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on Health Economics |
| By: | José J Escarce (UCLA); Kanika Kapur (University College Dublin) |
| Abstract: | Rural hospitals play a crucial role in providing healthcare to rural Americans, a vulnerable and underserved population; however, rural hospitals have faced threats to their financial viability and many have closed as a result. This paper examines the hospital characteristics that are associated with patients choosing rural hospitals, and sheds light on the types of patients who depend on rural hospitals for care and, hence, may be the most impaired by the closure of rural hospitals. Using data from California hospitals, the paper shows that patients were more likely to choose nearby hospitals, larger hospitals, and hospitals that offered more services and technologies. However, even after adjusting for these factors, patients had a propensity to bypass rural hospitals in favor of large urban hospitals. Offering additional services and technologies would increase the share of rural residents choosing rural hospitals only slightly. |
| Keywords: | Rural hospitals, hospital choice, rural health |
| Date: | 2009–01–19 |
| URL: | http://d.repec.org/n?u=RePEc:ucn:wpaper:200902&r=hea |
| By: | Robert W Fairlie (University of California); Kanika Kapur (University College Dublin); Susan Gates (RAND) |
| Abstract: | The focus on employer-provided health insurance in the United States may restrict business creation. We address the limited research on the topic of “entrepreneurship lock” by using recent panel data from matched Current Population Surveys. We use difference-indifference models to estimate the interaction between having a spouse with employer-based health insurance and potential demand for health care. We find evidence of a larger negative effect of health insurance demand on the entrepreneurship probability for those without spousal coverage than for those with spousal coverage. We also take a new approach in the literature to examine the question of whether employer-based health insurance discourages entrepreneurship by exploiting the discontinuity created at age 65 through the qualification for Medicare. Using a novel procedure of identifying age in months from matched monthly CPS data, we compare the probability of business ownership among male workers in the months just before turning age 65 and in the months just after turning age 65. We find that business ownership rates increase from just under age 65 to just over age 65, whereas we find no change in business ownership rates from just before to just after for other ages 55-75. Our estimates provide some evidence that "entrepreneurship lock" exists, which raises concerns that the bundling of health insurance and employment may create an inefficient allocation of which or when workers start businesses. |
| Date: | 2009–01–19 |
| URL: | http://d.repec.org/n?u=RePEc:ucn:wpaper:200903&r=hea |
| By: | Cahit Guven; Rudolph Saloumidis |
| Abstract: | World life expectancy has risen by around 20 years in the last 50 years. This period has also witnessed rising happiness levels around the world suggesting that happiness might be one of the causes behind the decline in mortality. We investigate the relationship between happiness and mortality using the German Socio-Economic Panel. We consider doctor visits, self-reported health, and presence of chronic illness as health measures. After controlling for initial health conditions, we find that happiness extends life expectancy. 10 percent increase in happiness decreases probability of death by four percent, and this effect is more pronounced for men and younger people. Happiness plays a more important role for chronically ill people in decreasing mortality than for those who are not chronically ill. The positive influence of happiness on mortality can offset the negative impact of chronic illness. Marriage decreases mortality and this effect appears to work through increased happiness. |
| Keywords: | Happiness, mortality, health, chronic illness |
| JEL: | I10 I12 |
| Date: | 2009 |
| URL: | http://d.repec.org/n?u=RePEc:diw:diwsop:diw_sp198&r=hea |
| By: | Peter Haan; Michal Myck |
| Abstract: | While there is little doubt that the probability of poor health increases with age, and that less healthy people face a more difficult situation on the labour market, the precise relationship between facing the risks of health deterioration and labour market instability is not well understood. Using twelve years of data from the German Socio-Economic Panel we study the nature of the relationship between poor health and non-employment on a sample of German men aged 30-59. We propose to model poor health and non-employment as interrelated risks determined within a dynamic structure conditional on a set of individual characteristics. Applying dynamic panel estimation we identify the mechanism through which poor health contributes to the probability of being jobless and vice versa. We find an important role of unobserved heterogeneity and evidence for correlation in the unobservable characteristics determining the two processes. The results also show strong persistence in the dynamics of poor health and non-employment. |
| Keywords: | Health, non-employment, risk, ageing, dynamic panel data |
| JEL: | C33 J21 J14 |
| Date: | 2009 |
| URL: | http://d.repec.org/n?u=RePEc:diw:diwsop:diw_sp195&r=hea |
| By: | Dennis Petrie; Kam Ki Tang; D.S. Prasada Rao (School of Economics, The University of Queensland) |
| Abstract: | Life expectancy at birth is the most commonly used measure for health system output. However, there are a number of reasons why it may be a poor proxy. First, life expectancy assumes a stationary population and thus does not take into account the current demographic structure of a country; and second, the output of a health system should be measured in terms of the value-added to the population’s health status rather than health status itself. The paper develops a new measure of health system output, the Incremental Life Years to address these problems. The new measure is applied to study health system output, efficiency and total factor productivity in OECD countries for the years 2000 and 2004. The new measure provides different results compared to those based on the traditional life expectancy measure, and the differences are further accentuated when changes in efficiency and productivity are estimated. |
| Date: | 2009 |
| URL: | http://d.repec.org/n?u=RePEc:qld:uq2004:393&r=hea |
| By: | Vladimir M. Shkolnikov (Max Planck Institute for Demographic Research, Rostock, Germany); Evgueni M. Andreev (Max Planck Institute for Demographic Research, Rostock, Germany); Dmitri A. Jdanov (Max Planck Institute for Demographic Research, Rostock, Germany); Domantas Jasilionis (Max Planck Institute for Demographic Research, Rostock, Germany); Tapani Valkonen |
| Abstract: | This study examines the relationship between growing inequality within the population, and the general mortality decline in Finland after 1971. The general mortality trend is considered as a simultaneous shift of population groups toward lower mortality over time, with the group-specific mortality rates linked to the mortality trend in the best practice (vanguard) group. The inequality measure accounting for all groups and their population weights reveals increases in both relative and absolute mortality inequalities. Changes in population composition by education and by marital status tend to compensate each other and the combined change does not produce significant effect on the total mortality. The widening of mortality inequalities produces important impact on the total mortality trend. The modeling allows to quantify this impact. If mortality inequalities remained frozen after 2000, the total mortality in 2026-30 would be by about one quarter lower compared to trend-based expectations. |
| Keywords: | Finland, differential mortality, education, marital status |
| JEL: | J1 Z0 |
| Date: | 2009–06 |
| URL: | http://d.repec.org/n?u=RePEc:dem:wpaper:wp-2009-019&r=hea |
| By: | Nataliia Levchuk (Max Planck Institute for Demographic Research, Rostock, Germany) |
| Abstract: | Ukraine has experienced a long-term decline in life expectancy since the late 1960s. While spectacular improvement in longevity has been observed in Western countries, the trend in Ukraine has been accompanied by increasing or stagnating mortality. Although many studies indicate that alcohol is one of the leading contributors to low life expectancy in Eastern Europe, little is known about its impact on premature mortality in Ukraine. The aim of this study is to estimate alcohol-attributable deaths at working ages (20-64) in Ukraine. We investigate the contribution of alcohol to adult mortality between 1980 and 2007 using a new method for estimating alcohol-attributable fractions by causes of death. We also assess the public health burden of alcohol in terms of length of life losses. We find that in 2007 alcohol-related deaths constituted 40% and 22% of all deaths among adult men and women, respectively. The results also indicate that alcohol-related deaths at working ages account for approximately one-third of the male and one-fifth of the female life expectancy difference between Ukraine and western countries. Alcohol is an important public health threat in Ukraine and should be addressed by relevant measures. |
| JEL: | J1 Z0 |
| Date: | 2009–06 |
| URL: | http://d.repec.org/n?u=RePEc:dem:wpaper:wp-2009-017&r=hea |
| By: | Alex van den Heever (Consulting Health Economist) |
| Abstract: | This study makes particular use of concentration curves to isolate distributional effects and information graphically. The main source for data is the GHS2006. However, the GHS2006 does not provide adequate income date for the incidence analysis. A distribution of household per capita income was consequently developed by the broader project combining income distribution information from the Income and Expenditure Survey of 2006 (Statistics South Africa) with asset information from the GHS2006. Concentration curves are used throughout to demonstrate possible distributional effects within the health system. It is found that the medical scheme population typically makes use of private health providers, while the non-medical scheme population predominantly uses the public provider system. The findings with regard to the non-medical scheme population indicate that certain conditions are biased toward low-income groups while others other biased higher-income groups. Within the former group are Tuberculosis (TB), Diarrhoea, and AIDS. However, AIDS is not as pronounced in the lowest income groups as is the case with TB and HT. Trauma appears to closely follow the equality line, while chronic conditions associated with lifestyle show a slight bias toward higher income groups. Satisfaction with services also differs according to income groups in which individuals are found. |
| Keywords: | National government expenditure, Health |
| JEL: | H5 I1 |
| Date: | 2009 |
| URL: | http://d.repec.org/n?u=RePEc:sza:wpaper:wpapers84&r=hea |
| By: | Markussen, Simen (Ragnar Frisch Centre for Economic Research); Roed, Knut (Ragnar Frisch Centre for Economic Research); Røgeberg, Ole J. (Ragnar Frisch Centre for Economic Research); Gaure, Simen (Ragnar Frisch Centre for Economic Research) |
| Abstract: | Based on comprehensive administrative register data from Norway, we examine the determinants of sickness absence behavior; in terms of employee characteristics workplace characteristics, panel doctor characteristics, and economic conditions. The analysis is based on a novel concept of a worker's steady state sickness absence propensity, computed from a multivariate hazard rate model designed to predict the incidence and the duration of sickness absence for all workers. Key conclusions are i) that most of the cross-sectional variation in absenteeism is caused by genuine employee heterogeneity; ii) that the identity of a person's panel doctor has a significant impact on absence propensity; iii) that sickness absence insurance is frequently certified for reasons other than sickness; and iv) that the recovery rate rises enormously just prior to the exhaustion of sickness insurance benefits. |
| Keywords: | sickness absence, multivariate hazards, MMPH, NPMLE |
| JEL: | C14 C41 H55 I18 J22 |
| Date: | 2009–06 |
| URL: | http://d.repec.org/n?u=RePEc:iza:izadps:dp4240&r=hea |
| By: | Barone, Adriana (University of Salerno); O'Higgins, Niall (University of Salerno) |
| Abstract: | In this paper, we focus on the causes and consequences of adolescent obesity from an economic perspective. The paper examines the determinants of obesity and its role in influencing early school leaving amongst adolescents in the province of Salerno in Southern Italy. A simple human capital investment model is employed and this provides a framework within which to analyse the interrelated 'decisions' regarding schooling and overeating, taking into account the importance of time preference and the differential effects of adolescent obesity for males and females. We find that: a) there is a strong and robust positive effect of obesity on early school leaving; b) there are significant gender differences in the nature of this relationship; and, c) although not statistically significant, there is support for the idea that contextual factors – such as the type of school attended - are important in determining the effects of obesity on early school leaving. These findings have important policy implications. In particular, evidence on the positive causal link running from obesity to early school leaving suggests: i) that action aimed at reducing obesity – such as the encouragement of sporting activity - may also have beneficial effects in terms of reducing early school leaving rates; ii) the introduction of financial incentives to encourage educational participation; and, iii) the significant differences identified between young men and young women suggest the adoption of some gender- specific policy measures. |
| Keywords: | obesity, early school-leaving |
| JEL: | I12 I21 J13 |
| Date: | 2009–06 |
| URL: | http://d.repec.org/n?u=RePEc:iza:izadps:dp4229&r=hea |
| By: | Kumagai, Narimasa |
| Abstract: | Despite a decrease in the number of working generations supporting Japan's social security system, the relationship between public pension benefits and health care expenditures since the inception of universal health insurance system has not been explored. We obtained one stable long-run equilibrium relationship among those three variables over the period from 1966 to 2002. We employed the forecast error variance decomposition to examine the determination of social insurance burden rate. It is found that health care shock was important for the long-run determination of social insurance burden rate. Because it appears that a free health service system for the elderly (health care shock) caused the increase in the doctor's consultation, we estimated the health care function to analyze price policy in the health care sector. We finally accepted the dynamic OLS model with lead lags as an aggregated health care function. The price elasticity of health care has declined in absolute value since the universal health insurance system started, and it has been around 0.6 since the early 1980s. The policy which eliminated health care fees for the elderly in the 1970s was a mistake since the elderly increased their health care expenditures. The out-of-pocket expenses for health care of the elderly should have been raised in the 1970s. |
| Keywords: | cointegration, dynamic OLS, price elasticity of health care, variance decomposition, vector error correction model |
| Date: | 2009–02 |
| URL: | http://d.repec.org/n?u=RePEc:hit:piecis:413&r=hea |
| By: | Hanaoka, Chie |
| Abstract: | In Japan, as in other developed countries, smoking rates have been decreasing among men but it has been increasing among women. The prevalence of smoking may relate to accompanying gender differences in the labor market. The purpose of this paper is to empirically examine how occupation affects smoking behavior, with a particular emphasis on the differential effects for gender. The types of occupations have significant effects on smoking for both men and women, even after controlling for employment status, income, education, and demographic characteristics. Furthermore, the detailed classification of occupation reveals the stark difference in a response to the types of occupations among men and women, while showing the similarity in a response to cigarette price, income and education. The results suggest that smoking cessation policies should be designed more effectively with taking into consideration for gender differences of occupation on smoking. |
| Keywords: | cigarettes, smoking, gender, occupation |
| Date: | 2009–01 |
| URL: | http://d.repec.org/n?u=RePEc:hit:piecis:411&r=hea |
| By: | Iversen, Tor (Institute of Health Management and Health Economics) |
| Abstract: | The literature on supplier inducement suffers from inability to distinguish the effect of better access from the effect of patient shortage. Data from the Norwegian capitation trial in general practice give us an opportunity to make this distinction and hence, study whether service provision by physicians is income motivated. In the capitation trial each general practitioner (GP) has a personal list of patients. The payment system is a mix of a capitation fee and a fee for service. The data set has information on patient shortage, i.e. a positive difference between a GP’s preferred and actual list size, at the individual practice level. From a model of a GP’s optimal choice we derive the optimal practice profile contingent on whether a GP experiences a shortage of patients or not. To what extent GPs, who experience a shortage, will undertake measures to attract patients or embark on a service intensive practice style, depends on the costs of the various measures relative to their expected benefit. The model classifies GPs into five types. In the empirical analysis a panel of GPs is followed for five years. Hence, short-term effects due to transition to a new system should have been overcome. We show that even in the longer run, GPs who experience a shortage of patients have a higher income per listed person than their unrationed colleagues. This result is robust with regard to correction for potential selection bias based on observable and unobservable characteristics. We do not find any significant difference in income per listed person dependent on whether a rationed GP obtains an increase in the number of patients or not. A policy implication is that patient shortage is costly to the insurer because of income motivated behavior of unknown benefit to the patient. |
| Keywords: | Economic motives; Capitation; General practice; Patient shortage; Service provision |
| JEL: | H42 I11 I18 |
| Date: | 2009–06–21 |
| URL: | http://d.repec.org/n?u=RePEc:hhs:oslohe:2003_001&r=hea |
| By: | Sæther, Erik Magnus (Ragnar Frisch Centre for Economic Research) |
| Abstract: | Shift work has a documented negative impact on workers’ health and social life, effects which are compensated for with higher wages and shorter working hours. Many countries face a ‘nursing shortage’, and increasing wages is argued to lead to an increase in the short-term labor supply in health care. Omitting shift work in the evaluation of such policies may lead to biased estimates of the wage elasticities. Focusing on registered nurses (RN) employed in the public health sector, this paper presents an econometric analysis that allows the nurses to compose their ‘job package’ in three steps by choosing: a) hospital or primary care, b) daytime or shift work and c) one of four categories of hours. The utility maximization problem is solved by discretizing the budget set and choosing the optimal job package from a finite set of alternatives. The nested structure is estimated on Norwegian micro data. There is some variation in the responsiveness to wage between shift and day workers and by care level. The job-specific elasticities are small but positive. However, the simulation of a wage increase in all job types, when conditioning the analysis to those already participating in the sector, indicates a slight reduction in hours. Thus, the income effect seems to dominate in the labor supply of nurses. |
| Keywords: | Registered nurses; discrete choice; labor supply; selection; nested logit; sector-specific wages |
| JEL: | C25 I10 J22 |
| Date: | 2009–06–14 |
| URL: | http://d.repec.org/n?u=RePEc:hhs:oslohe:2004_009&r=hea |
| By: | Kravdal, Øystein (Department of Economics) |
| Abstract: | Discrete-time hazard models for cancer mortality in cancer patients were estimated from register and census data to find out whether various socio-economic, ideational and institutional community factors had an impact on cancer survival in Norway in the 1990s, also beyond that of the corresponding individual-level variables. Such a multilevel approach has not been employed in previous analyses of cancer survival. In addition to confirming the better prognosis for patients with high education, it was found that, among patients at the same educational level, mortality was lowest for those who lived in a municipality where the average education was relatively high. The impact of economic resources was less pronounced. While a low unemployment rate in the municipality and high individual income reduced mortality among cancer patients, a high average income had no effect. Also those who lived in municipalities where a large proportion voted with the Christian Democratic Party had an advantage, which suggests a beneficial impact of affiliation with religious communities or support for the central Christian ideas. Moreover, there was an excess mortality among patients who lived in municipalities served by a relatively small hospital that did not have any responsibility beyond the county level. These patients may have got somewhat inadequate treatment at a low level in the hospital structure, or they have perhaps not wanted, or been able to fully comply with, the recommended follow-up treatment at the highest level. Even with such factors included in the model, there was significant regional variation. Cancer survival was relatively poor, net of differences in the stage distribution, in the capital, the central parts of Southern and Western Norway, and the peripheral parts of Southern Norway. |
| Keywords: | Cancer; Hospital; Multilevel; Region; Socio-economic; Survival; Education; Income; Religion; Unemployment |
| JEL: | I19 |
| Date: | 2009–06–14 |
| URL: | http://d.repec.org/n?u=RePEc:hhs:oslohe:2004_008&r=hea |
| By: | Edvardsen, Dag Fjeld (The Norwegian Building Research Institute, Norway); Føsund, Finn R. (Department of Economics); Kittelsen, Sverre A.C. (The Frisch Centre, Norway) |
| Abstract: | The units found strongly efficient in DEA studies on efficiency can be divided into self-evaluators and active peers, depending on whether the peers are referencing any inefficient units or not. The contribution of the paper starts with subdividing the selfevaluators into interior and exterior ones. The exterior self-evaluators are efficient “by default”; there is no firm evidence from observations for the classification. These units should therefore not been regarded as efficient, and be removed from the observations on efficiency scores when performing a two-stage analysis of explaining the distribution of the scores. A method for classifying self-evaluators based on the additive DEA model is developed. The application to municipal nursing- and home care services of Norway shows significant effects of removing exterior self-evaluators from the data when doing a two-stage analysis. |
| Keywords: | Self-evaluator; interior and exterior self-evaluator; DEA; efficiency; referencing zone; nursing homes |
| JEL: | C44 C61 D24 I19 L32 |
| Date: | 2009–06–21 |
| URL: | http://d.repec.org/n?u=RePEc:hhs:oslohe:2003_007&r=hea |
| By: | Lurås, Hilde (Institute of Health Management and Health Economics) |
| Abstract: | The purpose of this paper is to gain more knowledge concerning individuals’ preferences for alternative GPs within a municipality. We have data on the population’s first, second and third choice of GPs. The data stem from the entry form the inhabitant filled in as a result of the implementation of a list patient system in general practice in Norway. To assess the potential demand for GPs3 or individuals’ request for a position on a certain GP’s list, we formulate and estimate a structural demand model based on probabilistic theories of individual choice behaviour. The model originates from the work of Luce (see for instance Luce, 1959 and Block and Marschak, 1960). Such models are successfully used to obtain knowledge of people’s preferences for different transportation vehicles. We raise the question of whether individuals’ choice of GPs is informed or purely random, as well as the question of whether observable demographic characteristics of a GP can tell us anything about the person who wants him or her as a personal physician. We find systematic dependencies between characteristics of an individual and characteristics of his or her choice of a GP. But we also find that the random part plays a major role in the choice process. In the last part of the paper we discuss policy implications of our findings. Central points are both how local health authorities can use the information on rankings to put together collegiums of GPs that serve the need – or the demand – of the inhabitants in the best way, and how a payment system for GPs should be designed if our results should be taken into account. |
| Keywords: | General practitioner; GP; individual preferences |
| JEL: | I18 |
| Date: | 2009–06–21 |
| URL: | http://d.repec.org/n?u=RePEc:hhs:oslohe:2003_005&r=hea |
| By: | Sæther, Erik Magnus (Ragnar Frisch Centre for Economic Research) |
| Abstract: | When entering the job market registered nurses (RNs) face job alternatives with differences in wages and other job attributes. Previous studies of the nursing labor market have shown large earnings differences between similar hospital and non-hospital RNs. Corresponding differences are found in some of the analyses of shift and regular daytime workers. In the first part of this paper I analyze the wage differentials in the Norwegian public health sector, applying a switching regression model. I find no hospital premium for the shift RNs and a slightly negative hospital premium for the daytime RNs, but it is not significant for the hospital job choice. I find a positive shift premium. The wage rate is 19% higher for the shift working hospital RNs and 18% for the sample of primary care workers. The shift premium is only weakly significant for the shift work choice for the sample of hospital RNs, and not for the primary care RNs. I identify some selection effects. In the second part of the paper I focus on the shift compensation only, and present a structural labor supply model with a random utility function. This is done to identify the expected compensating variation necessary for the nurses to remain on the same utility level when they are “forced” from a day job to a shift job. The expected compensating variations are derived by Monte Carlo simulations and presented for different categories of hours. I find that on average the offered combination of higher wages, shorter working hours and increased flexibility overcompensates for the health and social strains related to shift work. |
| Keywords: | Registered nurses; compensating variations; switching regression; random utility models; discrete choice; shift work; labor supply |
| JEL: | C25 I10 J31 J33 |
| Date: | 2009–06–14 |
| URL: | http://d.repec.org/n?u=RePEc:hhs:oslohe:2004_010&r=hea |
| By: | Grepperud, Sverre (Institute of Health Management and Health Economics) |
| Abstract: | This work evaluates policy recommendations on medical error reporting systems presented in, To err is human, a report published by the Institute of Medicine. Here mandatory reporting should be applied for adverse events, while voluntary reporting is recommended for near misses. This analysis shows that an error reporting scheme of this type is not an optimal one since both near misses and adverse events may remain unreported. This work makes evident that penalising health care decision makers for not reporting errors, independent of error category, is crucial for reaching the first-best solution. |
| Keywords: | Microeconomic theory; agency; iatrogenic injury |
| JEL: | D82 I18 K42 |
| Date: | 2009–06–14 |
| URL: | http://d.repec.org/n?u=RePEc:hhs:oslohe:2004_011&r=hea |
| By: | Lurås, Hilde (Institute of Health Management and Health Economics) |
| Abstract: | On June 1, 2001 a reform took place in Norwegian general practice. This implied some advantages of importance to empirical analysis. First, a new organisation and a new payment system were introduced, which makes it possible to perform before-after analysis. Second, the GPs' preferred list-sizes are known, which makes it possible to analyse the effect of patient constraints for individual GPs. Third, the size and composition of patient-lists are known on the individual practice level. Previously, it was not known whether consultations provided during a certain period were given to a large or a small number of persons, and this made it difficult to compare practice styles. If, for instance, two GPs provide the same number of services during one year, but GP A is responsible for twice as many patients as GP B, GP B has a more service-intensive practice style. When information on the number of patients on the list is not known, we might erroneously conclude that A and B have the same practice style. <p> Last, but not least, the population filled in an entry form ahead of the nationwide reform - which gives us information on preferences for GPs for the whole population. <p> Report 2004: 1 "General Practice: Four Empirical Essays on GP Behaviour and Individuals Preferences for GPs" focuses on the General Practitioner reform. Four essays show different impacts this reform had on the general practitioners practice and preferences in the population. <p> Summing up the reform in general practice is very well suited for collecting interesting data and doing empirical analysis. The first three analyses in this doctoral thesis by Hilde Lurås are based on the evaluation of the list patient trial (in four municipalities in 1993-1996). The last analysis is based on the evaluation of the nationwide reform in 2001. |
| Keywords: | General practice; Payment systems; Capitation; Service provision; Preferences; Applied econometrics |
| JEL: | C25 C33 I11 I18 |
| Date: | 2009–06–14 |
| URL: | http://d.repec.org/n?u=RePEc:hhs:oslohe:2004_001&r=hea |
| By: | Kittelsen, Sverre A.C. (The Ragnar Frisch Centre for Economic Research); Magnussen, Jon (SINTEF Unimed, Health Services Research) |
| Abstract: | From 2002 the Norwegian hospital sector is to be transferred from county to state ownership, organised through regional semiautonomous companies. A major motivation for the reform is to allow for more specialised hospital production. If there are economies or diseconomies of scope, the production of hospital services in a region could become more efficient by exploiting any cost savings that may stem from an optimal division of service production between units. While the theory of economics of scope is well developed, applications have chiefly been concerned with testing for natural monopoly, and few studies of hospital production have been concerned with scope. This paper estimates a multiple output cost function from data on Norwegian hospitals using the non-parametric Data Envelopment Analysis (DEA) method. The cost function is specified with total running costs as the only input, but with seven different outputs to focus on the properties of the output transformation frontier. To overcome the methodological assumption of convexity inherent in DEA, the sample is split into relative specialised and differentiated hospitals, before comparing costs. This partitioning is achieved through grouping as specialised the first and fifth quintiles of the hospitals ranked by the share of the relevant output, since in fact no hospital is fully specialised by producing only one output, or nothing of an output. Exploring scope economies of the best practice cost frontier along three different dimensions, strong economies are found for surgical and medical services, intermediate for inpatient and outpatient production, while elective and emergency care cases have only week economies of scope, which may not be statistically significant. Results for the output mix of individual observations, reveal both economies and diseconomies in the last of these three dimensions. Contrary to these results, average efficiencies are found to be lower for differentiated than specialised hospitals, in all of the dimensions mentioned, although the differences are not very large. Since the DEA method measures hospitals with the largest production of each output as efficient by default, the results for average efficiency may be due to the methods employed. |
| Keywords: | Hospital performance; DEA; Economies of Scope |
| JEL: | I11 I12 |
| Date: | 2009–06–21 |
| URL: | http://d.repec.org/n?u=RePEc:hhs:oslohe:2003_008&r=hea |
| By: | Carbone, Jared (Economics Department); Kverndokk, Snorre (Ragnar Frisch Centre for Economic Research); Røgeberg, Ole-Jørgen (Ragnar Frisch Centre for Economic Research) |
| Abstract: | In the present paper we examine how different sets of beliefs about the health effects of smoking would influence a rational smoker. By embedding the rational addiction theory in a Grossman model of health investment modified to take account of psychological adaptation effects, we present a model of a rational addict that allows us to explicitly specify beliefs about a direct and indirect effect on both death risk and utility. This allows us to study how a rational addict would smoke with different beliefs of cancer risks, and with or without the well-documented ability to adapt to health changes. Numerical simulation results illustrate a number of different incentives that influence the smoking paths and health investments under the various beliefs, and suggests that beliefs have different impacts at different ages, providing a richer set of dynamics than might initially be expected. |
| Keywords: | Rational addiction; Demand for health; Adaptation; Risk; Life extension |
| JEL: | C61 D91 I12 |
| Date: | 2009–06–21 |
| URL: | http://d.repec.org/n?u=RePEc:hhs:oslohe:2003_012&r=hea |
| By: | Kravdal, Øystein (Department of Economics) |
| Abstract: | Models for all-cause mortality among 45000 men and women with cancer in 12 different sites were estimated, using register and census data for complete Norwegian birth cohorts. This observed-survival method seemed to be an adequate approach. The results support the idea that women who were pregnant shortly before a breast cancer diagnosis may have a poorer prognosis than others. In principle, such an effect may also reflect that these women have a young child during the follow-up period, and are burdened by that. However, this social explanation can hardly be very important, given the absence of a corresponding significant effect in men and for other cancer sites in women. Breast cancer is different from other malignancies also with respect to the effect of parenthood more generally, regardless of the timing of the pregnancies. On the whole, male and female cancer patients with children experience a lower mortality than the childless, although without a special advantage associated with adult children. This suggests a social effect, perhaps operating through a link between parenthood, life style and general health. No parity effect was seen for breast cancer, however, which may signal that the social effect is set off against an adverse physiological effect of motherhood for this particular cancer. Among men, both marriage and parenthood were associated with a good prognosis. Married male cancer patients with children had a mortality 1/3 lower than that among the childless and never-married. Women who had never married did not have the same disadvantage. |
| Keywords: | Cancer; Census; Children; Family; Marriage; Register; Social; Survival |
| JEL: | J11 J12 |
| Date: | 2009–06–21 |
| URL: | http://d.repec.org/n?u=RePEc:hhs:oslohe:2003_003&r=hea |
| By: | Strand, Jon (Department of Economics) |
| Abstract: | I derive alternative measures of maximum willingness to pay (WTP) and value of statistical life (VSL) related to changes in the supply of a public good affecting mortality for both members of two-person households, when members are selfish, live for at most two periods, and strike efficient Nash bargains over consumption of individual and household goods. I find no systematic bias in letting one household member conduct the (WTP or VSL) valuation on behalf of the household. Publicgood VSL may exceed private-good VSL due to each member attaching (purely selfish) preferences to the event that the other member survives or dies, and to a possible net income potential of the other member when surviving in period 2. When period 2 is a retirement period and household members’ incomes are then fixed, interview surveys tend to overvalue VSL due to ignored negative effects of own survival on government pension budgets. |
| Keywords: | Value of statistical life; household bargaining; intertemporal allocation models; optimal life insurance |
| JEL: | I18 |
| Date: | 2009–06–14 |
| URL: | http://d.repec.org/n?u=RePEc:hhs:oslohe:2004_002&r=hea |
| By: | Hallsteinli, Vidar (SINTEF Unimed, Health Services Research); Magnussen, Jon (SINTEF Unimed, Health Services Research); Kittelsen, Sverre A.C. (The Ragnar Frisch Centre for Economic Research) |
| Abstract: | Norwegian government policy is to increase the supply of psychiatric services to children and young persons, both by increasing the number of personnel and by increasing productivity in the psychiatric outpatient clinics (BUP). Increased accessibility to services is observed for the last years, measured as the number of children receiving services every year. The question is to what extent this is related to increased productivity. The paper aims to estimate change in productivity among outpatient clinics. Questions whether change in productivity is related to the personnel mix of the clinics, growth in treatment capacity or change in financial incentives are analysed. We utilise a non-parametric method called Data Envelopment Analysis (DEA) to estimate a best-practise production frontier. The potential for efficiency improvement are estimated as the difference between actual and best-practice performance, while allowing for trade-offs between different staff groups and different mixes of service production. A Malmquist output-based productivity index is calculated, decomposed in technical efficiency change, scale efficiency change and frontier shifts. The paper analyses panel data on the psychiatric outpatient clinics of Norway for the period of 1996-2001. Output is measured as number of direct and indirect patientrelated interventions (visits and consultations) while input is measured by usage of different types of personnel. The results indicate increased overall productivity, with important contribution from increased technical efficiency. Personell growth has a negative influence on productivity growth, while a growth in the share of university educated personell improves productivity. The financial reform of 1997 that gave greater weight for interventions per patient lead to lower productivity growth in the subsequent period for those that had an inital budgetary gain from the reform. |
| Keywords: | Health Care; Mental health; Productivity; Data; Envelopment Analysis; Malmquist |
| JEL: | C61 D24 I12 |
| Date: | 2009–06–21 |
| URL: | http://d.repec.org/n?u=RePEc:hhs:oslohe:2003_009&r=hea |
| By: | Røgeberg, Ole Jørgen (Ragnar Frisch Centre for Economic Research) |
| Abstract: | The effects of public policies on the welfare of different groups in society are in many cases unclear. Economists often study such effects through welfare analyses based on a mathematical model of an individual decision maker. I show for the case of Rational Addiction theory that we have both theoretical and empirical reasons to think that the model fails to reflect the welfare of real people. I argue that the acceptance and standing of the theory is due to a failure to apply relevant criteria when evaluating such welfare analyses, that this failure makes the profession take absurd theories seriously, and that such welfare analyses should therefore be treated with scepticism and great care. |
| Keywords: | Welfare Analysis; Rational Choice; Rational; Addiction; Gary Becker; Jon Elster |
| JEL: | I18 |
| Date: | 2009–06–14 |
| URL: | http://d.repec.org/n?u=RePEc:hhs:oslohe:2004_012&r=hea |
| By: | Zhu, Weichen (Ragnar Frisch Centre for Economic Research) |
| Abstract: | The focus of this paper is to discuss and compare different approaches to calculate the statistical value of life (VSL) based on survey data. In this paper, we find out that people significantly prefer to reduce the premature death related to the environmental pollution than to reduce the premature death caused by heart disease by using discrete choice technique and estimate a simple logit and ordered logit model. But no significant evidence indicates saving lives from environmental pollution is more preferred than saving lives from traffic accident, or vice versa. VSL is directly calculated from preferences based on our estimates. We try to link the WTP with the random utility framework in this paper. A new way to make use of the information of WTP is introduced. We show that in theory the common estimates on study of the relationship between WTP and other socio-economic variables by using OLS is biased due to the selection problem. By introducing an “instrument variable” into the regression, it’s possible to correct the selection bias. |
| Keywords: | Statistical value of life; VSL; traffic accident; willingness to pay |
| JEL: | I18 |
| Date: | 2009–06–14 |
| URL: | http://d.repec.org/n?u=RePEc:hhs:oslohe:2004_003&r=hea |
| By: | Lurås, Hilde (Institute of Health Management and Health Economics) |
| Abstract: | When the list patient system was introduced in Norway in 2001, the population was requested to choose a general practitioner (GP). Prior to the reform they were asked to rank their three most preferred GPs in an entry form. Information from the entry form was input for the algorithm1 that allocated GPs and inhabitants. The first aim of this paper is to explore what factors the Norwegian population considered to be important when they filled in the entry form and selected their preferred GP. We question whether they considered the GP’s medical skill, practical matters or continuity of care, or if they felt that the opportunity set restricted their possibilities to make a choice. The second aim of the study is to identify factors of importance to the outcome of the allocation process. Important questions are whether the whole population participates in the list patient system, what factors characterize those who refuse to participate, and what factors that determine whether individuals’ are allocated to their first-choice doctor. The third aim of the study is to identify factors of importance as to whether people express satisfaction with their GP after the reform. We question whether predisposing factors, prior illness or individuals’ preferences matter, whether characteristics of the personal GP are of importance and finally, whether the outcome of the allocation process and the organization of the local health care market influence individuals’ satisfaction with their GP. |
| Keywords: | General practice; GP choice; Patient satisfaction |
| JEL: | C25 I11 I18 |
| Date: | 2009–06–14 |
| URL: | http://d.repec.org/n?u=RePEc:hhs:oslohe:2004_013&r=hea |
| By: | Grepperud, Sverre (Institute of Health Management and Health Economics) |
| Abstract: | This work examines the role of penalties as providers of incentives to prevent medical errors and ensure that such incidents, once they occur, become common knowledge. It is shown that a scheme with two penalties (accountability and non-report) is able to induce the first-best solution. However, this scheme needs not imply a punitive environment, but may, under given circumstances, yield insignificant and even negative penalties. Alternative incentive systems, such as voluntary reporting and legal immunity, are found to have less desirable properties. An exception is the principle of confidentiality (anonymity) which turns out to be an optimal scheme. It is also shown that when a judicial upper limit is binding, for the non-report penalty, it becomes rationale to go “soft” on the accountability penalty. |
| Keywords: | Iatrogenic injury; adverse events; reporting incentives; confidentiality |
| JEL: | D82 I18 K42 |
| Date: | 2009–06–21 |
| URL: | http://d.repec.org/n?u=RePEc:hhs:oslohe:2003_010&r=hea |
| By: | Sæther, Erik Magnus (Ragnar Frisch Centre for Economic Research) |
| Abstract: | Many registered nurses (RNs) in Norway work part-time, or in non-health jobs. The nurses’ trade organizations claim that a wage increase will increase the short-term labor supply in health care. This paper is an attempt to identify the effects of job-type specific wage increases through policy simulations on micro data. The individual’s labor supply decision can be considered as a choice from a set of discrete alternatives (job packages). These job packages are characterized by attributes such as hours of work, sector specific wages and other sector specific aspects of the jobs. The unique data set covers all RNs registered in Norway and their families. The spouses’ incomes and age of the children are vital when estimating the labor supply of this profession. For married females the results indicate job type specific wage elasticities for hours of work of 0.17 in hospitals and 0.39 in primary care. The total hours worked in health and non-health jobs are actually predicted to be slightly reduced, but the change is not significantly different from zero. Single females are somewhat more responsive to wage changes than married ones. |
| Keywords: | Registered nurses; discrete choice; non-convex budget sets; labor supply; sector-specific wages |
| JEL: | C25 I10 J22 |
| Date: | 2009–06–14 |
| URL: | http://d.repec.org/n?u=RePEc:hhs:oslohe:2004_007&r=hea |
| By: | Bergh, Andreas (Department of Economics, Lund University); Nilsson, Therese (Department of Economics, Lund University) |
| Abstract: | This paper analyzes the relation between three dimensions of globalization (economic, social and political) and life expectancy using a panel of 92 countries over the period 1970-2005. Using different estimation techniques and sample groupings we find a very robust positive effect from economic globalization on life expectancy, even when controlling for income, nutritional intake, literacy, number of physicians and several other factors. The result also holds when the sample is restricted to low income countries only. For political and social globalization we find no robust effects. |
| Keywords: | Globalization; health; life expectancy; development |
| JEL: | F02 H51 I10 |
| Date: | 2009–06–08 |
| URL: | http://d.repec.org/n?u=RePEc:hhs:lunewp:2009_009&r=hea |
| By: | Franco Sassi; Jody Church; Michele Cecchini; Francesca Borgonovi |
| Abstract: | An epidemic of obesity has been developing in virtually all OECD countries over the last 30 years. Existing evidence provides strong suggestions that such epidemic has affected certain social groups more than others. In particular, education appears to be associated with a lower likelihood of obesity, especially among women. A range of analyses of health survey data from Australia, Canada, England and Korea were undertaken with the aim of exploring the relationship between education and obesity. The findings of these analyses show a broadly linear relationship between the number of years spent in full-time education and the probability of obesity, with most educated individuals displaying lower rates of the condition (the only exception being men in Korea). This suggests that marginal returns to education, in terms of reduction in obesity rates, are approximately constant throughout the education spectrum. The findings obtained confirm that the education gradient in obesity is stronger in women than in men. Differences between genders are minor in Australia and Canada, more pronounced in England and major in Korea. The causal nature of the link between education and obesity has not yet been proven with certainty; however, using data from France we were able to ascertain that the direction of causality appears to run mostly from education to obesity, as the strength of the association is only minimally affected when accounting for reduced educational opportunities for those who are obese in young age. Most of the effect of education on obesity is direct. Small components of the overall effect of education on obesity are mediated by an improved socio-economic status linked to higher levels of education, and by a higher level of education of other family members, associated with an individual’s own level of education. The positive effect of education on obesity is likely to be determined by at least three factors: (a) greater access to health-related information and improved ability to handle such information; (b) clearer perception of the risks associated with lifestyle choices; and, (c) improved self-control and consistency of preferences over time. However, it is not just the absolute level of education achieved by an individual that matters, but also how such level of education compares with that of the individual’s peers. The higher the individual’s education relative to his or her peers’, the lower is the probability of the individual being obese.<P>Éducation et obésité dans quatre pays de l’OCDE<BR>Une épidémie d’obésité est en train de s’étendre dans presque tous les pays de l’OCDE depuis les 30 dernières années. Les preuves existantes suggèrent fortement qu’une telle épidémie a davantage affecté certains groupes sociaux que d’autres. En particulier, l’éducation paraît être associée à une plus faible probabilité d’obésité, notamment chez les femmes. Une série d’analyses de données d’enquête de santé concernant l’Australie, le Canada, l’Angleterre et la Corée a été menée dans le but d’explorer la relation entre l’éducation et l’obésité. Les résultats de ces analyses montrent une relation généralement linéaire entre le nombre d’années d’éducation à plein temps et la probabilité d’obésité, les individus les plus éduqués ayant de plus bas taux d’obésité (la seule exception étant les hommes en Corée). Ceci suggère que les rendements marginaux de l’éducation, en termes de réduction des taux d’obésité, sont approximativement constants quelque soit le nombre d’années d’éducation. Les résultats obtenus confirment que le gradient d’obésité selon le niveau d’éducation est plus fort chez les femmes que chez les hommes. Les différences entre les genres sont faibles en Australie et au Canada, plus prononcées en Angleterre et importantes en Corée. La nature causale du lien entre l’éducation et l’obésité n’a pas encore été prouvée avec certitude ; cependant, en utilisant des données françaises, nous avons pu établir que le sens de la causalité semble aller de l’éducation vers l’obésité, puisque la force de l’association est faiblement affectée quand on tient compte d’une moindre éducation pour ceux qui sont obèses aux jeunes âges. La plupart des effets de l’éducation sur l’obésité sont directs. De petites composantes de l’effet total de l’éducation sur l’obésité sont médiées par un meilleur statut socio-économique lié à des niveaux d’éducation plus élevés, et par un meilleur niveau d’éducation des autres membres de la famille, associé au niveau d’éducation propre à l’individu. Il est probable que l’effet positif de l’éducation sur l’obésité soit déterminé par au moins trois facteurs : (a) un meilleur accès à l’information liée à la santé et une meilleure capacité à utiliser une telle information ; (b) une perception plus claire des risques associés aux choix de vie ; et, (c) un meilleur contrôle de soi et une cohérence des préférences dans le temps. Cependant, ce n’est pas seulement le niveau absolu de l’éducation acquis par un individu qui importe, mais aussi comment un tel niveau d’éducation se place par rapport à celui de l’entourage de l’individu. Plus le niveau d’éducation relatif à son entourage est élevé, plus faible est la probabilité que l’individu soit obèse. |
| Keywords: | education, éducation, obesity, obésité |
| JEL: | I12 I21 |
| Date: | 2009–06–15 |
| URL: | http://d.repec.org/n?u=RePEc:oec:elsaad:46-en&r=hea |
| By: | Willems, Anouk; Willems, Jan; Hadjasinski, Andrzej (Nyenrode Business Universiteit) |
| Abstract: | The research report takes the perspective of Information Logistics and investigates relating concepts like Knowledge Management, Information Systems and Context Awareness in the context of the healthcare industry. The aim of Information Logistics is to deliver the right information product, in the right format, at the right place at the right time for the right people in a customer demand driven approach. This principle is of high importance in dynamic organizations like the healthcare industry. Many problems arise in this industry as a consequence of the present lack of congruous media. This is caused not only by the parallel usage of both paper-based and digital documents, but also by the usage of different digital data structure formats which leads to inconsistencies of the data collected. With multiple data structures, miscommunications arise easily and negatively affect performance. Therefore, the principle of Information Logistics is necessary in the healthcare industry to structure, manage and use information in the right way. A relating concept of Information Logistics is Knowledge Management as it discusses the access and use of knowledge and information in organizations. More specific, Knowledge Management keeps track of know-how in organizations and enables transparency of knowledge- and information flows. Information Logistics is present in organizations in memory systems and information systems. Healthcare organizations use Health- and Hospital Information Systems to grasp the rapidly changing information elements in and between health organizations. An important factor has to be taken into account when discussing Information Logistics, namely context awareness. In order to deliver relevant information at the right time to its users, systems need to be aware of the users’ context, which includes the current time, their location, or the devices they use. |
| Keywords: | Information Logistics, Knowledge Management, Tacit Knowledge, Explicit Knowledge, Knowledge Logistics, Medical Informatics, Information Systems, Health Information Systems, Context Awareness |
| Date: | 2009 |
| URL: | http://d.repec.org/n?u=RePEc:dgr:nijrep:2009-04&r=hea |
| By: | Otto H. Swank (Erasmus University Rotterdam) |
| Abstract: | A physician performs two tasks: making diagnoses and determining treatments. To reduce medical error, residents are supposed to consult their supervisors when they face uncommon circumstances. However, recent research shows that residents are reluctant to do so. This paper presents a model that explains (i) which residents shy away from consulting; (ii) when residents are reluctant; (iii) the importance of protocols in the medical sector; and (iv) when consulting is a sign of strength or a sign of weakness. Furthermore, I show that encouraging residents to consult by investigating mishaps leads to another distortion: residents will give too much weight to own assessments. |
| Keywords: | Medical error; medical decision-making; reputational concerns; consulting |
| JEL: | D21 D82 D83 |
| Date: | 2009–05–14 |
| URL: | http://d.repec.org/n?u=RePEc:dgr:uvatin:20090042&r=hea |
| By: | Layte, Richard (Economic and Social Research Institute (ESRI)); Nolan, Anne (Economic and Social Research Institute (ESRI)) |
| Date: | 2009–06 |
| URL: | http://d.repec.org/n?u=RePEc:esr:wpaper:rb20090201&r=hea |
| By: | Harald Tauchmann; Stefan Felder |
| Abstract: | The inefficiency of health care provision presents a major health policy concern in Germany. In order to address the issue of efficiency comprehensively – i.e. at the level of the entire system of health care provision rather than individual service providers – empirical analyses are often based on data at the regional level.However, regional efficiencies might be subject to spatial dependence, rendering any analysis biased that aims at identifying the determinants of efficiency differentials. We address this issue by specifying a spatial autoregressive model to explain efficiency scores for German districts which we derive through data envelopment analysis. Regression results suggest that spatial dependence is not a dominant feature in the data. Hence, ignoring spatial interdependence is unlikely to severely bias results of efficiency analyses based on regional data.This holds, in particular, for the role of the states in the efficiency of health production. Significant heterogeneity among states is found in the data regardless of whether or not spatial dependence is accounted for. |
| Keywords: | Health production, data envelopment analysis, spatial autoregressive model |
| JEL: | I12 R10 |
| Date: | 2009–06 |
| URL: | http://d.repec.org/n?u=RePEc:rwi:repape:0112&r=hea |
| By: | Stefan Felder; Anja Olbrich |
| Abstract: | The US and the EU recently introduced regulation to curb the extent of risky off-label drug use. It offers manufacturers a prolongation of patent protection or exclusivity if they invest in pediatric clinical tests. This paper shows that a reinforcement of physician liability for off-label use may be the preferred instrument for achieving dynamic efficiency. The liability threat reduces the demand for off-label use, giving manufacturers an appropriate incentive to invest in extended approval. By contrast, patent prolongation does not affect physicians' prescription decisions and increases the likelihood of investments in cases where the induced additional benefit falls short of testing costs. |
| Keywords: | Off-label use, patent protection, exclusivity, liability |
| JEL: | I11 K13 |
| Date: | 2009–06 |
| URL: | http://d.repec.org/n?u=RePEc:rwi:repape:0114&r=hea |
| By: | Christoph Schwierz; Boris Augurzky; Jürgen Wasem |
| Abstract: | This paper investigates the relationship between health outcomes and variations in staffing levels as approximated by admissions on weekdays versus admissions on weekends. Because days of admission are potentially endogenous, we instrument on emergency admissions only, which are reasonably exogenous to the time of admission. Further,we introduce a direct measure for within- diagnosis variation in severity across days of admission to control for the unobservable selection of patients.We find that after controlling for patient heterogeneity and endogeneity of the day of admission there is still a significant variation in mortality rates between weekend and weekday admissions. Patients admitted during the weekend exhibit higher in-hospital mortality rates. We also find signs of premature discharge, as patients with short lengths of stay tend to exhibit higher probability to be readmitted as emergency cases. |
| Keywords: | Hospital quality, weekend effect, inpatient outcomes |
| JEL: | I12 I18 |
| Date: | 2009–05 |
| URL: | http://d.repec.org/n?u=RePEc:rwi:repape:0105&r=hea |
| By: | Christoph Schwierz |
| Abstract: | Over the last 20 years, acute care hospitals in most OECD have built up costly overcapacities. From the perspective of economic policy, it is desirable to know how hospitals of different ownership form respond to changes in demand and are probably best suited to deal with existing overcapacities. This paper examines ownership-specific differences in the responsiveness to changes in demand for hospital services in Germany between 1996 and 2006. With respect to the speed of adaptation to changes in demand, the study finds for-profit ownership to be superior to public and nonprofit ownership. Further, it is shown that declining demand can contribute to the expansion of for-profits through conversions by mainly publicly owned hospitals. Thus, the study finds evidence that to some extent the privatization of the hospital sector may be an adequate answer to reduce excess capacities. |
| Keywords: | Hospital ownership, privatization, hospital market structure |
| JEL: | I11 I12 L31 |
| Date: | 2009–05 |
| URL: | http://d.repec.org/n?u=RePEc:rwi:repape:0106&r=hea |
| By: | Aditi Roy (SMU) |
| Abstract: | Estimating the causal impact of child work on the contemporaneous health of a child has proven quite challenging given non-random selection into the labor market and the inability to find strong and valid instruments. Our data, the Indonesian Family Life Survey is no different. Recognizing the lack of a credible instrument, we instead pursue a different strategy based on the methodology of Altonji et al. (JPE, 2005). This method assesses the robustness of the impact of child work estimated under the assumption of random selection (i.e., selection into child work on observable attributes only) to varying degrees of non-random selection (i.e., selection into child labor on unobservable attributes). If the estimated effect is found to be extremely sensitive to selection on unobservables, then one should be wary about inferring an adverse causal effect of child work. In addition, the nature of the selection process is identified using parametric assumptions. The results are striking, suggesting positive selection of children into work when we consider underweight and high weight status as dependent variables. This indicates that there is both healthy worker selection effect as well as unhealthy worker selection effect. There is however negative selection into work for the children belonging to the intermediate weight range. This heterogeneity in the selection process across the distribution has not been previously identified in the literature. Moreover, we also find evidence suggesting a heterogeneous impact of child work on health once we allow for a modest amount of selection on unobservables. Specifically, we find evidence of a negative causal effect of work on healthier children, but evidence of beneficial impact of work on the least healthy children. |
| Keywords: | Child work; health; selection on unobservables; Indonesia. |
| JEL: | I12 J13 J22 J28 |
| Date: | 2009–06 |
| URL: | http://d.repec.org/n?u=RePEc:smu:ecowpa:0905&r=hea |
| By: | Mary A. Burke; Frank Heiland; Carl Nadler |
| Abstract: | We test for differences across the two most recent NHANES survey periods (1988–1994 and 1999–2004) in self-perception of weight status. We find that the probability of self-classifying as overweight is significantly lower on average in the more recent survey, for both men and women, controlling for objective weight status and other factors. Among women, the decline in the tendency to self-classify as overweight is concentrated in the 17–35 age range, and, within this range, is more pronounced among women with normal BMI than among those with overweight BMI. Among men, the shift away from feeling overweight is roughly equal across age groups, except that the oldest group (56–74) exhibits no difference between surveys. In addition, overweight men exhibit a sharper decline in feeling overweight than normal-weight men. Despite the declines in feeling overweight between surveys, weight misperception did not increase significantly for men and decreased by a sizable margin among women. The shifts in selfclassification are not explained by differences between surveys in body fatness or waist circumference, nor by shifting demographics. We interpret the findings as evidence of a generational shift in social norms related to body weight, and propose various mechanisms to explain such a shift, including: (1) higher average adult BMI and adult obesity rates in the later survey cohort, (2) higher childhood obesity rates in the later survey cohort, and (3) public education campaigns promoting healthy body image. The welfare implications of the observed trends in self-classification are mixed. |
| Keywords: | Obesity |
| Date: | 2009 |
| URL: | http://d.repec.org/n?u=RePEc:fip:fedbwp:09-3&r=hea |
| By: | Stefanie Behncke |
| Abstract: | This paper investigates the effects of retirement on various health outcomes. Data stem from the first three waves of the English Longitudinal Study of Ageing (ELSA). With this informative data, non-parametric matching methods can be applied to identify causal effects. It is found that retirement significantly increases the risk of being diagnosed with a chronic condition. In particular, it raises the risk of developing a cardiovascular disease and being diagnosed with cancer. Estimates also indicate that retirement has quite diverse effects for different individuals. |
| Keywords: | retirement, health, matching methods, ELSA |
| JEL: | I10 J14 J26 |
| Date: | 2009–06 |
| URL: | http://d.repec.org/n?u=RePEc:usg:dp2009:2009-13&r=hea |
| By: | Fabbri, D; Robone, S |
| Abstract: | Every year 35% of the 10 million hospital admissions in Italy occurs outside the patients' Local Health Authority of residence. In this paper we look for explanation for this phenomenon and estimate gravity equations for "trade" in hospital care using a Poisson pseudo maximum likelihood method. Our results suggest that the gravity model is a good framework for explaining patient mobility in most of the examined diagnostic groups. We find that the ability to restrain the imports of hospital services increases with the size of the pool of enrollees. Moreover, the ability to export hospital services, as proxied by the ratio of export-to-internal demand, is U-shaped. Therefore our evidence suggests that there are scale effects played by the size of the pool of enrollees. |
| Keywords: | patients mobility, hospital care, gravity model, Italian National Health Service |
| Date: | 2009–06 |
| URL: | http://d.repec.org/n?u=RePEc:yor:hectdg:09/10&r=hea |
| By: | Yoshiro Tsutsui (Graduate School of Economics, Osaka University); Uri Benzionb (Department of Economics, Ben Gurion University); Shosh Shahrabanic (Economics and Management Department, Max Stern Academic College of Emek Yezreel); Gregory Yom Din (Golan Research Institute, University of Haifa,Ohalo College) |
| Abstract: | The aims of this study were to identify predictors regarding peoplefs willingness to be vaccinated against influenza and to determine how to improve the inoculation rate using our original large-scale survey in the USA in 2005. The main results are (a) a model of bounded rationality explains vaccination behavior fairly well, i.e., people evaluate the costs and benefits of vaccination by applying risk aversion and time preference, while the estatus quo biasf of those who received vaccinations in the past affect their decision to be vaccinated in the future, (b) it is recommended to increase peoplefs knowledge regarding flu vaccination, but not regarding influenza illness, (c) reducing the vaccination fee may be ineffective in raising the rate of vaccination. |
| Keywords: | Influenza, Inoculation, Health belief model, Survey, Time preference. |
| JEL: | I19 |
| Date: | 2009–06 |
| URL: | http://d.repec.org/n?u=RePEc:osk:wpaper:0917&r=hea |
| By: | Gallipoli, Giovanni; Turner, Laura |
| Abstract: | What are idiosyncratic shocks and how do people respond to them? This paper starts from the observation that idiosyncratic shocks are experienced at the individual level, but responses to shocks can encompass the whole household. Understanding and accurately modeling these responses is essential to the analysis of intra-household allocations, especially labour supply. Using longitudinal data from the Canadian Survey of Labour and Income Dynamics (SLID) we exploit information about disability and health status to develop a life-cycle framework which rationalizes observed responses of household members to idiosyncratic shocks. Two puzzling findings associated to disability onset motivate our work: (1) the almost complete absence of ‘added worker’ effects within households and, (2) the fact that single agents’ labour supply responses to disability shocks are larger and more persistent than those of married agents. We show that a first-pass, basic model of the household has predictions about dynamic labour supply responses which are at odds with these facts; despite such failure, we argue that these facts are consistent with optimal household behaviour when we account for two simple mechanisms: the first mechanism relates to selection into and out of marriage, while the second hinges on insurance transfers taking place within households. We show that these mechanisms arise naturally when we allow for three features: a linkage between human capital accumulation and life-cycle labour supply, endogenous marriage contracts and the possibility of time transfers between partners. We also report evidence that the extended model with endogenous marriage contracts can fit divorce patterns observed in Canadian data, as well as correlations between disability prevalence and marital status, providing an ideal framework to study intra-household risk-sharing with limited commitment. |
| Keywords: | Idiosyncratic Risk, Disability, Household Behaviour, Marriage, Insurance |
| JEL: | E20 I10 H31 J12 |
| Date: | 2009–06–22 |
| URL: | http://d.repec.org/n?u=RePEc:ubc:clssrn:clsrn_admin-2009-32&r=hea |
| By: | Velamuri, Malathi |
| Abstract: | I examine whether the availability of health coverage through the spouse’s health plan influences a married woman’s decision to become self-employed. The Tax Reform Act of 1986 (TRA86) introduced a tax subsidy for the self-employed to purchase their own health insurance. I test whether this ‘natural’ experiment induced more women without spousal health insurance cov-erage to select into self-employment. The difference-in-difference estimates based on an analysis of employed women indicate that the incidence of self-employment among women who did not enjoy spousal health benefits rose significantly - between 14% and 25% - in the post-TRA86 pe- riod, while a multinomial specification based on a sample of both employed and non-employed women suggests that the increase was around 9%. |
| Keywords: | Health Insurance; Self-Employment |
| JEL: | J3 J0 I1 |
| Date: | 2009 |
| URL: | http://d.repec.org/n?u=RePEc:pra:mprapa:15731&r=hea |
| By: | Pandey, Manoj K. |
| Abstract: | In this paper, the effect of maternal health on the under-five mortality has been examined. Third wave of micro-level National Family Health Survey 2005-06 data for rural India is used. Using various alternative measures of maternal health, the paper finds strong association between maternal health and child mortality. In particular, the effects of maternal height, weight, presence of any disease and anemia are found significant. Based on our findings, we argue that if the possible generational transfer of poor health from a mother to her child has to avoid, policies aimed at attaining the millennium development goal of reduced child mortality should be directed on improving the health of existing and future mothers. |
| Keywords: | under-five mortality; maternal height; maternal weight; body mass index; anemia |
| JEL: | J13 I12 D6 |
| Date: | 2009–06–25 |
| URL: | http://d.repec.org/n?u=RePEc:pra:mprapa:15934&r=hea |
| By: | Pandey, Manoj K.; Kaur, Charanjit |
| Abstract: | This paper examines the trend and economic determinants of the suicidal deaths in India. Time-series data over the period 1967-2006 is used from various sources. The paper analyzes the suicidal trend and exploratory relationships between suicide rate and some of the demographic and other economic variates. Further, we use ARDL model to find out the association between suicide and some economic variables. We find that inflation, per capita real GDP and industrial growth encourages the incidences of suicides whereas increased per capita household income helps in reducing suicidal deaths in India. |
| Keywords: | Suicide; Economic factors; Trends; Time series; ARDL model |
| JEL: | I12 C22 |
| Date: | 2009–04–15 |
| URL: | http://d.repec.org/n?u=RePEc:pra:mprapa:15732&r=hea |
| By: | Pandey, Manoj K. |
| Abstract: | In this paper, the trend and determinants of health and poverty among the elderly in rural India is analysed. Two rounds of National Sample Survey (NSS) data for the year 1995-96 and 2004 are employed. The analysis has been done with independent and pooled datasets. Our analysis shows that levels of consumption poverty have declined marginally between 1995-96 and 2004 while increased proportion of elderly with poor health status is continued. Results suggest that poverty is one of the key determinants of health among elderly in rural India. |
| Keywords: | health; poverty; elderly |
| JEL: | J14 I12 I32 |
| Date: | 2009–06–25 |
| URL: | http://d.repec.org/n?u=RePEc:pra:mprapa:15926&r=hea |
| By: | Amanda E. Kowalski |
| Abstract: | The extent to which consumers respond to marginal prices for medical care is important for policy. Using recent data and a new censored quantile instrumental variable (CQIV) estimator, I estimate the price elasticity of expenditure on medical care. The CQIV estimator allows the estimates to vary across the skewed expenditure distribution, it allows for censoring at zero expenditure nonparametrically, and it allows for the insurance-induced endogenous relationship between price and expenditure. For identification, I rely on cost sharing provisions that generate marginal price differences between individuals who have injured family members and individuals who do not. I estimate the price elasticity of expenditure on medical care to be stable at -2.3 across the .65 to .95 conditional quantiles of the expenditure distribution. These quantile estimates are an order of magnitude larger than previous mean estimates. I consider several explanations for why price responsiveness is larger than previous estimates would suggest. |
| JEL: | I1 |
| Date: | 2009–06 |
| URL: | http://d.repec.org/n?u=RePEc:nbr:nberwo:15085&r=hea |
| By: | Naci H. Mocan; Erdal Tekin |
| Abstract: | Obesity is associated with serious health problems, and it can generate adverse economic outcomes. We analyze a nationally-representative sample of young American adults to investigate the interplay between obesity, wages and self-esteem. Wages can be impacted directly by obesity, and they can be influenced by obesity indirectly through the channel of obesity to self-esteem to wages. We find that female wages are directly influenced by body weight, and self-esteem has an impact on wages in case of whites. Being overweight or obese has a negative impact on the self-esteem of females and of black males. The results suggest that obesity has the most significant impact on white women’s wages. |
| JEL: | I1 I12 J3 J31 |
| Date: | 2009–06 |
| URL: | http://d.repec.org/n?u=RePEc:nbr:nberwo:15101&r=hea |
| By: | Phillip B. Levine; Robin McKnight; Samantha Heep |
| Abstract: | This paper assesses the impact of two recent policies designed to increase insurance coverage for older teens and young adults. The introduction of SCHIP in 1997 enabled low and moderate income teens up to age 19 to gain access to public health insurance. More recent policies adopted by a number of states have enabled young adults between the ages of 19 and (typically) 24 to remain covered under their parents’ health insurance. We take advantage of the discrete break in coverage at age 19 to evaluate the impact of SCHIP. We also use quasi-experimental variation across states and years along with the targeted nature of eligibility to evaluate the impact of these “extended parental coverage†laws. Our results suggest that both types of policies were effective at increasing health insurance coverage, especially among their respective target populations. Overall, SCHIP increases insurance coverage by 3 percentage points; those with incomes under 150 percent of poverty are found to experience a 7 percentage point increase. We find little evidence of crowd-out associated with the introduction of SCHIP. Extended parental coverage laws have minimal aggregate effects on coverage, but they increase coverage by up to 5 percentage points for select groups. These laws may generate reverse crowd-out, as individuals leave public insurance coverage to take advantage of the private coverage now available to them. |
| JEL: | I18 |
| Date: | 2009–06 |
| URL: | http://d.repec.org/n?u=RePEc:nbr:nberwo:15114&r=hea |
| By: | Dalton Conley; Jennifer A. Heerwig |
| Abstract: | Research on the effects of Vietnam military service suggests that Vietnam veterans experienced significantly higher mortality than both non-Vietnam veterans and the civilian population at large. These results, however, may be biased by non-random selection into the military if unobserved background differences between veterans and non-veterans affect mortality directly. The present study generates unbiased estimates of the causal impact of Vietnam era draft eligibility on male mortality. Using records from the Vietnam draft lottery to assign decedents born 1950-1952 draft lottery numbers, the study estimates excess mortality among observed draft eligible male decedents as compared to the (1) expected proportion of draft eligible decedents given Vietnam draft eligibility cutoffs and (2) observed proportion of draft eligible female decedents. The results demonstrate that there appears to be no effect of draft exposure on mortality (even cause-specific death rates). When we examine population subgroups—including splits by race, educational attainment, nativity and marital status—we find weak evidence for an interaction between education and draft eligibility. On the whole, these results suggest that previous research, which has shown that Vietnam-era veterans experienced significantly higher mortality than non-veterans, may be biased by non-random selection into the military and may thus overstate the need for compensatory government pensions. |
| JEL: | H56 I10 I18 |
| Date: | 2009–06 |
| URL: | http://d.repec.org/n?u=RePEc:nbr:nberwo:15105&r=hea |
| By: | Jason M. Fletcher; Jody L. Sindelar; Shintaro Yamaguchi |
| Abstract: | We examine whether the job characteristics of physical demands and environmental conditions affect individual’s health. Five-year cumulative measures of these job characteristics are used to reflect findings in the biologic and physiologic literature that indicate that cumulative exposure to hazards and stresses harms health. To create our analytic sample, we merge job characteristics from the Dictionary of Occupational Titles with the Panel Study of Income Dynamics dataset. We control for early and lagged health measures and a set of pre-determined characteristics to address concerns that individuals self-select into jobs. Our results indicate that individuals who work in jobs with the ‘worst’ conditions experience declines in their health, though this effect varies by demographic group. For example, for non-white men, a one standard deviation increase in cumulative physical demands decreases health by an amount that offsets an increase of two years of schooling or four years of aging. We also find evidence that job characteristics are more detrimental to the health of females and older workers. Finally, we report suggestive evidence that earned income, another job characteristic, partially cushions the health impact of physical demands and harsh environmental conditions for workers. These results are robust to inclusion of occupation fixed effects. |
| JEL: | I1 J0 |
| Date: | 2009–06 |
| URL: | http://d.repec.org/n?u=RePEc:nbr:nberwo:15121&r=hea |
| By: | Anthony T. Lo Sasso; Lorens A. Helmchen; Robert Kaestner |
| Abstract: | We use unique data from an insurer that exclusively offers high-deductible, "consumer-directed" health plans to identify the effect of plan features, notably the spending account, on health care spending. Our results show that the marginal dollar in the spending account is entirely spent on outpatient and pharmacy services. In contrast, inpatient and out-of-pocket spending were not responsive to the amount in the spending account. Our results represent the first plausibly causal estimates of the components of consumer-driven health plans on health spending. The magnitudes of the effects suggest important moral hazard consequences to higher spending account levels. |
| JEL: | I11 I18 |
| Date: | 2009–06 |
| URL: | http://d.repec.org/n?u=RePEc:nbr:nberwo:15106&r=hea |
| By: | Dana Goldman; Darius Lakdawalla; Yuhui Zheng |
| Abstract: | A popular policy option for addressing the growth in weight has has been the imposition of a “fat tax†on selected foods that are deemed to promote obesity. Understanding the public economics of “fat taxes†requires an understanding of how or even whether individuals respond to changes in food prices over the long-term. We study the short- and long-run body weight consequences of changing food prices, in the Health and Retirement Study (HRS). We found very modest short-term effects of price per calorie on body weight, and the magnitudes align with the previous literature. The long-term effect is much bigger, but it takes a long time for the effect to reach the full scale. Within 30 years, a 10% permanent reduction in price per calorie would lead to a BMI increase of 1.5 units (or 3.6%). The long term effect is an increase of 1.9 units of BMI (or 4.2%). From a policy perspective, these results suggest that policies raising the price of calories will have little effect on weight in the short term, but might curb the rate of weight growth and achieve weight reduction over a very long period of time. |
| JEL: | I1 |
| Date: | 2009–06 |
| URL: | http://d.repec.org/n?u=RePEc:nbr:nberwo:15096&r=hea |
| By: | Seema Jayachandran; Adriana Lleras-Muney; Kimberly V. Smith |
| Abstract: | This paper studies the contribution of sulfa drugs, a groundbreaking medical innovation in the 1930s, to declines in U.S. mortality. For several often-fatal infectious diseases, sulfa drugs represented the first effective treatment. Using time-series and difference-in-differences methods (with diseases unaffected by sulfa drugs as a comparison group), we find that sulfa drugs led to a 25 to 40 percent decline in maternal mortality, 17 to 36 percent decline in pneumonia mortality, and 52 to 67 percent decline in scarlet-fever mortality between 1937 and 1943. Altogether, they reduced mortality by 2 to 4 percent and increased life expectancy by 0.4 to 0.8 years. We also find that sulfa drugs benefited whites more than blacks. |
| JEL: | I10 J11 N32 |
| Date: | 2009–06 |
| URL: | http://d.repec.org/n?u=RePEc:nbr:nberwo:15089&r=hea |