Chris Sampson’s journal round-up for 27th February 2017

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.

Does it pay to know prices in health care? American Economic Journal: Economic Policy Published February 2017

In the US, people in need of health care have to pay for it – or for insurance to cover it – without knowing in advance how much said health care actually costs. Weird, right? Instinctively, it feels as if people really ought to be able to find out. However, if knowing prices in advance doesn’t actually affect consumption, maybe we can say it really doesn’t matter. Well, we can’t. As this new study shows, having access to price information affects consumer choices. There’s plenty of price dispersion to make this potentially important: in this study’s dataset, a move from the 90th to the 50th percentile is on average associated with a price drop of 35%. The data relate to 387,774 procedures for 6,208 people working for a corporate client of a price information firm. Access to this service was staggered for different employees, creating the potential for experimental investigation. The principal strategy is difference-in-differences regression analysis. Access to the price information service was associated with prices around 1.6% lower on average. For primary care – which might be less price sensitive – and for complex cases where lots of procedures are taking place, the effect is weakened. The results seem robust to matching and other tests. The author is able to provide further insight by showing that access to price information increases the probability of seeing a new doctor by 14%. And when an instrumental variable approach is used to assess the price reduction specifically for people who searched for price information and then received a procedure within 30 days, the reduction in price reaches a whopping 17%. This suggests that the average impact of a 1.6% reduction could be a lot higher if people searched for price information more frequently. The fact that they don’t is likely due to a particular kind of moral hazard being at play. Moral hazard in search occurs when people have no incentive to search for cheaper services. The author goes on to show that in any given week an individual is around 90% less likely to search if they have already met their deductible, and that this translates into an elasticity of search propensity to the proportion out-of-pocket expense of approximately 1.8. We mustn’t forget the other side of the welfare coin here. What if people are choosing lower quality care in order to save money, or foregoing it altogether? Looking at the rate of follow-through after searches and bringing in hospital quality data seems to show that this isn’t a concern here. This group of people aren’t representative of the general population so it may be that access to prices is only valuable to certain groups. Nevertheless, this paper tells us a lot about the importance of price information and in particular the special kind of moral hazard that can arise in the presence of comprehensive insurance coverage.

Mitigating the consequences of a health condition: The role of intra- and interhousehold assistance. Journal of Health Economics Published 20th February 2017

There’s a lot of research around the effect that an individual’s health problem can have on their immediate family, both in terms of the overspill in quality of life impacts and the costs of satisfying need for health care. However, large panel data research can be limited because the data can’t connect non-coresident family members. This study considers informal insurance and consumption smoothing within families beyond the current household. The data come from the Panel Study of Income Dynamics, with 7,578 individuals and around 33,000 household years from 2001-2011. The panel follows offspring after they leave a household, facilitating the identification of genetically linked families. Participants are asked whether they suffer from 11 different health problems and, if they do, the extent to which it limits their daily activities. The data also include information on different categories of spending, including health. The analysis involves regression that accounts for individual fixed effects and looks at the impact of a change in health status on consumption. If a household is fully insured, changes in health status should not affect non-health expenditures. The analysis focuses on the impact of severe limitations, which are reported at some point by 1,321 people. Such a change in health status was associated with a reduction in annual working hours of around 20%, corresponding to $5000 for men and $2800 for women. Additionally, household health expenditures increased by $479 on average. The notion of complete insurance facilitating consumption smoothing appears to fail, with a decline in consumption of around 10%. Partial insurance smoothes roughly half the loss. Households with formal insurance exhibit a much smaller reduction in consumption. A key finding is that being married may facilitate consumption smoothing to the extent of full insurance, while unmarried couples take a bigger hit. Home equity seems to play an important role in this dynamic, with married couples more likely to remortgage in response to a health shock. Married couples also receive more in social security transfers. Unmarried couples, it seems, have to turn to non-coresident family members instead and are 50% more likely to use this channel than married couples. Male children are more likely to use their own home equity to support their parents, while female children tend to reduce their own consumption. This study identifies a lot of interesting relationships and divergent strategies for consumption smoothing that warrant further investigation.

Handling missing data in within-trial cost-effectiveness analysis: a review with future recommendations. PharmacoEconomics – Open Published 9th February 2017

If you conduct trial-based cost-effectiveness analyses then chances are that at some point you’ve had to go and figure out how to deal with all that missing data. There are a handful of quality papers out there that offer guidance. If we all followed their advice then we’d be doing a decent job of it. This new paper demonstrates that we aren’t all doing a good job of it and offers fresh guidance. The paper starts by outlining the ‘principled’ approach to handling missing data. Essentially it means being sensible with the data, considering the most appropriate statistical model and describing assumptions about the missing data mechanism. Imputation methods that can support this principled approach are briefly discussed. The authors present a quality evaluation scheme, which can be used to assess the appropriateness of methods adopted in a study and the completeness of reporting. It makes recommendations with respect to the description of missing data, the methods used to handle it and the limitations associated with the study. The quality evaluation scheme can be used to score and rank papers from A-E. This is what the authors go on to do, with a systematic review including 81 eligible papers. A previous review found complete case analysis to be the most popular base case method adopted. In 2009-2015, multiple imputation became the most frequently used base case method, though complete case analysis remains common and many studies are still unclear about the methods adopted. Most articles did not describe any robustness analysis, reporting only the base case approach to missing data. Many articles were classified as the lowest quality (E), though this has improved over time. The authors demonstrate that their proposed grading system is associated with the strength of the assumptions in the adopted methods. If you’re engaged in trial-based economic evaluation, you ought to read this paper.

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