Insurance-induced moral hazard: A dynamic model of within-year medical care decision making under uncertainty

Abstract Insurance-induced moral hazard may lead individuals to overconsume medical care. Many studies estimate this overconsumption using models that aggregate medical care decisions up to the annual level. Using employer-employee matched data from the Medical Expenditure Panel Survey (MEPS), I estimate the effect of moral hazard on medical care expenditure using a dynamic model of within-year medical care consumption that allows for endogenous health transitions, variation in medical care prices, and individual uncertainty within a health insurance year. I then calculate moral hazard effects under a second set of conditions that are consistent with the assumptions of most annual decision-making models. The within-year decision-making model produces a moral hazard effect that is 24% larger than the alternative model. I also provide evidence of heterogeneous moral hazard effects, particularly between insured and uninsured individuals, and discuss related policy implications. The paper concludes with a counterfactual policy simulation that implements the individual mandate provision of the 2010 Patient Protection and Affordable Care Act. I find that full implementation of the individual mandate decreases the percentage of uninsured individuals in the population being analyzed from 11.8% to 6.0% and increases average medical care expenditure 77% among the newly insured. JEL Classification: C61, D81, G22, I12, I1

Do maximum waiting times guarantees change clinical priorities for elective treatment? Evidence from Scotland.

The level and distribution of patient waiting times for elective treatment are a major concern in publicly funded health care systems. Strict targets, which have specified maximum waiting times, have been introduced in the NHS over the last decade and have been criticised for distorting existing clinical priorities in scheduling hospital treatment. We demonstrate the usefulness of conditional density estimation (CDE) in the evaluation of the reform using data for Scotland for 2002 and 2007. We develop a modified goodness of fit test to discriminate between models with different numbers of bins. We document a change in prioritisation between different patient groups with longer waiting patients benefiting at the expense of those who previously waited less. Our results contribute to understanding the response of publicly funded health systems to enforced targets for maximum waiting times

Evaluation of a COVID-19 convalescent plasma program at a U.S. academic medical center

Amidst the therapeutic void at the onset of the COVID-19 pandemic, a critical mass of scientific and clinical interest coalesced around COVID-19 convalescent plasma (CCP). To date, the CCP literature has focused largely on safety and efficacy outcomes, but little on implementation outcomes or experience. Expert opinion suggests that if CCP has a role in COVID-19 treatment, it is early in the disease course, and it must deliver a sufficiently high titer of neutralizing antibodies (nAb). Missing in the literature are comprehensive evaluations of how local CCP programs were implemented as part of pandemic preparedness and response, including considerations of the core components and personnel required to meet demand with adequately qualified CCP in a timely and sustained manner. To address this gap, we conducted an evaluation of a local CCP program at a large U.S. academic medical center, the University of North Carolina Medical Center (UNCMC), and patterned our evaluation around the dimensions of the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to systematically describe key implementation-relevant metrics. We aligned our evaluation with program goals of reaching the target population with severe or critical COVID-19, integrating into the structure of the hospital-wide pandemic response, adapting to shifting landscapes, and sustaining the program over time during a compassionate use expanded access program (EAP) era and a randomized controlled trial (RCT) era. During the EAP era, the UNCMC CCP program was associated with faster CCP infusion after admission compared with contemporaneous affiliate hospitals without a local program: median 29.6 hours (interquartile range, IQR: 21.2–48.1) for the UNCMC CCP program versus 47.6 hours (IQR 32.6–71.6) for affiliate hospitals; (P<0.0001). Sixty-eight of 87 CCP recipients in the EAP (78.2%) received CCP containing the FDA recommended minimum nAb titer of ≥1:160. CCP delivery to hospitalized patients operated with equal efficiency regardless of receiving treatment via a RCT or a compassionate-use mechanism. It was found that in a highly resourced academic medical center, rapid implementation of a local CCP collection, treatment, and clinical trial program could be achieved through re-deployment of highly trained laboratory and clinical personnel. These data provide important pragmatic considerations critical for health systems considering the use of CCP as part of an integrated pandemic response

UNC health system hospitals that participated in the CCP EAP and EUA.

(TIFF)</p

Comparisons of recipient factors of time from admission to CCP infusion of EAP participants at UNCMC.

(A) those that were consented in English vs those that required use of a Spanish interpreter, (B) sex, (C) race, (D) ethnicity, (E) age, and (F) blood type. Medians are reported. P values obtained via a non-parametric Mann-Whitney U test. (TIF)</p

Proportions and cumulative titered units collected and transfused during the EAP era at UNCMC.

(A) Monthly proportions of low (gray) versus standard (blue) versus high (black) titered units collected. Percentages at tops of bars are cumulative proportions of standard + high titered units. (B) Monthly proportions of low (gray) versus standard (blue) versus high (black) titered units transfused. Percentages at tops of bars are cumulative proportions of standard + high titered units. (C) Cumulative total units collected and transfused over time, cumulative units with titers ≥1:160 collected and transfused over time, cumulative national supplier units transfused over time.</p

CCP recipient and non-recipient characteristics.

CCP recipient and non-recipient characteristics.</p

CCP administration process schematic.

Steps, eligibility criteria, and personnel involved in administering COVID-19 Convalescent Plasma (CCP) in the inpatient setting at The University of North Carolina Medical Center (UNCMC). The major process events of admission, enrollment, and infusion depicted in Fig 1 are scaled proportionally to the median time intervals spent on these activities at UNCMC. EAP = expanded access program, PCR = polymerase chain reaction, RCT = randomized controlled trial, GI = gastrointestinal, ICU = intensive care unit, ID = infectious diseases, MD = medical doctor, APP = advanced practice provider, RN = registered nurse, NP = nurse practitioner, QC = quality control.</p

Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) constructs.

Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) constructs.</p

Time to CCP infusion comparisons.

(A). Time from admission to enrollment, enrollment to CCP infusion and admission to CCP infusion via the EAP at UNCMC in the ICU (blue open circles) versus the non-ICU (black open squares). (B) Time from admission to CCP infusion via the EAP at UNCMC for those admitted during the day shift (7am-7pm) (middle blue open squares) versus the night shift (7pm-7am) (dark blue squares). Medians are reported. P values obtained via a non-parametric Mann-Whitney U test.</p