Les permis d’émission et les charges : efficacité et substituabilité

Cet article examine l’effet des technologies polluantes sur l’efficacité de l’échange des permis d’émissions. Nous démontrons que la capacité des entreprises à substituer les polluants, lorsqu’il y a absence de marché pour certains d’entre eux, fera probablement obstacle à l’efficacité dynamique normalement attribuée aux instruments de marché. Il est à noter que le régulateur dispose d’une mesure qui lui permet d’évaluer l’ampleur de ce problème. Par ailleurs, on examine la façon dont le gouvernement peut s’approprier la rente provenant de l’échange de permis alloués gratuitement. Nous comparons les effets de quatre méthodes d’appropriation de rente, soit une surcharge sur le prix des permis d’émission, une charge sur les profits, une charge sur le produit et une charge sur le transfert des permis d’émission. On démontre que ces méthodes d’appropriation de rente ont des effets différents sur l’efficacité des permis d’émission transférables. L’analyse de ces méthodes est faite dans un contexte où le régulateur fait face à de l’information imparfaite et où les entreprises peuvent substituer les polluants.This paper examines how the pollution generating technologies of firms affect the efficacy of tradeable emission permits. It is shown that the ability of firms to substitute among pollutants whenever markets are missing for a subset of pollutants is likely to prevent the dynamic efficiencies normally attributed to market based instruments. We argue that regulators have a readily implementable rule for assessing the extent of this problem. The paper also examines how the government may capture the scarcity rent that accrues to tradeable permits allocated gratis. We compare the effects of four possible methods of rent capture: an emissions permit rental charge, profit charge, output charge, and an emissions permit transfer charge. These methods of rent capture are shown to have different impacts on the efficiency of tradeable emission permits. The methods of rent capture are also examined whenever the regulator faces imperfect information and firms can substitute among pollutants

Les permis d’émission et les charges : efficacité et substituabilité

This paper examines how the pollution generating technologies of firms affect the efficacy of tradeable emission permits. It is shown that the ability of firms to substitute among pollutants whenever markets are missing for a subset of pollutants is likely to prevent the dynamic efficiencies normally attributed to market based instruments. We argue that regulators have a readily implementable rule for assessing the extent of this problem. The paper also examines how the government may capture the scarcity rent that accrues to tradeable permits allocated gratis. We compare the effects of four possible methods of rent capture: an emissions permit rental charge, profit charge, output charge, and an emissions permit transfer charge. These methods of rent capture are shown to have different impacts on the efficiency of tradeable emission permits. The methods of rent capture are also examined whenever the regulator faces imperfect information and firms can substitute among pollutants. Cet article examine l’effet des technologies polluantes sur l’efficacité de l’échange des permis d’émissions. Nous démontrons que la capacité des entreprises à substituer les polluants, lorsqu’il y a absence de marché pour certains d’entre eux, fera probablement obstacle à l’efficacité dynamique normalement attribuée aux instruments de marché. Il est à noter que le régulateur dispose d’une mesure qui lui permet d’évaluer l’ampleur de ce problème. Par ailleurs, on examine la façon dont le gouvernement peut s’approprier la rente provenant de l’échange de permis alloués gratuitement. Nous comparons les effets de quatre méthodes d’appropriation de rente, soit une surcharge sur le prix des permis d’émission, une charge sur les profits, une charge sur le produit et une charge sur le transfert des permis d’émission. On démontre que ces méthodes d’appropriation de rente ont des effets différents sur l’efficacité des permis d’émission transférables. L’analyse de ces méthodes est faite dans un contexte où le régulateur fait face à de l’information imparfaite et où les entreprises peuvent substituer les polluants.

Comparative Efficiency Assessment of Primary Care Models Using Data Envelopment Analysis

This paper compares the productive efficiencies of four models of primary care service delivery in Ontario, Canada, using the data envelopment analysis (DEA) method. Particular care is taken to include quality of service as part of our output measure. The influence of the delivery model on productive efficiency is disentangled from patient characteristics using regression analysis. Significant differences are found in the efficiency scores across models and within each model. In general, the fee-for-service arrangement ranks the highest and the community-health-centre model the lowest in efficiency scoring. The reliance of our input measures on costs and number of patients, clearly favours the fee-for-service model. Patient characteristics contribute little to explaining differences in the efficiency ranking across the models.Productive Efficiency; DEA; Primary Health Care

The impact of the diabetes management incentive on diabetes-related services: evidence from Ontario, Canada.

Financial incentives have been introduced in several countries to improve diabetes management. In Ontario, the most populous province in Canada, a Diabetes Management Incentive (DMI) was introduced to family physicians practicing in patient enrollment models in 2006. This paper examines the impact of the DMI on diabetes-related services provided to individuals with diabetes in Ontario. Longitudinal health administrative data were obtained for adults diagnosed with diabetes and their family physicians. The study population consisted of two groups: DMI group (patients enrolled with a family physician exposed to DMI for 3 years), and comparison group (patients affiliated with a family physician ineligible for DMI throughout the study period). Diabetes-related services was measured using the Diabetic Management Assessment (DMA) billing code claimed by patient\u27s physician. The impact of DMI on diabetes-related services was assessed using difference-in-differences regression models. After adjusting for patient- and physician-level characteristics, patient fixed-effects and patient-specific time trend, we found that DMI increased the probability of having at least one DMA fee code claimed by patient\u27s physician by 9.3% points, and the probability of having at least three DMA fee codes claimed by 2.1% points. Subgroup analyses revealed the impact of DMI was slightly larger in males compared to females. We found that Ontario\u27s DMI was effective in increasing the diabetes-related services provided to patients diagnosed with diabetes in Ontario. Financial incentives for physicians help improve the provision of targeted diabetes-related services

Family physician remuneration schemes and specialist referrals: Quasi-experimental evidence from Ontario, Canada.

Understanding how family physicians respond to incentives from remuneration schemes is a central theme in the literature. One understudied aspect is referrals to specialists. Although the theoretical literature has suggested that capitation increases referrals to specialists, the empirical evidence is mixed. We push forward the empirical research on this question by studying family physicians who switched from blended fee-for-service to blended capitation in Ontario, Canada. Using several health administrative databases from 2005 to 2013, we rely on inverse probability weighting with fixed-effects regression models to account for observed and unobserved differences between the switchers and nonswitchers. Switching from blended fee-for-service to blended capitation increases referrals to specialists by about 5% to 7% per annum. The cost of specialist referrals is about 7 to 9% higher in the blended capitation model relative to the blended fee-for-service. These results are generally robust to a variety of alternative model specifications and matching techniques, suggesting that they are driven partly by the incentive effect of remuneration. Policy makers need to consider the benefits of capitation payment scheme against the unintended consequences of higher referrals to specialists

Stirring the pot: Switching from blended fee-for-service to blended capitation models of physician remuneration.

In Canada\u27s most populous province, Ontario, family physicians may choose between the blended fee-for-service (Family Health Group [FHG]) and blended capitation (Family Health Organization [FHO] payment models). Both models incentivize physicians to provide after-hours (AH) and comprehensive care, but FHO physicians receive a capitation payment per enrolled patient adjusted for age and sex, plus a reduced fee-for-service while FHG physicians are paid by fee-for-service. We develop a theoretical model of physician labor supply with multitasking to predict their behavior under FHG and FHO, and estimable equations are derived to test the predictions empirically. Using health administrative data from 2006 to 2014 and a two-stage estimation strategy, we study the impact of switching from FHG to FHO on the production of a capitated basket of services, after-hours services and nonincentivized services. Our results reveal that switching from the FHG to FHO reduces the production of capitated services to enrolled patients and services to nonenrolled patients by 15% and 5% per annum and increases the production of after-hours and nonincentivized services by 8% and 15% per annum

Physician remuneration schemes, psychiatric hospitalizations and follow-up care: Evidence from blended fee-for-service and capitation models.

Psychiatric hospitalizations could be reduced if mental illnesses were detected and treated earlier in the primary care setting, leading to the World Health Organization recommendation that mental health services be integrated into primary care. The mental health services provided in primary care settings may vary based on how physicians are incentivized. Little is known about the link between physician remuneration and psychiatric hospitalizations. We contribute to this literature by studying the relationship between physician remuneration and psychiatric hospitalizations in Canada\u27s most populous province, Ontario. Specifically, we study family physicians (FPs) who switched from blended fee-for-service (FFS) to blended capitation remuneration model, relative to those who remained in the blended FFS model, on psychiatric hospitalizations. Outcomes included psychiatric hospitalizations by enrolled patients and the proportion of hospitalized patients who had a follow-up visit with the FP within 14 days of discharge. We used longitudinal health administrative data from a cohort of practicing physicians from 2006 through 2016. Because physicians practicing in these two models are likely to be different, we employed inverse probability weighting based on estimated propensity scores to ensure that switchers and non-switchers were comparable at the baseline. Using inverse probability weighted fixed-effects regressions controlling for relevant confounders, we found that switching from blended FFS to blended capitation was associated with a 6.2% decrease in the number of psychiatric hospitalizations and a 4.7% decrease in the number of patients with a psychiatric hospitalization. No significant effect of remuneration on follow-up visits within 14 days of discharge was observed. Our results suggest that the blended capitation model is associated with fewer psychiatric hospitalizations relative to blended FFS

Quality of Diabetes Care in Blended Fee-for-Service and Blended Capitation Payment Systems.

OBJECTIVES: In the middle to late 2000s, many family physicians switched from a Family Health Group (FHG; a blended fee-for-service model) to a Family Health Organization (FHO; a blended capitation model) in Ontario, Canada. The evidence on the link between physician remuneration schemes and quality of diabetes care is mixed in the literature. We examined whether physicians who switched from the FHG to FHO model provided better care for individuals living with diabetes relative to those who remained in the FHG model. METHODS: Using longitudinal health administrative data from 2006 to 2016, we investigated the impact of physicians switching from FHG to FHO on 8 quality indicators related to diabetes care. Because FHO physicians are likely to be systematically different from FHGs, we employed propensity-score-based inverse probability-weighted fixed-effects regression models. All analyses were conducted at the physician level. RESULTS: We found that FHO physicians were more likely to provide glycated hemoglobin testing by 2.75% (95% confidence interval [CI], 1.89% to 3.60%), lipid assessment by 2.76% (CI, 1.95% to 3.57%), nephropathy screening by 1.08% (95% CI, 0.51% to 1.66%) and statin prescription by 1.08% (95% CI, 0.51% to 1.66%). Patients under FHOs had a lower estimated risk of mortality by 0.0124% (95% CI, 0.0123% to 0.0126%) per physician per year. However, FHG and FHO physicians were similar for annual eye examination, prescription of angiotensin-converting enzyme inhibitors (or angiotensin II receptor blockers) and patients\u27 risk of avoidable diabetes-related hospitalizations. CONCLUSIONS: Compared with blended fee-for-service, blended capitation payment is associated with a small, but statistically significant, improvement in some aspects of diabetes care

Production of physician services under fee-for-service and blended fee-for-service: Evidence from Ontario, Canada.

We examine family physicians\u27 responses to financial incentives for medical services in Ontario, Canada. We use administrative data covering 2003-2008, a period during which family physicians could choose between the traditional fee for service (FFS) and blended FFS known as the Family Health Group (FHG) model. Under FHG, FFS physicians are incentivized to provide comprehensive care and after-hours services. A two-stage estimation strategy teases out the impact of switching from FFS to FHG on service production. We account for the selection into FHG using a propensity score matching model, and then we use panel-data regression models to account for observed and unobserved heterogeneity. Our results reveal that switching from FFS to FHG increases comprehensive care, after-hours, and nonincentivized services by 3%, 15%, and 4% per annum. We also find that blended FFS physicians provide more services by working additional total days as well as the number of days during holidays and weekends. Our results are robust to a variety of specifications and alternative matching methods. We conclude that switching from FFS to blended FFS improves patients\u27 access to after-hours care, but the incentive to nudge service production at the intensive margin is somewhat limited