worsens when smoking smoke less in the future, and are more likely to quit. This correlation is consistent with both a Grossman model of health demand (where all parameters are known) and with learning about the health consequences of smoking (where there is uncertainty). There is little effect on smoking from health developments amongst other smokers in the same household. As such, impersonal information provision may have less of an effect on smoking than the delivery of personalised health information, for example through the medical profession.     

Do environmental factors drive obesity? Evidence from international graduate students

International students offer a unique window into the role environmental factors play in driving obesity. Naïve estimates of the relationship between environmental factors and obesity are often plagued by reverse causation, sample selection, and omitted variable bias. In this study, we survey international students at 40 public universities across the United States. We use this unique data to link the weight gain of international students to the prevalence of obesity where they live. We argue that our estimates are less likely to be biased as international students have limited control over the environment to which they are exposed upon arrival in the United States. We find that students living in areas with a higher prevalence of obesity show a biologically important and statistically significantly greater increase in weight as compared to those living in areas with a lower prevalence of obesity. Results provide cautious evidence that environmental characteristics of a region can affect the weight gain of individuals.