Relative Price, Payer Mix and Regional Variations in Medical Care

项目总结/摘要 美国各地区的医疗保险利用率和支出差异很大（Fisher 2003 a，2003 b）， 并且在高成本领域的额外支出几乎没有已知的价值（Fisher等人，2009年）。我们所知的要少得多 这些变化的原因。两个相关的流行假设是，地方规范创造了一个地区的 “签名风格”，以及高支出的结果，太多的医院和医生。根据这些 假设，医疗保险和私人支出预计在给定的时间内具有高度的相似性， 地区在这些假设下，在医疗保险和美国，更高水平的支出纯粹是浪费 整个医疗保健系统。一些政策是合理的，这些假设，包括限制 减少医生和医院的数量，降低高支出地区的医疗保险报销水平。 在这项研究中，我们提出并测试了不同的理论解释医疗保险的区域差异。 我们通过使用一个丰富的，新的数据集与其他数据结合来测试一个广泛的， 供应商行为的经济学理论。具体来说，我们将使用来自FAIR Health，Thomson 路透社MarketScan和医疗保险B部分，以测试医疗保险支出的地理差异是否 医生可以通过医疗保险相对于其他支付者的盈利能力来解释。我们开发了这个 基于逐步需求经济模型的假设。这个模型的核心观点是， 医疗保险的变化是直截了当的：医疗保险的盈利能力相对于其他付款人影响医疗保险 使用和支出。发生这种情况是因为供应商通过改变其 付款人组合。提供者通过改变他们向私人保险患者收取的价格来实现这一点。相反 成本转移，这产生了一个假设，即医疗保险费用变化的减少将得到满足 降低私人保险患者的价格。同样与成本抵消相反，这一假设是， 医疗保险报销的减少将导致医疗保险利用率的降低，而不是提高。 该项目将实现三个具体目标。在具体目标1中，我们将测试成本转移。我们 初步研究否定了成本转移假说，并从逐步的角度支持了这一假说。 需求模型这就更加需要完成具体目标2和3。在具体目标2中，我们将测试 成本抵消。在具体目标3中，我们研究了医疗保险的区域差异是否以及在多大程度上 支出和利用是由于医生改变他们的付款人组合，以应对医疗保险的盈利能力 相对于私人保险的患者。这将确定医疗保险的区域差异百分比 支出是由于医疗保险相对于私人保险患者的盈利能力差异 本研究的广泛、长期目标是指导研究人员和政策制定者理解 医生对医疗保险报销变化的反应和医疗保险变化的来源。这些 结果将告知应实施哪些政策（如果有的话）来减少这些差异。

Project Summary/Abstract Medicare utilization and spending vary substantially across regions of the US (Fisher 2003a, 2003b), and the additional spending in high-cost areas has little known value (Fisher et al., 2009). Far less is known about the causes of such variations. Two related, prevailing hypotheses are that local norms create a region's "signature style", and that high spending results from too many hospitals and physicians. Under these hypotheses, Medicare and private spending are predicted to have a high degree of similarity within a given region. Under these hypotheses, the higher levels of spending represent pure waste in Medicare and in the US health care system as a whole. A number of policies are justified by these hypotheses, including restricting the number of doctors and hospitals and reducing Medicare reimbursement levels in high spending areas. In this study we propose and test a different theoretical explanation of Medicare's regional variations. We accomplish this by using a rich, newly-available dataset in conjunction with other data to test a widely- familiar economic theory of provider behavior. Specifically, we will use data from FAIR Health, Thomson Reuters MarketScan, and Medicare Part B to test whether geographic variations in Medicare spending for physicians can be explained by the profitability of Medicare relative to other payers. We develop this hypothesis based on the economic model of stepwise demand. The central insight from this model relevant to Medicare variations is straightforward: Medicare's profitability relative to other payers affects Medicare utilization and spending. This occurs because providers respond to Medicare's profitability by altering their payer mix. Providers accomplish this by altering the prices they charge to privately-insured patients. Contrary to cost shifting, this yields the hypothesis that reductions in Medicare fee changes would be met with reductions in prices for privately-insured patients. Also contrary to cost offsets, this hypothesizes that reductions in Medicare reimbursement would lead to lower, not higher, Medicare utilization. This project will achieve three specific aims. In Specific Aim 1, we will test for cost shifting. Our preliminary studies contradict the cost-shifting hypothesis and support the hypothesis from the stepwise demand model. This heightens the need to complete Specific Aims 2 and 3. In Specific Aim 2 we will test for cost offsets. In Specific Aim 3 we examine whether and to what extent the regional variations in Medicare spending and utilization are due to physicians altering their payer mix in response to Medicare's profitability relative to privately-insured patients. This will establish what percent of the regional variation in Medicare spending is due to differences in the profitability of Medicare relative to privately-insured patients The broad, long term objective of this study is to guide researchers and policy makers' understanding of physicians' responses to changes in Medicare reimbursement and the source of Medicare variations. These results will inform which policies, if any, should be implemented to reduce these variations.