Jurisdictional Advantage

Our objective in this paper is to define jurisdictional advantage, the recognition that location is critical to firms' innovative success and that every location has unique assets that are not easily replicated. The purpose is to be normative and policy oriented. Drawing from the well-developed literature on corporate strategy, we consider analogies to cities in their search for competitive advantage. In contrast to the more passive term locational advantage, our use of the term jurisdiction denotes geographically-defined legal and political decision-making authority and coordination. Thus, jurisdictions may be constructed and managed to promote a coherent activity set. We review recent advances in our understanding of patterns of urban specialization and the composition of activities within cities, which suggest strategies that may generate economic growth as well as those strategies to avoid. This paper then considers the role of firms and their responsibility to jurisdictions in light of the net benefits received from place-specific externalities, and concludes by considering the challenges to implementing jurisdictional advantage.

A Competitive Bidding Approach to Medicare Reform

Medicare reform is a critical issue for the public agenda. The most promising option for addressing Medicare reform is competitive bidding -- using health plans' bids to determine the government's contribution to a basic set of benefits in every market area. This paper begins with a review of the history of competitive bidding in Medicare. It then moves to a definition of terms, which is crucial in any discussion of competitive pricing because the often-heated public debate around these issues frequently distorts positions and confuses issues by conflating different terms and making some arguments appear other than they are. Following this terminological exercise, the report includes a series of sections discussing competitive bidding in Medicare, with special focus on the challenges to introducing it

Global Budgets and Excess Demand for Hospital Care

Excess demand is a pervasive feature of health care systems that use global budgets to pay for hospital care, regardless of the amount of money spent by those systems. This paper presents a theory that explains this feature of global budgets. The theory emphasizes that hospital administrators control the allocation of their budget, and that they choose quantity and resource intensity to maximize their own utility. The equilibrium quantity of care provided may be less than quantity demanded by consumers, leading to excess demand for admissions. An increase in the hospital’s budget may even be associated with an increase in excess demand.Publicad

The Welfare Consequences of Hospital Mergers

In the 1990s the US hospital industry consolidated. This paper estimates the impact of the wave of hospital mergers on welfare focusing on the impact on consumer surplus for the under-65 population. For the purposes of quantifying the price impact of consolidations, hospitals are modeled as an input to the production of health insurance for the under-65 population. The estimates indicate that the aggregate magnitude of the impact of hospital mergers is modest but not trivial. In 2001, average HMO premiums are estimated to be 3.2% higher than they would have been absent any hospital merger activity during the 1990s. In 2003, we estimate that because of hospital mergers private insurance rolls declined by approximately .3 percentage points or approximately 695,000 lives with the vast majority of those who lost private insurance joining the ranks of the uninsured. Our estimates imply that hospital mergers resulted in a cumulative consumer surplus loss of over $42.2 billion between 1990 and 2001. It is estimated that all but a modest$95.4 million of the loss in consumer surplus is transferred from consumers to providers.

Did the HMO Revolution Cause Hospital Consolidation?

During the 1990s US healthcare markets underwent a significant transformation. Managed care rose to become the dominant form of insurance in the private sector. Also, a wave of hospital consolidation occurred. In 1990, the mean population-weighted hospital Herfindahl-Hirschman Index (HHI) in a Health Services Area (HSA) was .19. By 2000, the HHI had risen to .26. This paper explores whether the rise in managed care caused the increase in hospital concentration. We use an instrumental variables approach with 10-year differences to identify the relationship between managed care penetration and hospital consolidation. Our results strongly imply that the rise of managed care did not cause the hospital consolidation wave. This finding is robust to a number of different specifications.

Susceptibility to intestinal infection and diarrhoea in Zambian adults in relation to HIV status and CD4 count.

BACKGROUND: The HIV epidemic in sub-Saharan Africa has had a major impact on infectious disease, and there is currently great interest in the impact of HIV on intestinal barrier function. A three year longitudinal cohort study in a shanty compound in Lusaka, Zambia, carried out before anti-retroviral therapy was widely available, was used to assess the impact of HIV on susceptibility to intestinal infectious disease. We measured the incidence and seasonality of intestinal infection and diarrhoea, aggregation of disease in susceptible individuals, clustering by co-habitation and genetic relatedness, and the disease-to-infection ratio. METHODS: Adults living in a small section of Misisi, Lusaka, were interviewed every two weeks to ascertain the incidence of diarrhoea. Monthly stool samples were analysed for selected pathogens. HIV status and CD4 count were determined annually. RESULTS: HIV seroprevalence was 31% and the prevalence of immunosuppression (CD4 count 200 cells/microL or less) was 10%. Diarrhoea incidence was 1.1 episodes per year and the Incidence Rate Ratio for HIV infection was 2.4 (95%CI 1.7-3.3; p < 0.001). The disease-to-infection ratio was increased at all stages of HIV infection. Aggregation of diarrhoea in susceptible individuals was observed irrespective of immunosuppression, but there was little evidence of clustering by co-habitation or genetic relatedness. There was no evidence of aggregation of asymptomatic infections. CONCLUSION: HIV has an impact on intestinal infection at all stages, with an increased disease-to-infection ratio. The aggregation of disease in susceptible individuals irrespective of CD4 count suggests that this phenomenon is not a function of cell mediated immunity

Recruitment, training and knowledge transfer in the London Dyers’ Company, 1649-1826

This thesis studies the role of a craft guild as a training organisation. The study looks at the London Dyers’ Company binding and joining records over 150 years, available from the mid seventeenth century to the early nineteenth century. The study initially deals with transmission of knowledge from master to apprentice, a single generation. It then looks at factors associated with chains of transmission over several generations, taking advantage of available occupational specialization data. The Dyers’ Company records of membership are estimated to be at least 94 percent complete from 1710-1792, and probably similarly complete in the earlier period 1660-1710. In 1750, 93 percent and in 1792 81 percent of dyers in livery companies were members of the Dyers’ Company. In those same years, 34 percent in the livery of the Dyers’ Company were not practicing dyers. Chapters 2 and 3 describe the dynamics of the Dyers’ Company from binding and joining information. The apprentice binding data includes information about families of apprentices, their places of residence, their father’s occupation, along with what premia were paid when they were bound. Information is presented about time as a journeyman, about how many apprentices an individual master bound in a lifetime, and about women apprentices and women who bound apprentices. Scattered information about specialized dyeing occupations allowed categorisation of chains of transmission by occupation. One specialty, calico printing, potentially the most innovative of any in the dyeing trade, was not fully represented in the Dyers’ Company records. Sixty one percent of all chains were no more than three generations long. Chains involving silk dyers were more often longer than those involving dyers with no stated specialty. Long chains might either be evidence of technological conservatism, a more technically difficult craft, greater use of innovation, or increased economic activity