The B.E. Journal of Economic Analysis & Policy

Published by De Gruyter

Volume 11 Issue 2 - “Industrial Organization and Healthcare” edited by Fiona Scott Morton

December 2011

Issue of The B.E. Journal of Economic Analysis & Policy

Contents
Journal Overview

Advances Article

January 3, 2011

Pecuniary and Non-Pecuniary Incentives in Prescription Pharmaceuticals: The Case of Statins

Frank Limbrock

Abstract

Health insurance companies seek to influence the type of care patients receive in order to increase value in relation to cost. Traditional health insurance relies primarily on price mechanisms to affect patients' and doctors' choices, whereas managed care plans such as HMOs, as the name implies, affect choices directly thorough various forms of managed care. I investigate the effect of pecuniary and non-pecuniary incentives used by health insurance companies to influence prescription decisions in an important class of pharmaceuticals, cholesterol-lowering drugs called Statins, using a discrete-choice demand model on patient-level data. My results suggest that HMOs are significantly more successful at influencing drug choice than traditional indemnity insurers. In conjunction with volume-contingent discounts given by drug producers, this could explain part of the cost-effectiveness differential between HMOs and traditional indemnity insurers.

January 3, 2011

Strategic Responses to Parallel Trade

Margaret Kyle

Abstract

High prices for patented pharmaceuticals have prompted many governments to consider allowing competition from parallel imports, or products first sold at lower prices in other countries. This paper examines how pharmaceutical firms have responded to changes in intellectual property rights and trade barriers that legalized parallel imports within the European Union (EU). The threat of arbitrage by parallel traders reduces the ability of firms to price discriminate across countries. Due to regulations on price and antitrust law on rationing supply, pharmaceutical firms may rely on non-price responses. Such responses include differentiation of products across countries and selective culling of product lines to reduce arbitrage opportunities, as well as raising arbitrageurs costs through choice of packaging. Using a dataset of drug prices and sales from 1993-2004 covering 30 countries, I find evidence that the behavior of pharmaceutical firms in the EU with respect to their product portfolios is consistent with attempts to reduce parallel trade. This may at least partially explain why parallel trade has not yet resulted in significant price convergence across EU countries. Accounting for non-price strategic responses may therefore be important in assessing the welfare effects of competition from parallel imports.

January 3, 2011

Managed Care, Drug Benefits and Mortality: An Analysis of the Elderly

Gautam Gowrisankaran, Robert Town, Eric Barrette

Abstract

We evaluate the impact of the Medicare HMO program and prescription drug coverage on elderly mortality using data from 1993 to 2000. We specify a model of plan entry and benefit choice and Medicare enrollee plan choice and health outcomes. We derive an estimator that is consistent with endogenous plan selection by using the quasi-experimental variation caused by peculiarities of the Medicare reimbursement system for HMOs. We find that, relative to traditional Medicare, enrollment in an HMO without drug coverage increases mortality while enrollment in an HMO with drug coverage has no significant impact. The economic value of the reduction in mortality from drug coverage far outweighs the costs. HMOs, those without drug coverage in particular, attract healthier enrollees than average.

January 3, 2011

Insurance, Consumer Choice, and the Equilibrium Price and Quality of Hospital Care

Michael L Katz

Abstract

I analyze price and quality competition in a model that captures important institutional features of U.S. hospital markets. I first consider duopoly hospitals serving a population of patients who are covered by insurance that their employers purchase from duopoly health plans. I show that second-best quality levels can be sustained as equilibrium outcomes under both indemnity insurance and managed care even when patients are fully insured. I also demonstrate that a monopoly hospital system can yield efficient quality levels and that prices may be lower under monopoly than duopoly even when there are no technical efficiencies associated with monopoly. The latter result arises when employers and health insurance plans view the hospitals as complements even though any given consumer views them as substitutes.

January 3, 2011

Does the Market Punish Aggressive Experts? Evidence from Cesarean Sections

David Dranove, Subramaniam Ramanarayanan, Andrew Sfekas

Abstract

In many credence goods markets, a seller simultaneously diagnoses a problem and offers a recommendation to fix it. One might wonder what prevents these sellers from always exaggerating their customers needs. In this paper, we offer a simple explanation, namely, consumers may spurn sellers who have a reputation for such demand inducement. We test this explanation by examining patient choice of obstetrician in Florida. In most of the counties that we study, we find that maternity patients are significantly less likely to choose obstetricians who perform more than the expected number of cesarean sections. We address simultaneity by instrumenting for inducement propensity using information about the obstetrician's training. Although the instrument is weak, a series of robustness tests suggests that our findings are plausible while ruling out alternative explanations.

January 3, 2011

Measuring the Return on Government Spending on the Medicare Managed Care Program

Anne E Hall

Abstract

I estimate the welfare provided to beneficiaries by the Medicare managed care program, and its net costs, for the years 1999-2002. I measure beneficiary welfare with a nested logit model of demand for Medicare HMO plans using detailed data on plan benefits. From this, I find that total beneficiary welfare provided by the program over the four-year period is about $61 billion (2000 $). I also use data on and estimates of the favorable selection enjoyed by Medicare HMOs from the research literature to estimate net costs of the program, which range from $21 billion to $31 billion (2000 $). Estimated net beneficiary welfare of the program therefore ranges from $30 billion to $40 billion and the estimated return on government spending ranges from 96 percent to 186 percent. Even though managed care plans are overpaid by Medicare, the program still enjoys a substantial return due to the popularity of its offerings.

Contributions Article

January 3, 2011

Health Care Network Formation and Policyholders' Welfare

David Bardey, Jean-Marc Bourgeon

Abstract

We develop a model in which two insurers and two health care providers compete for a fixed mass of policyholders. Insurers compete in premium and offer coverage against financial consequences of health risk. They have the possibility to sign agreements with providers to establish a health care network. Providers, partially altruistic, are horizontally differentiated with respect to their physical address. They choose the health care quality and compete in price. First, we show that policyholders are better off under a competition between conventional insurance rather than under a competition between integrated insurers (Managed Care Organizations). Second, we reveal that the competition between a conventional insurer and a Managed Care Organization (MCO) leads to a similar equilibrium than the competition between two MCOs characterized by a different objective, i.e. private versus mutual. Third, we point out that the ex ante providers' horizontal differentiation leads to an exclusionary equilibrium in which both insurers select one distinct provider. This result is in sharp contrast with frameworks that introduce the concept of option value to model the (ex post) horizontal differentiation between providers.

January 3, 2011

Data Impediments to Empirical Work on Health Insurance Markets

Leemore Dafny, David Dranove, Frank Limbrock, Fiona Scott Morton

Abstract

We compare four datasets that researchers might use to study competition in the health insurance industry. We show that the two datasets most commonly used to estimate market concentration differ considerably from each other (both in levels and in changes over time), and reflect implausibly high volatility in market shares. By comparison, market share volatility is much lower in a private dataset gathered by a leading investment bank, and in state-level hospital discharge data. We also demonstrate that the outcome of regressions using these data vary considerably by the source used. We conclude that researchers should be cautious about using available data and recommend a new source be developed for public use.

About this journal

Objective
The B.E. Journal of Economic Analysis & Policy (BEJEAP) welcomes submissions that employ microeconomics to analyze issues in organizational economics, consumer behavior, and public policy. Articles submitted to BEJEAP can come in two formats: research papers and letters. Authors should bring to their analysis whatever microeconomic theoretical, experimental or econometric tools are helpful. We publish both empirical work and applied theory (though not more abstract forms of applied theory), and our aim is to disseminate papers that have practical implications for public policy, organizational or individual decision making.

Topics

Design of organizations and institutions
Industrial organization
Health economics
Public finance
Labour Economics
Economics of education, family, development, law, or the environment
Effects of domestic and international policy

Article formats
Research Papers, Letters

> Information on submission process