MEDICAL OUTCOMES IN THE PRICING OF HOSPITAL PROCEDURES

该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 我们将专注于心脏手术，如CABG和PTCA。 这些是相对昂贵但常见的手术，其特征也是显著的住院死亡率。价格方程的经验规范将来自纳什讨价还价模型，描述了医院-保险公司的相互作用。 虽然这个模型最近被用来描述阑尾切除术的定价，我们进行进一步的扩展，包括产品质量。 经验性战略将以工具变量（IV）技术为基础，并接受适当的规格测试。 除质量外，价格还取决于代表医院议价能力（赫芬达尔指数、所有权、系统从属关系）、保险公司议价能力（HMO渗透率、市场份额、计划类型）以及患者和临床特征的变量，这些变量说明了给定程序中的技术变化。 将通过测量医院规模（床位、天数等）的质量来实现模型的统计识别，手术具体体积和进行这些手术的倾向（教学强度、急性和重症监护天数）。 根据早期的文献，预计医院数量将改善结局。鉴于我们关注的是价格知情的机构参与者，要检验的主要假设是，较高的价格反映了较高的质量，保持市场结构不变。 我们将进一步研究管理式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的网络之外，我们将区分紧急或选择性的程序。最后，还将审查区域价格变化。核心数据将取自1995-1996年MarketScan索赔数据库的住院病人部分，以及医院一级和病人一级死亡率相匹配的补充档案。 这些数据将与来自MEDPAR、AHA年度医院调查和地区资源文件的数据元素合并。 1995年以前的数据将不使用，因为MarketScan尚未包括保险计划的详细说明。 然而，根据1994年的频率，最终样本预计将在每年900至2 400例之间，这取决于手术和择期/急诊情况。

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.