Measuring Hospital Quality and Its Effects on Bargaining

描述（由申请人提供）：本论文将研究构建医院质量的公正措施的方法，然后使用这些措施来评估医院质量如何影响医院-保险公司在强化心脏手术定价背景下的议价结果。首先，本文将着手构建医院质量的公正度量。先前的研究人员已经注意到，由于未观察到疾病的严重程度，从行政数据中得出的医院质量的传统估计可能存在偏差。由于收集更详细的临床数据所涉及的高昂成本，研究人员对使用管理数据来监测医院质量保持了兴趣。最近，研究人员提出使用工具变量的方法——使用线性距离作为工具——来解释未被观察到的疾病严重程度。所提出的论文将产生模拟数据，其中变量之间的相关性是确定的，并且可以通过实验改变，以确定工具变量方法可以产生无偏估计医院质量的条件。其次，本文将确定医院的质量是否对其相对于保险公司的议价能力产生积极影响。为了实现这一点，拟议的论文使用了一个通用的讨价还价模型，明确地说明了双方可用的外部机会。分析将集中在冠状动脉搭桥手术和经皮腔内冠状动脉成形术的议价上。之所以选择这些强化心脏手术，是因为它们是昂贵的手术，经常在医院和保险公司之间的定价谈判中被分割出来，而且它们的特点是院内死亡率相对较高。除了医院质量，其他决定相对议价能力的因素也将被调查（如系统隶属关系、市场集中度和地区HMO渗透）。本论文的核心分析数据文件将从MEDSTAT MarketScan商业索赔和遭遇数据库的住院病人部分提取。要使用的其他数据源包括：医疗保险提供者分析和审查文件；医疗成本与利用项目国家住院病人数据库；美国医院协会年度调查；和区域资源文件。

DESCRIPTION (provided by the applicant): This proposed dissertation will investigate methods to construct unbiased measures of hospital quality and then use these measures to evaluate how hospital quality affects hospital-insurer bargaining outcomes in the context of pricing for intensive cardiac procedures. First, the proposed dissertation will undertake to construct unbiased measures of hospital quality. Previous investigators have noted that conventional estimates of hospital quality derived from administrative data may be biased due to unobserved severity of illness. Because of the prohibitive cost involved in collecting more detailed clinical data, investigators have retained an interest in using administrative data for monitoring hospital quality. Recently, investigators have proposed using the method of instrumental variables-using linear distance as an instrument-to account for unobserved severity of illness. The proposed dissertation will generate simulated data, in which the correlations between variables are known with certainty and can be experimentally altered, to identify the conditions under which the method of instrumental variables can produce unbiased estimates of hospital quality. Second, the proposed dissertation will undertake to determine whether a hospital's quality exerts a positive effect on its bargaining power relative to the insurer. To accomplish this, the proposed dissertation uses a generalized bargaining model that explicitly accounts for the external opportunities available to both parties. The analysis will focus on negotiated prices for coronary artery bypass graft surgery and percutaneous transluminal coronary angioplasty. These intensive cardiac procedures were selected because they are expensive procedures that are frequently carved out in pricing negotiations between hospitals and insurers and because they are characterized by relatively frequent in-hospital mortality. In addition to hospital quality, other determinants of relative bargaining power will be investigated (such as system affiliation, market concentration, and area HMO penetration). The core analytic data file for this dissertation will be drawn from the inpatient component of the MEDSTAT MarketScan Commercial Claims and Encounters Database. Other data sources to be used include: the Medicare Provider Analysis and Review file; the Healthcare Cost and Utilization Project State Inpatient Databases; the American Hospital Association Annual Survey; and the Area Resource File.