Every Monday our authors provide a round-up of some of the most recently published peer reviewed articles from the field. We don’t cover everything, or even what’s most important – just a few papers that have interested the author. Visit our Resources page for links to more journals or follow the HealthEconBot. If you’d like to write one of our weekly journal round-ups, get in touch.
This week’s journal round up-is a special edition featuring a series of papers on health econometrics published in this month’s issue of the Journal of the Royal Statistical Society: Series A.
Healthcare facility choice and user fee abolition: regression discontinuity in a multinomial choice setting. JRSS: A [RePEc] Published October 2016
Charges for access to healthcare – user fees – present a potential barrier to patients in accessing medical services. User fees were touted in the 1980s as a way to provide revenue for healthcare services in low and middle income countries, improve quality, and reduce overuse of limited services. However, a growing evidence base suggests that user fees do not achieve these ends and reduce uptake of preventative and curative services. This article seeks to provide new evidence on the topic using a regression discontinuity (RD) design while also exploring the use of RD with multinomial outcomes. Based on South African data, the discontinuity of interest is that children under the age of six are eligible for free public healthcare whereas older children must pay a fee; user fees for the under sixes were abolished following the end of apartheid in 1994. The results provide evidence that removal of user fees resulted in more patients using public healthcare facilities than costly private care or care at home. The authors describe how their non-parametric model performs better, in terms of out-of-sample predictive performance, than the parametric model. And when the non-parametric model is applied to examine treatment effects across income quantiles we find that the treatment effect is among poorer families and that it is principally due to them switching between home care and public healthcare. This analysis supports an already substantial literature on user fees, but a literature that has previously been criticised for a lack of methodological rigour, so this paper makes a welcome addition.
Do market incentives for hospitals affect health and service utilization?: evidence from prospective pay system–diagnosis-related groups tariffs in Italian regions. JRSS: A [RePEc] Published October 2016
The effect of pro-market reforms in the healthcare sector on hospital quality is a contentious and oft-discussed topic, not least due to the difficulties with measuring quality. We critically discussed a recent, prominent paper that analysed competitive reforms in the English NHS, for example. This article examines the effect of increased competition in Italy on health service utlisation: in the mid 1990s the Italian national health service moved from a system of national tariffs to region-specific tariffs in order for regions to better incentivise local health objectives and reflect production costs. For example, the tariffs for a vaginal delivery ranged from €697 to €1,750 in 2003. This variation between regions and over time provides a source of variation to analyse the effects of these reforms. The treatment is defined as a binary variable at each time point for whether the regions had switched from national to local tariffs, although one might suggest that this disposes of some interesting variation in how the policy was enacted. The headline finding is that the reforms had little or no effect on health, but did reduce utilisation of healthcare services. The authors interpret this as suggesting they reduce over-utilisation and hence improve efficiency. However, I am still pondering how this might work: presumably the marginal benefit of treating patients who do not require particular services is reduced, although the marginal cost of treating those patients who do not need it is likely also to be lower as they are healthier. The between-region differences in tariffs may well shed some light on this.
Short- and long-run estimates of the local effects of retirement on health. JRSS: A [RePEc] Published October 2016
The proportion of the population that is retired is growing. Governments have responded by increasing the retirement age to ensure the financial sustainability of pension schemes. But, retirement may have other consequences, not least on health. If retirement worsens one’s health then delaying the retirement age may improve population health, and if retirement is good for you, the opposite may occur. Retirement grants people a new lease of free time, which they may fill with health promoting activities, or the loss of activity and social relations may adversely impact on ones health and quality of life. In addition, people who are less healthy may be more likely to retire. Taken all together, estimating the effects of retirement on health presents an interesting statistical challenge with important implications for policy. This article uses the causal inference method du jour, regression discontinuity design, and the data are from that workhorse of British economic studies, the British Household Panel Survey. The discontinuity is obviously the retirement age; to deal with the potential reverse causality, eligibility for the state pension is used as an instrument. Overall the results suggest that the short term impact on health is minimal, although it does increase the risk of a person becoming sedentary, which in the long run may precipitate health problems.
Other articles on health econometrics in this special issue:
This paper finds evidence that increased between hospital competition does not lead to improved outcomes as patients were choosing hospitals on the basis of information from their social networks. We featured this paper in a previous round-up.
This article considers the problem of modelling non-normally distributed healthcare costs data. Linear models with square root transformations and generalised linear models with square root link functions are found to perform the best.
Not strictly health econometrics, more demographics, this article explores how to make inferences about population mortality rates and trends when there are unreliable population data due to fluctuations in birth patterns. For researchers using macro health outcomes data, such corrections may prove useful.