Measuring Hospital Quality and Its Effects on Bargaining

描述(由申请人提供)：本论文将调查构建医院质量无偏衡量标准的方法，然后使用这些衡量标准来评估在强化心脏手术定价的背景下，医院质量如何影响医院与保险公司的谈判结果。首先，本文将致力于构建医院质量的无偏衡量标准。之前的调查人员已经注意到，由于没有观察到疾病的严重性，从行政数据得出的对医院质量的传统估计可能是有偏见的。由于收集更详细的临床数据所涉及的高昂成本，研究人员一直对使用管理数据来监测医院质量保持兴趣。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--来解释未观察到的疾病严重程度。这篇论文将产生模拟数据，其中变量之间的相关性是确定无疑的，并且可以通过实验来改变，以确定工具变量方法在什么条件下可以产生对医院质量的无偏估计。其次，本文将致力于确定医院的质量是否会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，本文使用了一个广义的讨价还价模型，该模型明确地考虑了双方都可以获得的外部机会。分析将集中在冠状动脉搭桥术和经皮冠状动脉腔内成形术的谈判价格上。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达成协议，而且它们的特点是相对频繁的住院死亡。除了医院质量，还将调查相对议价能力的其他决定因素(如系统从属关系、市场集中度和地区医疗保险渗透率)。本文的核心分析数据文件将来自MedSTAT MarketScan商业索赔和遭遇数据库的住院部分。其他要使用的数据来源包括：医疗保险提供者分析和审查文件；医疗保健成本和利用项目状态住院患者数据库；美国医院协会年度调查；以及区域资源文件。

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.