Relative Price, Payer Mix and Regional Variations in Medical Care

项目摘要/摘要 医疗保险的利用和支出在美国各地区有很大不同(Fisher 2003a，2003b)， 高成本地区的额外支出价值鲜为人知(Fisher等人，2009年)。我们所知的要少得多 关于这种变化的原因。两个相关的、流行的假设是，地方规范创造了一个地区的 “标志性风格”，而这种高支出是由太多的医院和医生造成的。在这些下面 假设，医疗保险和私人支出预计在一个给定的 区域。在这些假设下，在医疗保险和美国，更高的支出水平代表着纯粹的浪费 医疗保健系统作为一个整体。这些假设证明了许多政策的合理性，包括限制 增加医生和医院的数量，并降低高支出地区的医疗保险报销水平。 在这项研究中，我们提出并检验了一种不同的医疗保险地区差异的理论解释。 我们通过使用丰富的、新获得的数据集以及其他数据来测试广泛的 熟悉的供应商行为经济学理论。具体地说，我们将使用来自公平健康，汤姆森的数据 路透社MarketScan和联邦医疗保险B部分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 基于阶梯式需求经济模型的假设。来自该模型的核心见解与 联邦医疗保险的变化很简单：联邦医疗保险相对于其他支付者的盈利能力会影响联邦医疗保险 使用率和支出。之所以会出现这种情况，是因为医疗保险提供商通过改变其 支付者组合。医疗服务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。相反的 对于成本转移，这产生了一种假设，即医疗保险费用变化的减少将满足 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 减少医疗保险报销将导致更低而不是更高的医疗保险利用率。 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。我们的 初步研究与成本转移假说相矛盾，并从循序渐进的角度支持该假说 需求模型。这增加了完成具体目标2和3的必要性。在具体目标2中，我们将测试 成本补偿。在具体目标3中，我们考察了医疗保险的地区差异是否以及差异程度 支出和使用率是由于医生根据联邦医疗保险的盈利能力改变了支付者组合 相对于私人参保的患者。这将确定医疗保险地区差异的百分比 支出是由于联邦医疗保险相对于私人保险患者的盈利能力不同 这项研究的广泛、长期目标是指导研究人员和政策制定者对 医生对联邦医疗保险报销变化的反应以及联邦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)以减少这些差异。

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.