MEDICAL OUTCOMES IN THE PRICING OF HOSPITAL PROCEDURES

这项建议利用定价行为的经济模型来评估医院质量对主要医疗医院程序价格的影响。医院质量是根据医疗结果来定义的，即低于预期的住院死亡率。我们将重点介绍CABG和PTCA等心脏手术。这些都是相对昂贵但常见的手术，也具有显著的住院死亡率。价格方程的经验规范将从描述医院-保险公司互动的纳什讨价还价模型中推导出来。虽然这个模型最近被用来描述阑尾切除术的定价，但我们进行了进一步的扩展，以纳入产品质量。经验性策略将以工具变量(IV)技术为基础，并接受适当的规格测试。除了质量，价格还将取决于代表医院讨价还价能力(Herfindahl指数、所有权、系统从属关系)、保险公司讨价还价能力(HMO渗透率、市场份额、计划类型)以及患者和临床特征的变量，这些变量考虑了给定程序中的技术差异。模型的统计识别将通过测量医院规模(床位、天数等)、程序比容和执行这些程序的倾向(教学强度、急性和重症监护天数)的质量来实现。根据早期的文献，预计医院容量将改善结果。鉴于我们将重点放在了解价格的机构参与者身上，需要检验的主要假设是，更高的价格反映出更高的质量，保持市场结构不变。我们将进一步研究管理型医疗计划之间的差异，如PPO、EPO和服务点HMO，是否也会导致不同程度的价格折扣。由于紧急护理更有可能发生在保险公司S的网络之外，我们将区分紧急护理和选择性护理。最后，还将考察地区价格差异。核心数据将来自MarketScan索赔数据库1995-1996年的住院部分，以及医院和患者死亡率相匹配的补充档案。这些数据将与MEDPAR、AHA医院年度调查和地区资源文件中的数据元素合并。1995年以前的数据将不会被使用，因为MarketScan还没有包括对保险计划的详细描述。但是，根据1994年的频率，根据程序和选任/紧急情况，最后抽样数预计在每年900至2400之间。

This proposal utilizes economic models of pricing behavior to assess the effects of hospital quality on the prices of major medical hospital procedures. Hospital quality is defined in terms of medical outcomes, i.e., less-than-expected in-hospital mortality rates. We will focus on cardiac procedures such as CABG and PTCA. These are relatively expensive but common procedures that are also characterized by significant in-hospital mortality. The empirical specification of the price equation will be derived from a Nash-bargaining model that describes the hospital-insurer interaction. While this model had been recently used to describe appendectomy pricing, we undertake further extension to incorporate product quality. The empirical strategy will be based on instrumental variable (IV) techniques, subject to appropriate specification tests. Other than quality, prices will depend on variables representing hospital bargaining power (Herfindahl index, ownership, system affiliation), insurer bargaining power (HMO penetration, market share, type of plan) and patient and clinical traits that account for technical variations within a given procedure. Statistical identification of the model will be attained by instrumenting quality on hospital size (beds, days, etc.), procedure specific volume, and propensity to perform these procedures (teaching intensity, acute and intensive care days). Following earlier literature, hospital volume is expected to improve outcomes. Given our focus on price-informed institutional players, the main hypothesis to be tested states that higher prices reflect higher quality, holding market structure constant. We will further examine whether differences between managed care plans, such as PPOs, EPOs, and point-of-service HMOs, also lead to varying degrees of price discounting. Since emergency care is more likely to occur outside an insurer s network we will distinguish between procedure done on an emergent or elective basis. Finally, regional price variation will also be examined. The core data will be drawn from the inpatient component of the MarketScan claims database for 1995-1996, together with a complementary file with matching hospital level and patient level mortality rates. These data will be merged with data elements from MEDPAR, the AHA Annual Survey of Hospitals, and the Area Resource File. Data prior to 1995 will not be used because MarketScan had not yet included a detailed description of insurance plans. However, based on 1994 frequencies, final samples are expected to range from 900 to 2,400 per year, depending on the procedure and elective/emergency setting.