Multitasking, Competition and Provider Payment

Many important dimensions of quality health care are difficult to observe, monitor, and motivate. This paper examines how competition among providers interacts with payment system incentives when the allocation of provider effort among multiple such dimensions or ‘tasks’ is noncontractible. The framework highlights that an optimal provider payment system, including optimal risk adjustment, should take account of provider multitasking.payment incentives, competition, multitasking, capitation, managed care, rationing, risk adjustment

Physician Dual Practice: Access Enhancement or Demand Inducement?

In many developing countries, the majority of physicians employed in government clinics also have a private practice. We develop a simple model to show that allowing dual practice helps low-income governments retain skilled physicians to assure patient access. If dual-practice providers differentially refer higher-income patients to private practice, public funding becomes more effectively targeted on the poor. Yet dual practice physicians may also skimp on effort, pilfer supplies, and induce demand. Patterns of care-seeking in Indonesia, especially disproportionate use of private providers by the urban poor, are consistent with exacerbated incentive for physician self-referral to private practice in urban areas.

Measuring Selection Incentives in Managed Care: Evidence from the Massachusetts State Employee Insurance Program

Health economists and policymakers have long recognized that capitation gives insurers incentive to manipulate their offerings to deter the sick and attract the healthy. The shadow-price ap- proach to measuring such selection incentives was pioneered by Frank, Glazer and McGuire (2000). We extend their model to allow for partial capitation and nonfinancial concerns of insurers. We calculate three kinds of selection metrics using managed care medical and pharmacy spending data for fiscal years 2001 and 2002 from the Massachusetts state employee insurance program. Financial returns to risk selection are high, as indicated by all three selection indices as well as by the direct profits an insurer could earn if it could exclude unprofitable patients. Empirically, the financial temptation to distort service quality increases non- linearly with supply-side cost sharing. The more an insurer di- rectly values quality or patient benefit relative to profit, the less severe risk selection incentives become.risk selection; managed health care; shadow price; mixed payment

Hospital Competition under Regulated Prices: Application to Urban Health Sector Reforms in China

We develop a model of public-private hospital competition un- der regulated prices, recognizing that hospitals are multi-service Þrms and that equilibria depend on the interactions of patients, hospital administrators, and physicians. We then use data from China to calibrate a simulation model of the impact of China?s recent payment and organizational reforms on cost, quality and access. Both the analytic and simulation results show how provid- ing implicit insurance through distorted prices leads to over/under use of services by proÞtability, which in turn fuels cost escalation and reduces access for those who cannot a?ord to self-pay for care. Hospital competition for patients will improve social welfare only if policymakers pay careful attention to payment incentives and regulation.

Health Care Payment Incentives: A Comparative Analysis of Reforms in Taiwan, Korea and China

Payment incentives have significant consequences for the equity and efficiency of a health care system, and have recently come to the fore in health policy reforms. This paper first discusses the economic rationale for apparent international convergence toward payment systems with mixed demand and supplyside cost sharing. We then summarize the recent payment reforms undertaken in Taiwan, Korea and China. Available evidence clearly indicates that incentives matter, and that supply-side cost sharing in particular can improve efficiency without undermining equity. Further study and monitoring of quality and selection is warranted.

Health Policy in East Asia: Responding to Demographic and Epidemiologic Transition

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Innovation and shortage: The Yin and Yang of the health sector

The economic challenges countries face when adopting personalized medicine technologies provide an important illustration of many of the concepts articulated by János Kornai in his pioneering research on innovation in market-driven, capitalist surplus economies. In Chinese philosophy, Yin and Yang often represent contradictory yet inseparable opposites – two forces that not merely coexist, but are synergistic and mutually dependent. This concept is an apt analogy for the relationship between innovation and shortage in the health sector. Dangers arise from over-emphasizing the Yin of innovation over the Yang of access, and vice versa. If we over-constrain innovation, we die needlessly early and forfeit quality of life that innovations might have enabled. If we do not distribute access to innovations equitably, we diminish our humanity, suffer backlashes from populism and distrust of science and expertise, and risk social instability, even violent conflict

Provider Choice of Quality and Surplus

We study the quality choices of institutional health-care providers, such as hospitals, assuming that the utility function of the key organizational decision-maker includes both quality of care and financial surplus. An increase in the decision-maker’s rate of surplus retention leads to a decrease (increase) in quality if his coefficient of relative risk aversion is less than (greater than) 1, as is likely when the decision-maker faces prosperous (difficult) financial conditions. Such behavior is consistent with "target income behavior," where the target income is surplus sufficient to break even. An increase in productive efficiency always leads the provider to increase quality.

Managed Health Care and Provider Integration: a Theory of Bilateral Market Power

Recent empirical studies point to the need for a model of bilateral market power between health plans and provider organizations. We develop such a model and use it to analyze the impact on cost and access of alternative contractual relationships between plans and providers. The plans differentiate themselves through distinct, albeit overlapping, provider networks of specialized, complementary inputs (physician groups and hospitals). We analyze subgame perfect strategic pricing equilibria for a range of possible contractual relationships between the upstream providers and the downstream insurers, including different internal organizational structures of vertically integrated health plans, such as group- and staff-model HMOs and PPOs. The model suggests that forms of provider integration that help to overcome pricing coordination failures can have efficiency benefits above and beyond those associated with economies of scope in outpatient and inpatient delivery.managed care, HMO, PPO, networks, physician-hospital organizations, provider integration