VOLUME RESPONSE TO MEDICARE FEE CUTS WITH MULTI-PAYERS

尽管在20世纪80年代实施了许多成本控制措施， 医生的支出继续以两位数的速度增长。 与 1989年《综合预算调节法》（OBRA 89） 国会批准了一项新的支付医生工资的制度。 根据新 医疗保险系统根据资源免费向医生支付费用 成本，而不是备受诟病的习惯，普遍和合理的 支付系统. OBRA 89和OBRA 90已将医疗保险费用降低了245 “被高估”的程序高达30%以上。 费用 减少的幅度很大， 程序和地理区域。 因此，医疗保险费用的减少 为研究医生对这种疾病的反应创造了一个极好的机会， 随着多个专业组和地理位置的变化，外生费用沿着变化 对照组。 这种情况类似于一个“自然实验” 其中可以对体积响应进行方法学上强有力的估计。 由于缺乏普遍认同的理论模型， 适当的数据来源，以前的研究都不能明确 揭示收入的大小和费用变化的替代效应 在一个多付款人的环境。 拟议研究的目的是 检查音量响应的大小和决定因素，不仅 对于医疗保险服务，但对于那些提供给私人 患者也有保险。 建议的研究有两个具体目的：（1）研究 医疗保险费用减少对医生行为的影响;（2）测试 医生行为的模型，以响应费用的变化，在一个多- 由McGuire和Pauly根据来自Medicare和Medicare的数据制定的付款人系统 和私人支付来源。 这项拟议中的研究将使用来自医疗保险计划的数据源， 和私人保险公司，这是以前没有的。 的 分析数据文件包括（1）详细的排放数据， 专业委员会提供的约250家医院 和医院活动（CPHA）;（2）提供医生定价数据文件 MEDSTAT Systems，Inc.其中载有2004年至2006年期间 100个不同的保险公司，除了医疗保险和医疗补助;（3） 关于医疗保险费用减免和收费价格的信息 医生支付审查委员会（PPRC） 根据BMAD文件编制;（4）美国医院协会年度 医院调查;（5）地区资源档案。 会有45个 在OBRA 89之前的两年期间， OBRA 89后的一段时间和OBRA 90后的12个月。 为研究 使用随时间推移的汇总横截面观察结果，固定效应或 将使用随机效应模型来测试收入的大小， 替代效应。

Despite many cost control measures implemented in the 1980's, Medicare outlays to physicians continued to grow at double-digit rates. With the passage of the Omnibus Budget Reconciliation Act of 1989 (OBRA89), the Congress approved a new system of paying physicians. Under the new system, Medicare pays physicians on a free schedule based on resource costs instead of the much-maligned customary, prevailing and reasonable payment system. OBRA89 and OBRA90 have reduced Medicare fees for 245 "overvalued" procedures by as much as over 30 percent. the fee reductions were substantial in magnitude and varied across both procedures and geographic areas. As a result, Medicare fee reductions create an excellent opportunity for studying physician response to such exogenous fee changes along with multiple specialty groups and geographic comparison groups. This situation is similar to a "natural experiment" where a methodologically strong estimate of volume response can be made. Due to the lack of a generally agreed upon theoretical model and appropriate data sources, none of the previous studies could explicitly reveal the magnitude of income and substitution effects of a fee change in a multi-payer environment. The objective of the proposed study is to examine the magnitude and the determinants of volume response, not only for Medicare services, but for those services provided to privately insured patients as well. There are two specific aims of the proposed study: (1) to examine the impact of Medicare fee reductions on physician behavior; and (2) to test the model of physician behavior in response to fee change in a multi- payer system formulated by McGuire and Pauly with data from both Medicare and private payer sources. The proposed study will use data sources from both the Medicare program and private insurers that have not been made available before. The analytical data file consists of (1) detailed discharge data from approximately 250 hospitals provided by the Commission on Professional and Hospital Activities (CPHA); (2) physician pricing data file provided by MEDSTAT Systems, Inc. which contains summary claims records from over 100 different insurance companies other than Medicare and Medicaid; (3) information regarding Medicare fee reductions and the price charged for physician services by the Physician Payment Review Committee (PPRC) compiled from the BMAD file; (4) American Hospital Association's Annual Survey of Hospitals; and (5) the Area Resource File. There will be 45 months worth of data covering a two-year period before OBRA89, a 9 months period after OBRA89 and a 12 months period after OBRA90. As the study uses pooled cross-sectional observations over time, a fixed-effects or random-effects model will be used to test the magnitude of the income and substitution effects.