nep-hea New Economics Papers
on Health Economics
Issue of 2014‒04‒11
forty papers chosen by
Yong Yin
SUNY at Buffalo

  1. Do remittances help smooth consumption during health shocks? Evidence from Jamaica By Diether W. Beuermann; Inder J. Ruprah; Ricardo E. Sierra
  2. The role of relational competence in the health care sector By Bertrand Pauget; Mathieu Cabrol
  3. Spatial disparities in hospital performance By Laurent Gobillon; Carine Milcent
  4. Chronic Illnesses and Injuries: An Evaluation of their Impact on Occupation and Revenues / Maladies chroniques et accidents : une évaluation de leur impact sur le parcours professionnel et les revenus By Emmanuel Duguet; Christine Le Clainche
  5. Individual technologies for health - the implications of distinguishing between the ability to produce health investments and the capacity to benefit from those investments By Bolin, Kristian; Liljas, Bengt; Lindgren, Björn
  6. Non-monotonic health behaviours - implications for individual health-related behaviour in a demand-for-health framework By Bolin, Kristian; Lindgren, Björn
  7. Learning-by-doing in a highly skilled profession when stakes are high: evidence from advanced cancer surgery By Avdic, Daniel; Lundborg, Petter; Vikström, Johan
  8. Individual investments in education and health By Carbone, Jared C.; Kverndokk, Snorre
  9. Normative foundations for equity-sensitive population health evaluation functions By Moreno-Ternero, Juan D.; Østerdal, Lars Peter
  10. Mixed reimbursement of hospitals: Securing high activity and global expenditures control? By Socha, Karolina
  11. Creaming and Dumping: Who on Whom? By Socha-Dietrich, Karolina; Zweifel, Peter
  12. Does Increasing Schooling Improve Later Health Habits? Evidence from the School Reforms in Australia By Jinhu Li; Nattavudh Powdthavee
  13. Do Immigrants Bring Good Health? By Giuntella, Osea; Mazzonna, Fabrizio
  14. Does the Size of the Effect of Adverse Events at High Ages on Daily-Life Physical Functioning Depend on the Economic Conditions Around Birth? By Scholte, Robert; van den Berg, Gerard J.; Lindeboom, Maarten; Deeg, Dorly J. H.
  15. Cost-effectiveness of a web-based decision aid for parents deciding about MMR vaccination By Sandy Tubeuf; Richard Edlin; Swati Shourie; Francine Cheater; Hilary Bekker; Cath Jackson
  16. An economic model of cost effectiveness of peer interventions to prevent HIV infections in prison. By Roberta Longo; Claire Hulme; Armando Vargas-Palacios; Karen Vinall-Collier; Jane South; Anne Marie Bagnall; James Woodall; Gary Raine; Karina Kinsella
  17. The relationship between costs and quality in nonprofit nursing homes By Laura Di Giorgio; Massimo Filippini; Giuliano Masiero
  18. Taking a Teen Pregnancy Prevention Program to the Home: The AIM 4 Teen Moms Experience. By Subuhi Asheer; Ellen Kisker
  19. Structuring Payment to Medical Homes After the Affordable Care Act. By Samuel T. Edwards; Melinda K. Abrams; Richard J. Baron; Robert A. Berenson; Eugene C. Rich; Gary E. Rosenthal; Meredith B. Rosenthal; Bruce E. Landon
  20. Promising Findings from the Frontline Health Worker Team-Based Goals and Incentives Intervention in Bihar. By Dana Rotz; Anu Rangarajan; Evan Borkum Swetha Sridharan; Sukhmani Sethi; Mercy Manoranjini
  21. International Efforts to Serve Youth with Disabilities for the U.S. Disability Support System. By Todd Honeycutt; Jennifer A. Lyons; Lorenzo Moreno
  22. Is the 2010 Affordable Care Act Minimum Standard to Identify Disability in All National Datasets Good Enough for Policy Purposes? By Richard V. Burkhauser; T. Lynn Fisher; Andrew J. Houtenville; Jennifer R. Tennant
  23. Costs and benefits of a bicycle helmet law for Germany By Gernot Sieg
  24. A Pilot Inquiry on Incentives and Intrinsic Motivation in Health Care: the Motivational Capital Explained by Doctors By Mikel Berdud; Juan M. Cabasés Hita; Jorge Nieto
  25. Motivational Capital and Incentives in Health Care Organizations By Mikel Berdud; Juan M. Cabasés Hita; Jorge Nieto
  26. The ACA: Some Unpleasant Welfare Arithmetic By Casey B. Mulligan
  27. How Much Favorable Selection Is Left in Medicare Advantage? By Joseph P. Newhouse; Mary Price; J. Michael McWilliams; John Hsu; Thomas G. McGuire
  28. Health Spending Continues to Stagnate in Many OECD Countries By David Morgan; Roberto Astolfi
  29. Geographic Imbalances in Doctor Supply and Policy Responses By Tomoko Ono; Michael Schoenstein; James Buchan
  30. Early Life Circumstance and Adult Mental Health By James Fenske; Achyuta Adhvaryu; Anant Nyshadham
  31. Analysis of the Individually Paying Program of the Philippine Health Insurance Corporation By Silfverberg, Denise Valerie
  32. Analysis of the Employed Program of the Philippine Health Insurance Corporation By Silfverberg, Denise Valerie
  33. The Prevalence of Philippine Prescribing, Dispensing, and Use Behavior in Relation to Generic Drugs and their Risk Factors By Wong, John Q.; Baclay, J. Richelcyn M.; Duque, Richelle G.; Roque, Patricia Margarita S.; Serrano, Grace Kathleen T.; Tumlos, Jenina Olivia A.; Ronsing, Aisha-Aziza A.
  34. Barriers of Early TB Diagnosis among the Poor in Highly Urbanized Areas in the Philippines By Reyes, Krishna; Amores, Juan Carlos
  35. The Sponsored Program of the Philippine National Health Insurance - Analyses of the Actual Coverage and Variations Across Regions and Provinces By Silfverberg, Raymunda R.
  36. The Impact of An Increase in User Costs on the Demand For Emergency Services: The Case of Portuguese Hospitals By Pedro Ramos; Álvaro Almeida
  37. Multiple Chronic Diseases and Their Linkages with Functional health and Subjective Wellbeing among adults in the low-middle income countries: An Analysis of SAGE Wave1 Data, 2007/10 By Arokiasamy, Perianayagam; Uttamacharya, Uttamacharya; Jain, Kshipra
  38. The heterogeneous effects of HIV testing By Baird, Sarah; Gong, Erick; McIntosh, Craig; Ozler, Berk
  39. Maternal employment and childhood obesity in China: Evidence from the China Health and Nutrition Survey By Nie, Peng; Sousa-Poza, Alfonso
  40. A dynamic hurdle model for zero-inflated count data: with an application to health care utilization By Gregori Baetschmann; Rainer Winkelmann

  1. By: Diether W. Beuermann (Inter-American Development Bank); Inder J. Ruprah (Inter-American Development Bank); Ricardo E. Sierra (Inter-American Development Bank)
    Abstract: Social networks provide an important means by which individuals and households share risk. One of the mechanisms by which informal risk sharing could be achieved is through remittances. Accordingly, this paper identifies whether and how remittances facilitate consumption smoothing during health shocks in Jamaica. In addition, we identify whether remittances are subject to moral hazard by receivers, how the informal insurance provided by remittances interacts with formal health insurance, and whether there are differential effects by gender of the household head. Overall, we find that remittances offer complete insurance towards decreased consumption during health shocks and that moral hazard is weak. The role of remittances as a social insurance mechanism, however, is only relevant in the absence of private health insurance. Public formal health insurance is found to perform a poor job as a safety net that is completely offset by the social insurance provided by remittances.
    Keywords: Consumption Smoothing, Jamaica, Remittances, Health Shocks
    JEL: F24 I13 O15
    Date: 2014–04
  2. By: Bertrand Pauget (IREBS - Institut de recherche de l'European Business School - European Business School); Mathieu Cabrol (IREGE - Institut de Recherche en Gestion et en Economie - Université de Savoie - Institut d'Administration des Entreprises (IAE) - Savoie Mont-Blanc)
    Abstract: The role of entrepreneurs is highly regarded in our societies. It is widely recognized that their roles are not limited to the private sector, but can affect all sectors of the economy. In view of this, we focus on entrepreneurs acting in the healthcare sector. We concentrate more particularly on these entrepreneurs' specific competences. We propose to conceptualise the concept of relational competence, defined as the act of building and structuring relationships in order to adapt and innovate in a given environment. The aim of this exploratory study is to better understand why this type of competence is expected on the construction site of a new hospital in France.
    Keywords: Entrepreneur; relational processes; relational competence; hospital; healthcare system
    Date: 2013
  3. By: Laurent Gobillon (CEPR - Center for Economic Policy Research - CEPR, PSE - Paris-Jourdan Sciences Economiques - CNRS : UMR8545 - École des Hautes Études en Sciences Sociales (EHESS) - École des Ponts ParisTech (ENPC) - École normale supérieure [ENS] - Paris - Institut national de la recherche agronomique (INRA), EEP-PSE - Ecole d'Économie de Paris - Paris School of Economics - Ecole d'Économie de Paris, INED - Institut National d'Etudes Démographiques Paris - INED); Carine Milcent (PSE - Paris-Jourdan Sciences Economiques - CNRS : UMR8545 - École des Hautes Études en Sciences Sociales (EHESS) - École des Ponts ParisTech (ENPC) - École normale supérieure [ENS] - Paris - Institut national de la recherche agronomique (INRA), EEP-PSE - Ecole d'Économie de Paris - Paris School of Economics - Ecole d'Économie de Paris, CEPREMAP - Centre pour la recherche économique et ses applications)
    Abstract: Using a French exhaustive dataset, this article studies the determinants of regional disparities in mortality for patients admitted to hospitals for a heart attack. These disparities are large, with an 80% difference in the propensity to die within 15 days between extreme regions. They may reflect spatial differences in patient characteristics, treatments, hospital characteristics and local healthcare market structure. To distinguish between these factors, we estimate a flexible duration model. The estimated model is aggregated at the regional level and a spatial variance analysis is conducted. We find that spatial differences in the use of innovative treatments play a major role whereas the local composition of hospitals by ownership does not have any noticeable effect. Moreover, the higher the local concentration of patients in a few large hospitals rather than many small ones, the lower the mortality. Regional unobserved effects account for around 20% of spatial disparities.
    Keywords: Spatial health disparities ; Economic geography ; Stratified duration model
    Date: 2013–09
  4. By: Emmanuel Duguet (ERUDITE - Equipe de Recherche sur l'Utilisation des Données Individuelles Temporelles en Economie - Université Paris-Est Créteil Val-de-Marne (UPEC) : EA437 - Université Paris-Est Marne-la-Vallée (UPEMLV), TEPP - Travail, Emploi et Politiques Publiques - CNRS : FR3435 - Université Paris-Est Marne-la-Vallée (UPEMLV)); Christine Le Clainche (LAMETA - Laboratoire Montpelliérain d'Économie Théorique et Appliquée - Université Montpellier I - CNRS : UMR5474 - Institut national de la recherche agronomique (INRA) : UR1135 - Centre international de hautes études agronomiques méditerranéennes [CIHEAM], ENS Cachan - École Normale Supérieure de Cachan - École normale supérieure [ENS] - Cachan)
    Abstract: This paper investigates whether chronic illnesses and injuries have a significant impact on the individual's performance in the labor market. We use the "Santé et Itinéraires Professionnels" (SIP, "Health and Labor Market Histories") survey, conducted in France in 2006-2007. We use the propensity score method in order to evaluate the impact of chronic illnesses and accidents on labor market participation and earnings. We find that both health events, chronic illness and accidents have a negative effect on professional careers and earnings, and that accidents have a greater impact on women's earnings.
    Keywords: chronic illness; injury; career paths; difference in differences method with exact matching
    Date: 2014–03–27
  5. By: Bolin, Kristian (Department of Economics, School of Business, Economics and Law, Göteborg University); Liljas, Bengt (Astra Zeneca, R&D, Mölndal, Sweden); Lindgren, Björn (Centre for Health Economics at the University of Gothenburg; Lund University; National Bureau of Economic Research, Cambridge MA, US)
    Abstract: People differ in their ability to produce health investments and in their capacity to benefit from such efforts. In this paper, we assume (1) that the individual’s health-investment production function exhibits diminishing returns to scale and (2) that the individual’s capacity to benefit from the investments is diminishing in the stock of health. Previous research has only shown the importance of the first assumption for the health-capital adjustment process. The simultaneous effects go well beyond those results, however. Thus, this paper provides an extended demand-for-health framework that distinguishes between individuals both by their capacities to benefit and by their abilities to produce,when transforming health efforts into health increments. The potential usefulness of this framework for health-policy purposes is demonstrated by solving a numerically specified version of the model, and computing individual welfare effects of medical-care goods changes.
    Keywords: investments in health; diminishing returns; capacity to benefit; human capital; Grossman model
    JEL: I12 J24
    Date: 2014–03
  6. By: Bolin, Kristian (Department of Economics, School of Business, Economics and Law, Göteborg University); Lindgren, Björn (Centre for Health Economics, University of Gothenburg, Gotenburg, Sweden; Dept of Health Sciences, Lund University, Lund, Sweden; National Bureau of Economic Research, Cambridge MA, US)
    Abstract: A number of behaviours influence health in a non-monotonic way. Physical activity and alcohol consumption, for instance, may be beneficial to one’s health in moderate but detrimental in large quantities. We develop a demand-for-health framework that incorporates the feature of a physiologically optimal level. An individual may still choose a physiologically non-optimal level, because of the trade-off in his or her preferences for health versus other utility-affecting commodities. However, any deviation from the physiologically optimal level will be punished with respect to health. A set of steady-state comparative statics is derived regarding the effects on the demand for health and health-related behaviour, indicating that individuals will react differently to exogenous changes, depending on the amount of the health-related behaviour they demand. We also show (a) that a steady-state equilibrium is a saddle-point and (b) that the physiologically optimal level may be a steady-state equilibrium for the individual. Our analysis suggests that general public-health policies may, to some extent, be counterproductive due to the responses induced in parts of the population.
    Keywords: human capital; Grossman model; non-monotonic health investments; health; steadystate and stable equilibria
    JEL: I12
    Date: 2014–03–27
  7. By: Avdic, Daniel (Department of Ecconomics, Uppsala University); Lundborg, Petter (Department of Economics, Lund University); Vikström, Johan (IFAU - Institute for Evaluation of Labour Market and Education Policy)
    Abstract: Although learning-by-doing is believed to be an important source of productivity growth, there is limited evidence that production volume affects productivity in a causal sense. We document evidence of learning-by-doing in a highly skilled profession where stakes are high; advanced cancer surgery. For this purpose, we introduce a novel instrument that exploits the closure and opening of entire cancer clinics which have given rise to sharp and exogenous changes in the cancer surgical volumes at Swedish public sector hospitals. Using detailed register data on more than 100,000 episodes of advanced cancer surgery, our results suggest positive effects of surgery volumes on survival. In addition, we provide evidence on the mechanisms through which these improvements occur. We also show that the results are not driven by changes in patient composition or by other changes at the hospital level.
    Keywords: hospital volume; learning-by-doing; cancer surgery; survival; causal effect
    JEL: I11 I12 I18 L11
    Date: 2014–03–26
  8. By: Carbone, Jared C. (Department of Economics, University of Calgary); Kverndokk, Snorre (Ragnar Frisch Centre for Economic Research)
    Abstract: Empirical studies show that years of schooling are positively correlated with good health, and that education is better correlated with health than with variables like occupation and income. This can be explained in different ways as the implication may go from education to health, from health to education, and there may be variables that influence health and education in the same direction. The effect of different policy instruments to reduce the social gradient in health will depend on the strength of these causalities. In this paper we formalize a model that simultaneously determines an individual’s demand for knowledge and health based on the mentioned causal effects. We study the impacts on both health and education of different policy instruments such as subsidies on medical care, subsidizing schooling, income tax reduction, lump sum transfers and improving health at young age. Our results indicate that income transfers such as distributional policies may be the best instrument to improve welfare, while subsidies to medical care is the best instrument for longevity. However, subsidies to medical care or education would require large imperfections in the markets for health and education to be more welfare improving than distributional policies. Finally, our simulations suggest that underlying factors that impact both health and education is the main explanation for the correlation shown empirically.
    Keywords: Demand for health; Demand for education; Human capital; Numerical modeling; Causality
    JEL: C61 D91 I12 I21
    Date: 2014–03–01
  9. By: Moreno-Ternero, Juan D. (Department of Economics, Universidad Pablo de Olavide); Østerdal, Lars Peter (COHERE, Department of Business and Economics, University of Southern Denmark)
    Abstract: Standard models for the evaluation of population health, such as the so-called models of aggregate Quality Adjusted Life Years (QALYs), or aggregate Healthy Years Equiva- lent (HYEs), are usually criticized on equity grounds. We provide in this paper normative justi_cations for alternative equity-sensitive models, such as the so-called models of mul- tiplicative QALYs, multiplicative HYEs, and generalizations of the two. Our axiomatic approach assumes social preferences over distributions of individual health states experi- enced in a given period of time. It conveys informational simplicity, as it does not require information about individual preferences on health.
    Keywords: Population health; equity; HYEs; QALYs; axioms
    JEL: D63 I10
    Date: 2014–01–10
  10. By: Socha, Karolina (COHERE, Department of Business and Economics)
    Abstract: When introducing Diagnosis-Related Group (DRG) tariffs as the basis for paying hospitals in Europe, one of the major problems was to find a balancing point between the aim of increasing hospital activity and the need to control global expenditures on hospital care. Consequently, in several European countries, DRG-based reimbursement has been mixed with the already existing forms of hospital reimbursement, such as block budgets, instead of replacing the latter entirely. The mixed reimbursement is viewed as a cautious way of introducing DRG-based funding, which offers the potential for achieving activity expansion without jeopardizing global expenditures control. Denmark is one of the countries where DRG tariffs have been added to the system of block budgets coupled with activity targets. The transition to the mixed reimbursement occurred by replacing a part of each hospital’s ‘old’ block budget by a ‘new’ DRG-based component. The DRG-based component depends on a hospital’s case mix and applicable DRG tariffs, which are, however, reduced by, e.g. 30-50% as compared with a monetary value of a full tariff. The usual interpretation is that such a mix of reimbursement methods provides a specific set of incentives that is different from other hospital payment methods. Yet, the exact modus operandi of the mixed reimbursement remains obscure. It is not entirely clear whether and how the unit rate of reimbursement was changed after the transition? Was the entire volume of a hospital’s activity affected or only certain treatments and/or higher levels of activity? Another question is what happened with the activity targets that traditionally accompanied the ‘old’ block budgets? The aim of this article is to provide a comprehensive description of the change in hospital incentive scheme that followed the transition to the mixed reimbursement in Denmark. In doing so, the paper provides a qualitative assessment of the mixed reimbursement with regard to the asserted exceptionality of its incentive structure, with a particular focus on its ability to balance incentives for activity expansion and global expenditures control. We show that the mixed reimbursement is simply a veiled version of the usual block budget system, which due to certain added complications might even distort activity/efficiency improvements in a new way. The cautions way of implementing DRG –based reimbursement resulted in a system that has hardly moved away from the historical patterns of activity and costs. The sum of the ‘new’ DRG-based component and the remaining part of the ‘old’ block budget simply added up to the total of the ‘old’ block budget (+/- standard annual corrections for inflation, etc.), which allowed hospitals to produce unchanged sort and volume of activity at unchanged unit cost. Only few percent of the annual activity volume is indeed subject to altered reimbursement incentives. In sum, the mixed reimbursement as implemented in Denmark does not present any innovation. Hence, any empirical research based on the assumption that the incentive scheme for the entire volume of hospital activity was changed by the transition to the mixed reimbursement might produce false conclusions.
    Keywords: Diagnosis-Related Groups; Block budgets; Hospital reimbursement; Denmark
    JEL: I12 I13 I14
    Date: 2014–03–01
  11. By: Socha-Dietrich, Karolina (COHERE, Department of Business and Economics); Zweifel, Peter (Department of Economics)
    Abstract: In several countries, public healthcare providers purchase services from private providers to shorten waiting times. Some private providers in turn combine public service with practice in their own facilities. According to the existing literature, they are viewed as cream-skimming profitable (low-severity) public patients to the benefit of private practice, causing cost of treatment in the public sector to increase. This is particularly problematic when public provider payment is prospective. However, two facts seem to be neglected. First, cream skimming involves effort and thus does not occur in all circumstances. Second, public providers might have an incentive to select patients too, resulting in dumping of the least profitable (high-severity) patients on the private sector. This paper derives the conditions under which both creaming and dumping are predicted to occur.
    Keywords: Creaming; Dumping; Waiting lists; Public Service; Dual Practice
    JEL: I11 I18
    Date: 2014–03–01
  12. By: Jinhu Li (Melbourne Institute of Applied Economic and Social Research, The University of Melbourne); Nattavudh Powdthavee (Department of Economics and CentER, Tilburg University; Department of Economics, The University of Melbourne; CESifo (Munich); Centre for Economic Policy Research (London); and Institute for the Study of Labor (IZA))
    Abstract: This study estimates the causal effect of schooling on health behaviors. Using changes in the minimum school leaving age laws that varied by birth year and states in Australia from age 14 to 15 as a source of exogenous variation in schooling, the instrumental variables (IV) regression estimates imply that there is a positive, sizeable, and statistically significant effect of staying an extra year in school on later healthy lifestyle choices, including diet, exercise, and the decision to engage in risky health behaviors. We also demonstrate that the magnitudes of the schooling effect were effectively moderated by a selection of pre-determined characteristics of the individuals. Finally, this paper provides some evidence on the potential underlying mechanisms linking education and health behaviors by showing that increasing schooling also raised individuals’ conscientiousness levels and the perceived sense of control over one’s life.
    Keywords: Health behaviors, schooling, instrumental variables, education, HILDA, Australia
    JEL: I12 I21 C26
    Date: 2014–01
  13. By: Giuntella, Osea (University of Oxford); Mazzonna, Fabrizio (University of Lugano)
    Abstract: This paper studies the effects of immigration on health. We merge information on individual characteristics from the German Socio-Economic Panel with detailed local labor market characteristics for the period 1984 to 2009. We exploit the longitudinal component of the data to analyze how immigration affects the health of both immigrants and natives over time. Immigrants are shown to be healthier than natives upon their arrival ("healthy immigrant effect"), but their health deteriorates over time spent in Germany. We show that the convergence in health is heterogeneous across immigrants and faster among those working in more physically demanding jobs. Immigrants are significantly more likely to work in strenuous occupations. In light of these facts, we investigate whether changes in the spatial concentration of immigrants affect natives' health. Our results suggest that immigration reduces residents' likelihood to report negative health outcomes by improving their working conditions and reducing the average workload. We show that these effects are concentrated in blue-collar occupations and are larger among low educated natives and previous cohorts of immigrants.
    Keywords: immigration, health
    JEL: F22 I10 J15 J61
    Date: 2014–03
  14. By: Scholte, Robert (SEO Economic Research); van den Berg, Gerard J. (University of Mannheim); Lindeboom, Maarten (VU University Amsterdam); Deeg, Dorly J. H. (VU University Amsterdam)
    Abstract: This paper considers determinants of physical-functional limitations in daily-life activities at high ages. Specifically, we quantify the extent to which the impact of adverse life events on this outcome is larger in case of exposure to adverse economic conditions early in life. Adverse life events include bereavement, severe illness in the family, and the onset of chronic diseases. We use a longitudinal data set of individuals born in the first decades of the 20th century. The business cycle around birth is used as an indicator of economic conditions early in life. We find that the extent to which functional limitations suffer from the onset of chronic diseases is larger if the individual was born in a recession. The long-run effect of economic conditions early in life on functional limitations at high ages runs primarily via this life event.
    Keywords: functional limitations, long-run effects, business cycle, panel data, health, bereavement, chronic diseases
    JEL: I12 C33 J14
    Date: 2014–03
  15. By: Sandy Tubeuf (Leeds Institute of Health Sciences, University of Leeds); Richard Edlin (School of Population Health, University of Auckland); Swati Shourie (Monash Injury Research Institute, Monash University); Francine Cheater (School of Nursing Sciences, University of East Anglia); Hilary Bekker (Leeds Institute of Health Sciences, University of Leeds); Cath Jackson (York Trials Unit, University of York)
    Abstract: Background: Levels of measles in England and Wales are at their highest for 18 years and strategies targeting the different groups of parents who don’t vaccinate their children continue to be needed. Decision aids for childhood immunisation decisions appear to be effective in achieving vaccine uptake, however their cost effectiveness is unknown. Aim: To assess the cost-effectiveness of a web-based decision aid to increase MMR vaccine uptake. Design and Setting: Economic evaluation conducted alongside a cluster randomised controlled trial. 50 GP practices in the North of England were randomised to one of three trial arms (decision aid, leaflet, nothing) alongside usual practice. 220 first-time parents (child aged 3 to 12 months) were recruited. Methods: Parents self-reported their contacts with the NHS and other previous/expected resource utilisation; associated costs were calculated. Vaccine uptake was collected from GP practices. Cost-effectiveness is expressed in terms of incremental cost per first vaccine uptake. Multiple imputations were used to account for missing data and findings were adjusted for baseline differences in parents’ levels of decisional conflict for the MMR decision. Results: MMR uptake was highest for those receiving the decision aid (42/42, 100% vs. usual practice 61/62, 98% and leaflet arm 69/75, 92%) and was associated with lower cost. The decision aid has a high chance of being cost-effective regardless of the value placed on obtaining additional vaccinations. Conclusions: The decision aid appears to offer an efficient means of decision support for parents.
    Keywords: cost-effectiveness;decision aid; vaccination; immunisation; MMR
    Date: 2014
  16. By: Roberta Longo (Leeds Institute of Health Sciences, University of Leeds); Claire Hulme (Leeds Institute of Health Sciences, University of Leeds); Armando Vargas-Palacios (Leeds Institute of Health Sciences, University of Leeds); Karen Vinall-Collier (Leeds Institute of Health Sciences, University of Leeds); Jane South (Leeds Metropolitan University); Anne Marie Bagnall (Leeds Metropolitan University); James Woodall (Leeds Metropolitan University); Gary Raine (Leeds Metropolitan University); Karina Kinsella (Leeds Metropolitan University)
    Abstract: Aim: To assess the cost-effectiveness of peer-based sexual behaviour education interventions in prison settings to prevent primary and secondary HIV infections. Methods: Based on the results of a systematic review of peer-based interventions in prison settings, we developed a Bernoulli model to estimate the number of HIV infections averted, consequent loss of quality-adjusted life years (QALYs) avoided and associated savings in health care costs over a lifetime respectively for a peer-led and a professionally-led education intervention. Results: The economic model showed that peer-led and professionally-led educational interventions prevent future HIV infections among offenders in prison settings, thus saving a significant amount of health care costs compared to a ‘do nothing’ scenario. In addition the peer-led intervention is dominant when compared to the professionally-led intervention (it is more effective and less costly). Whilst the model is surrounded by considerable uncertainty, the dominance scenario is confirmed in the one-way and probabilistic sensitivity analysis conducted. Conclusions: This study adds to previous evidence on the effectiveness of peer based educational interventions in preventing HIV in prison by showing that these are not only more effective but also cost less than the professionally-led alternative.
    Keywords: Cost-effectiveness analysis; HIV; prevention in prison; sexual behaviour; peer education
    Date: 2014
  17. By: Laura Di Giorgio (Institute of Economics (IdEP), University of Lugano, Switzerland; Institute for Health Metrics and Evaluation (IHME), University of Washington, Seattle, USA); Massimo Filippini (Institute of Economics (IdEP), University of Lugano; ETH, Zurich, Switzerland); Giuliano Masiero (Department of Engineering, University of Bergamo, Italy; Institute of Economics (IdEP), University of Lugano, Switzerland)
    Abstract: We investigate the relationship between costs and quality in nonprofit nursing homes, a key issue in the present context of cost containment measures. In accordance with the economic theory of production, we estimate a three-inputs total cost function for nursing home services using data from 45 nursing homes in Switzerland between 2006 and 2010. Quality is measured by means of clinical indicators regarding process and outcome derived from the Minimum Data Set. We consider both composite and single quality indicators. Contrary to previous studies, we use panel data and control for unobserved heterogeneity. This allows to capture nursing homes specific features that may explain differences in structural quality or costs levels. We find evidence that poor levels of quality regarding outcome, as measured by the prevalence of severe pain and weight loss, lead to higher costs. Our results are robust to quality endogeneity concerns.
    Keywords: nursing home costs, nonprofit, quality indicators, cost-quality tradeoff
    JEL: I10 L3
    Date: 2014–03
  18. By: Subuhi Asheer; Ellen Kisker
    Keywords: Teen pregnancy prevention , repeat births, Teen Mothers, implementation evaluation
    JEL: I
    Date: 2014–02–21
  19. By: Samuel T. Edwards; Melinda K. Abrams; Richard J. Baron; Robert A. Berenson; Eugene C. Rich; Gary E. Rosenthal; Meredith B. Rosenthal; Bruce E. Landon
    Keywords: PCMH, Patient Centered Medical Home, Affordable Care Act, Structuring Payment
    JEL: I
    Date: 2014–04–30
  20. By: Dana Rotz; Anu Rangarajan; Evan Borkum Swetha Sridharan; Sukhmani Sethi; Mercy Manoranjini
    Keywords: TBGI, Frontline Health Worker Team Based Goals, Bihar, Ananya, International
    JEL: F Z
    Date: 2014–02–28
  21. By: Todd Honeycutt; Jennifer A. Lyons; Lorenzo Moreno
    Keywords: Youth Disabilities, Disability Support System, International, Disability
    JEL: I J
    Date: 2014–03–30
  22. By: Richard V. Burkhauser (Cornell University and University of Melbourne); T. Lynn Fisher (Social Security Administration); Andrew J. Houtenville (University of New Hampshire); Jennifer R. Tennant (Ithaca College)
    Abstract: Using linked 2009 Current Population Survey (CPS)-Annual Social and Economic Supplement/Social Security Administration records data and a definition of disability based on the six-question disability sequence (6QS) in the CPS-Basic Monthly Survey, we perform a face validity test that shows that the 6QS captures only 66.3 percent of those who administrative records confirm are receiving Social Security benefits based on their disability. Adding a work-activity question to the 6QS increases our capture rate by another 23.1 percentage points for a total of 89.3 percent. We find little difference in the distribution of conditions between those who only report a 6QS-based disability and those who only report a work activity-based disability. The four function-related questions in the 6QS do a relatively good job of capturing those receiving benefits based on these conditions. But the work-activity question does a far better job of capturing those receiving benefits than the two activity-related questions in the 6QS.
    Date: 2014–03
  23. By: Gernot Sieg (Institute of Transport Economics, Muenster)
    Abstract: This study presents a cost-benefit analysis of a law requiring cyclists to wear a helmet when riding a bicycle in Germany. The cost benefit-analysis takes into account the benefit of increased security when cyclists wear a helmet or use a transport mode that is less risky than cycling. The analysis also considers the cost of purchasing helmets, reduced fitness when cycling is replaced by a motorized transport mode, the discomfort of wearing helmets and environmental externalities. The benefits of a helmet law are estimated at about 0.714 of the costs. A bicycle helmet law for Germany is found to be a waste of resources.
    Keywords: bicycle helmets, cost-benefit analysis, helmet law
    JEL: K32 L91 R41
    Date: 2014–03
  24. By: Mikel Berdud (Departamento de Economía-UPNA); Juan M. Cabasés Hita (Departamento de Economía-UPNA); Jorge Nieto (Departamento de Economía-UPNA)
    Abstract: Where the contracts are incomplete, the resulting co-ordination problems may be attenuated if workers are intrinsically motivated to do the work. It is established by theoretical and empirical literature that workers within public organizations are intrinsically motivated to exert effort doing the job and have a strong sense of social agents with the mission of providing collective goods to citizens and tax payers. This paper is an empirical pilot study in the health care sector using methods of Qualitative Analysis research. We run semistructured interviews á-la- Bewley to sixteen physicians of Navarre’s health Care Servicio Navarro de Salud-Osasunbidea (SNS-O). The objective of the work is twofold: first, to find empirical evidence about doctors’ non-monetary motives and second, to find evidence about how these non-monetary motives shape doctors’behavior. We formulate several testable hypotheses: (1) Doctors are intrinsically motivated agents, (2) Economic incentives and control policies may crowd- out intrinsic motivation and (3) Well designed incentives may crowd-in agents intrinsic motivation. Results confirm the hypotheses formulated above and coming from our theoretical findings [11], [12]. Finally, we also found empirical evidence of conflict between political advisors or health managers (principals) and physicians (agents). Results are a step forward in the optimal design of incentive schemes and policies which crowd in doctors’ intrinsic motivation.
    Keywords: qualitative research, interviews, intrinsic motivation, crowding effects
    JEL: D03 D86
    Date: 2014
  25. By: Mikel Berdud (Departamento de Economía-UPNA); Juan M. Cabasés Hita (Departamento de Economía-UPNA); Jorge Nieto (Departamento de Economía-UPNA)
    Abstract: This paper explores optimal incentive schemes in public health institutions when agents (doctors) are intrinsically motivated. We develop a principal-agent dynamic model with moral hazard in which agents’ intrinsic motivation could be promoted (crowding-in) by combining monetary and non-monetary rewards, but could also be discouraged (crowding-out) when the health manager uses only monetary incentives. We discuss the conditions under which investing in doctors’ motivational capital by the use of well designed nonmonetary rewards is optimal for the health organizations manager. Our results show that such investments will be more efficient than pure monetary incentives in the long run. We will also prove that when doctors are riskaverse, it is profitable for the health manager to invest in motivational capital.
    Keywords: contracts, moral hazard, intrinsic motivation, crowding effects, motivational capital
    Date: 2014
  26. By: Casey B. Mulligan
    Abstract: Under the Affordable Care Act, between six and eleven million workers would increase their disposable income by cutting their weekly work hours. About half of them would primarily do so by making themselves eligible for the ACA's federal assistance with health insurance premiums and out-of-pocket health costs, despite the fact that subsidized workers are not able to pay health premiums with pre-tax dollars. The remainder would do so primarily by relieving their employers from penalties, or the threat of penalties, pursuant to the ACA's employer mandate. Women, especially those who are not married, are more likely than men to have their short-term financial reward to full-time work eliminated by the ACA. Additional workers, beyond the six to eleven million, could increase their disposable income by using reduced hours to climb one of the "cliffs" that are part of the ACA's mapping from household income to federal assistance.
    JEL: E24 H21 I38
    Date: 2014–03
  27. By: Joseph P. Newhouse; Mary Price; J. Michael McWilliams; John Hsu; Thomas G. McGuire
    Abstract: There are two types of selection models in the health economics literature. One focuses on choice between a fixed set of contracts. Consumers with greater demand for medical care services prefer contracts with more generous reimbursement, resulting in a suboptimal proportion of consumers in such contracts in equilibrium. In extreme cases more generous contracts may disappear (the “death spiral”). In the other model insurers tailor the contracts they offer consumers to attract profitable consumers. An equilibrium may or may not exist in such models, but if it exists it is not first best. The Medicare Advantage program offers an opportunity to study these models empirically, although unlike the models in the economics literature there is a regulator with various tools to address selection. One such tool is risk adjustment, or making budget neutral transfers among insurers using observable characteristics of enrollees that predict spending. Medicare drastically changed its risk adjustment program starting in 2004 and made a number of other changes to reduce selection as well. Previous work has argued that the changes worsened selection. We show, using a much larger data set, that this was not the case, but that some inherent selection may remain.
    JEL: I1 I13 I18
    Date: 2014–03
  28. By: David Morgan; Roberto Astolfi
    Abstract: The global economic crisis which began in 2008 has had a dramatic effect on health spending across OECD countries. Estimates of expenditure on health released back in 2012 showed that, for the first time, health spending had slowed markedly or fallen across many OECD countries after years of continuous growth. As a result, close to zero growth in health expenditure was recorded on average in 2010. Preliminary estimates suggested that the low or negative growth in health spending was set to continue in many OECD countries in following years... La crise économique mondiale qui a débuté en 2008 a profondément modifié l'évolution des dépenses de santé des pays de l’OCDE. Les estimations publiées en 2012 ont montré que, pour la première fois après des années de croissance ininterrompue, les dépenses de santé avaient sensiblement ralenti, voire diminué, dans de nombreux pays. Ainsi, leur taux de croissance moyen s’établissait autour de zéro en 2010 et, d’après les premières estimations, il serait resté faible ou négatif dans de nombreux pays en 2011...
    JEL: H51 I12 I18
    Date: 2014–04–03
  29. By: Tomoko Ono; Michael Schoenstein; James Buchan
    Abstract: Doctors are distributed unequally across different regions in virtually all OECD countries, and this causes concern about how to continue to ensure access to health services everywhere. In particular access to services in rural regions is the focus of attention of policymakers, although in some countries, poor urban and sub-urban regions pose a challenge as well. Despite numerous efforts this mal-distribution of physician supply persists. This working paper first examines the drivers of the location choice of physicians, and second, it examines policy responses in a number of OECD countries... La répartition des médecins entre les régions est inégale dans pratiquement tous les pays de l’OCDE, et cela pose la question de savoir comment continuer de garantir l’accès aux services de santé partout. L’accès aux services dans les régions rurales préoccupe tout particulièrement les responsables publics, même si, dans certains pays, les régions urbaines et suburbaines pauvres posent aussi un problème. En dépit d’importants efforts, les inégalités dans la répartition des effectifs médicaux persistent. Le présent document de travail examine, dans un premier temps, les critères déterminants, pour les médecins, dans le choix de leur lieu d’exercice et, dans un second temps, les réponses apportées par les pouvoirs publics dans un certain nombre de pays de l’OCDE...
    JEL: I18
    Date: 2014–04–03
  30. By: James Fenske; Achyuta Adhvaryu; Anant Nyshadham
    Abstract: We show that psychological well-being in adulthood varies substantially with circumstance in early life.� Combining a time series of real producer prices of cocoa with a nationally representative household survey in Ghana, we find that a one standard deviation rise in the cocoa price in early life decreases the likelihood of severe mental distress in adulthood by 3 percentage points (or half the mean prevalence) for cohorts born in cocoa-producing regions relative to those born in other regions.� Impacts on related personality traits are consistent with this result.� Maternal nutrition, reinforcing childhood investments, and adult circumstances are operative channels of impact.
    Keywords: mental health, subjective well-being, early life, fetal origins, endowments, commodity prices
    JEL: I12 I15 I31 Q02 O12
    Date: 2014–02–26
  31. By: Silfverberg, Denise Valerie
    Abstract: The Individually Paying Program (IPP) is the voluntary component of the Philippines` social health insurance program. The program caters to those in the informal sector and those without a formal employer-employee relationship. Coverage levels for the IPP were found to be considerably low with a regional average of 57 percent and a provincial average of 53 percent. Massive variation between provinces was found. Four important factors were identified when looking into said variation. First, availability and accessibility is an issue. Second, substitution effect between private and public facilities was observed. Third, income levels do not appear to be a factor in determining the level of insurance coverage. Lastly, the size of certain sectors had a significant effect on the coverage levels observed in the province. Although there is a need to corroborate the findings with an individual-level analysis, these results are good indicators to start with in order to address the lack of coverage in the voluntary program of PhilHealth.
    Keywords: health care financing, Philippines, social health insurance, universal coverage, informal sector, voluntary program
    Date: 2014
  32. By: Silfverberg, Denise Valerie
    Abstract: The Employed Program of the Philippine Health Insurance Corporation (PhilHealth) caters to those in the formal sector. Included are those in the government and private sectors with a formal employer-employee relationship. Coverage levels for both the government and private sectors are promising with regional averages of 74 percent and 71 percent, respectively; and provincial averages of 80 percent and 75 percent, respectively. For the private sector, certain sectors were found to be more prone to undercoverage. For the government sector, no clear pattern was found to explain the causes of variation between provinces. This is likely due to the absence of casual and contractual employees in the model. The findings for both sectors are possible propositions on how targeting should be implemented to address the gaps that exist in what is supposed to be a mandatory scheme.
    Keywords: health care financing, Philippines, social health insurance, universal coverage, formal sector, employed program
    Date: 2014
  33. By: Wong, John Q.; Baclay, J. Richelcyn M.; Duque, Richelle G.; Roque, Patricia Margarita S.; Serrano, Grace Kathleen T.; Tumlos, Jenina Olivia A.; Ronsing, Aisha-Aziza A.
    Abstract: This study was designed to address the issue of compliance of physicians and drugstores to the provisions of Generics Act of 1988. Furthermore, it aims to explore the awareness of consumers on generic medicines to explain current trends and practices in drug prescribing, dispensing, and use. The study utilized a cross-sectional design. It is a descriptive study that assessed four variables: generic drug prescription, generic drug substitution/dispensing, price menu cards, and use of generic drugs. The country was divided into six zones, namely: North Luzon, South Luzon, NCR, Visayas, Mindanao, and ARMM. Stratified cluster random sampling was used to identify which provinces and cities would be included in the study. Data collection techniques used include the following: a survey of consumers coming out of a drugstore (a total of 1,160 respondents), key informant interview of 30 physicians, and focus group discussion with 6 to 11 patients/watchers per zone. The survey revealed that five out of six drugs were written with generic names, with doctors in the public sector prescribing generics significantly more often than those in the private sector. Factors that positively affect generics prescribing behavior are patient`s welfare, compliance, patient`s financial situation, and fear of punishment. Quality concerns, lack of regulation by FDA, poor recall, patient`s preference, and personal experience are factors that negatively affect generics prescribing behavior. Less than half of the consumers were offered with generic alternatives, and even less number of consumers actually asked for the alternative. There is preference for branded medicines over generics. The consumers more likely to purchase generic medicines consulted a public facility, knew the requirement to write generic name, and was influenced by friends and relatives. Because there is already high compliance from drug prescribers, government efforts should now focus on the drugstores and consumers. Drugstore compliance should be regularly monitored, and consumers empowered on their right to know alternatives. Bioequivalence tests should be done to finally put an end to concerns on the quality of generic medicines.
    Keywords: Philippines, generics, prescribing, dispensing, drug use, social marketing, cross-sectional survey
    Date: 2014
  34. By: Reyes, Krishna; Amores, Juan Carlos
    Abstract: Over the last decade, there was a significant drop in mortality and morbidity cases attributed to tuberculosis (TB). The high TB Case Detection (CDR) and Treatment Success Rates (TSR) may have underpinned the decreasing prevalence. Despite these successes, TB still appears to be a major health problem in the country. Disturbingly, the rate of decrease in the mortality and morbidity is not fast enough. This makes the country`s MDG goal targets on TB eradication shaky. The Philippines is also in the list of 27 countries with the highest burden of TB. To further augment case detection rate and early diagnosis, this study aims to qualitatively explore the barriers to diagnosis among the poor highly urbanized population, one of the identified high-risk population groups. Using focus group discussions of TB patients with delayed diagnosis conducted in three highly urbanized cities in the Philippines, namely, Metro Manila, Cebu, and Davao, the researchers investigated and explored wide range of factors that hinder patients to seek health care despite the presence of triggering factors among urban poor. Results suggest sociocultural, financial, and health system factors are identified as important barriers. These factors ascertain the findings identified in most developing countries. This study hopes to augment the prevention and control program of the Department of Health and Philippine Health Insurance Corporation to increase awareness and health-seeking behavior.
    Keywords: poverty, Philippines, tuberculosis, TBDOTS, early diagnosis, case detection rate, highly urbanized population
    Date: 2014
  35. By: Silfverberg, Raymunda R.
    Abstract: This study established the breadth of socialized Philippine health insurance, known as the PhilHealth Sponsored Program. It examined the extent of coverage relative to its target "poor" population, how much coverage rates varied across provinces and the factors likely to explain variation. PhilHealth Sponsored Program appeared to have attained universal coverage over the targeted "poor" population at the national level for the year 2011. However, universal coverage was not true in all regions or provinces. Majority of provinces experienced mild to extreme leakages in the program. Several demand and supply variables identified to have strong statistical significance in explaining variations were age-groups, education, LGUs` real per capita income, health expenditures, governance style, accessibility to PHIC support offices and availability of health professionals, all of which were found to very likely affect undercoverage rates relative to full coverage. Severity of poverty, administrative and political governance, and availability of accredited RHUs and private hospitals provided strong statistical evidence in influencing the levels of leakage vis-a-vis full coverage. Effects of most variables conformed to expectations. Results of the study point to a number of research issues that can be undertaken and some policy recommendations addressed to the national agencies and local government implementers and financiers for the PhilHealth Sponsored Program.
    Keywords: Philippines, PhilHealth Sponsored Program, universal coverage, national health insurance, regional/provincial PhilHealth coverage, NHTS-PR data, Good Governance Index (GGI)
    Date: 2014
  36. By: Pedro Ramos (Faculdade de Economia, Universidade do Porto); Álvaro Almeida (CEF.UP and Faculdade de Economia, Universidade do Porto)
    Abstract: Evidence on the impact of user costs on healthcare demand in “universal” public National Health Service (NHS) systems is scarce. The changes in copayments and in the regulation of the provision of free patient transportation, introduced in early 2012 in Portugal, provide a natural experiment to evaluate that impact. However, those changes in user costs were accompanied with changes in the criteria that determine which patients are exempt from copayments, implying that changes to the underlying populations made simple comparisons of user rates meaningless. The aim of this paper is to evaluate the impact of increases in direct and indirect user costs on the demand for emergency services (ES), in the context of changes to the underlying populations of exempt and non-exempt patients. Our contributions are twofold: we develop a new methodology for analyzing ES demand changes following user cost increases when the underlying population is not constant, and we measure the relative impact of copayments and distance costs on ES demand, in NHS-countries, with “almost free” access to healthcare. Our results show that the increase in copayments did not have a significant effect in moderating ES demand by paying users. On the other hand, we find a significant effect of the change in transport regulation in the demand for ES, especially in the more general polyvalent ES and for older patients. Thus, our results support the conclusion that indirect costs may be more important than direct costs in determining healthcare demand in NHS-countries where copayments are small and wide exemption schemes are in place, especially for older patients.
    Keywords: Copayments; Indirect costs; healthcare demand
    JEL: I11 I13
    Date: 2014–03
  37. By: Arokiasamy, Perianayagam; Uttamacharya, Uttamacharya; Jain, Kshipra
    Abstract: This paper examines the prevalence and determinants of multiple chronic diseases and their association with the self-rated health, functional health and quality of life among adults in six SAGE countries: China, India, Russia, South Africa Mexico and Ghana. We use ADL and IADL activities as measures of functional health and WHOQoL index as a measure of quality of life. Poisson regression models are estimated to understand the social determinants of multiple chronic diseases. Logit models and OLS are estimated to examine the association between multiple chronic morbidities and self-rated health, functional health and quality of life. Russia had the highest prevalence of multi-morbidity (32.8%, 95%CI=25.5-41.1) followed by South Africa (22%, 95%CI=17.7-26.9); the other four countries had prevalence of multi-morbidity around 21%. Measures of socioeconomic status: education and wealth were found negatively associated with the number of chronic diseases. Higher number of chronic conditions was associated with the poorer self rated health, functional health and WHOQoL.
    Keywords: Multiple morbidity, Chronic diseases, Developing Countries, SAGE
    JEL: I14 I18
    Date: 2013–08
  38. By: Baird, Sarah; Gong, Erick; McIntosh, Craig; Ozler, Berk
    Abstract: An extensive multi-disciplinary literature examines the effects of learning one's HIV status on subsequent risky sexual behaviors. However, many of these studies rely on non-experimental designs; use self-reported outcome measures, or both. This study investigates the effects of a randomly assigned home based HIV testing and counseling (HTC) intervention on risky sexual behaviors and schooling investments among school-age females in Malawi. The study finds no overall effects on HIV, Herpes Simplex Virus (HSV-2), or achievement test scores at follow-up. However, among the small group of individuals who tested positive for HIV, a large increase in the probability of contracting HSV-2 is found, with this effect stronger among those surprised by their test results. Similarly, those surprised by HIV-negative test results see a significant improvement in achievement test scores, consistent with increased returns to investments in human capital. The finding of increased HSV-2 prevalence among HIV-positive individuals suggests that the conventional wisdom that those who learn they are HIV-positive will adopt safer sexual practices should be treated with caution.
    Keywords: Disease Control&Prevention,Population Policies,HIV AIDS,Gender and Health,HIV AIDS and Business
    Date: 2014–03–01
  39. By: Nie, Peng; Sousa-Poza, Alfonso
    Abstract: Using five waves from the China Health and Nutrition Survey (CHNS), we investigate the association between maternal employment and obesity in children aged 3 - 17 in both rural and urban China. Using BMI and waist circumference as measures for pediatric adiposity, we provide scant evidence for its relation to maternal employment. We also find no strong association between maternal employment and our measures for children's diet and physical activity. Our study also suggests that grandparenting could have beneficial effects on childhood obesity. --
    Keywords: Maternal employment,Childhood obesity,China
    JEL: I12 J13 J22
    Date: 2014
  40. By: Gregori Baetschmann; Rainer Winkelmann
    Abstract: Excess zeros are encountered in many empirical count data applications. We provide a new explanation of extra zeros, related to the underlying stochastic process that generates events. The process has two rates, a lower rate until the first event, and a higher one thereafter. We derive the corresponding distribution of the number of events during a fixed period and extend it to account for observed and unobserved heterogeneity. An application to the socio-economic determinants of the individual number of doctor visits in Germany illustrates the usefulness of the new approach.
    Keywords: Excess zeros, Poisson process, exposure, hurdle model
    JEL: C25 I10
    Date: 2014–04

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