Relative Price, Payer Mix and Regional Variations in Medical Care

描述（由申请人提供）：医疗保险的使用和支出在美国不同地区差异很大（Fisher 2003a, 2003b），高成本地区的额外支出几乎没有已知的价值（Fisher et al., 2009）。人们对这种变化的原因所知甚少。两种相关的普遍假设是，地方规范创造了一个地区的“标志性风格”，而这些高支出是由于太多的医院和医生造成的。在这些假设下，医疗保险和私人支出预计在特定地区具有高度的相似性。在这些假设下，较高的支出水平代表着医疗保险和整个美国医疗体系的纯粹浪费。这些假设证明了一些政策是合理的，包括限制医生和医院的数量，降低高支出地区的医疗保险报销水平。在这项研究中，我们提出并检验了医疗保险的地区差异的不同理论解释。我们通过使用丰富的新可用数据集和其他数据来测试一个广泛熟悉的提供者行为的经济理论来实现这一目标。具体地说，我们将使用来自FAIR Health、Thomson Reuters MarketScan和Medicare Part B的数据来测试医生在Medicare支出上的地域差异是否可以用Medicare相对于其他支付者的盈利能力来解释。我们基于逐步需求的经济模型提出了这一假设。该模型与医疗保险变化相关的核心见解是直截了当的：医疗保险相对于其他支付者的盈利能力影响医疗保险的利用和支出。这是因为医疗服务提供者通过改变他们的付款人组合来应对医疗保险的盈利能力。医疗服务提供者通过改变对私人保险患者的收费来实现这一目标。与成本转移相反，这产生了一个假设，即医疗保险费用变化的减少将与私人保险患者的价格下降相适应。同样与成本抵消相反，这一假设认为，减少医疗保险报销将导致更低，而不是更高，医疗保险的利用率。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。或者前期研究反驳了成本转移假说，支持了逐步需求模型的假设。这加强了完成具体目标2和3的必要性。在具体目标2中，我们将测试成本抵消。在具体目标3中，我们研究了医疗保险支出和利用的地区差异是否以及在多大程度上是由于医生改变了他们的付款人组合，以响应医疗保险相对于私人保险患者的盈利能力。这将

DESCRIPTION (provided by applicant): 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 those 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 hypothesizs 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. Or 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 o 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.