nep-hea New Economics Papers
on Health Economics
Issue of 2016‒09‒18
23 papers chosen by
Yong Yin
SUNY at Buffalo

  1. Methodology of the National Health Account for Germany - Database, compilation and results By Schwärzler, Marion Cornelia; Kronenberg, Tobias
  2. Malaria Risk and Civil Violence By Cervellati, Matteo; Esposito, Elena; Sunde, Uwe; Valmori, Simona
  3. Does competition from private surgical centres improve public hospitals’ performance? Evidence from the English National Health Service By Zack Cooper; Stephen Gibbons; Matthew Skellern
  4. Hospital Network Competition and Adverse Selection: Evidence from the Massachusetts Health Insurance Exchange By Mark Shepard
  5. Unlucky to Be Young? The Long-Term Effects of School Starting Age on Smoking Behaviour and Health By Bahrs, Michael; Schumann, Mathias
  6. The impact of technology diffusion in health care markets - Evidence from heart attack treatment By Hentschker, C.; Wübker, A.
  7. Money and Credit: Health and Health Inequality during the Great Recession: Evidence from the PSID By Huixia Wang; Chenggang Wang; Timothy Halliday
  8. The Dynamics of Income-Related Health Inequalities in Australia versus Great Britain By Calara, Paul Samuel; Gerdtham, Ulf-G; Petrie, Dennis
  9. Financial Risk Protection from Social Health Insurance By Kayleigh Barnes; Arnab Mukherji; Patrick Mullen; Neeraj Sood
  10. Healthcare Spending: The Role of Healthcare Institutions from an International Perspective By Titeca, Hannes
  11. Information expensiveness perceived by Vietnamese patients with respect to healthcare provider’s choice By Quan-Hoang Vuong
  12. Bridging the Gap in Workforce and Education Services: Career Coaching in the Virginia RETHINKS Health Sciences Education TAACCCT Program By Cecilia Speroni; Nan Maxwell
  13. Implementing the Virginia RETHINKS Health Sciences Education TAACCCT Grant By Margaret Sullivan; Brittany English; Alyson Burnett; Jillian Berk
  15. Determinants of Quality of Family Planning Counseling Among Private Health Facilities in Lagos By Doug Johnson; Jorge Ugaz
  17. Small Area Estimation: New Developments and Directions for HHS Data By John L. Czajka; Amang Sukasih; Alyssa Maccarone
  18. Nursing Home Choice, Family Bargaining and Optimal Policy in a Hotelling Economy By Marie-Louise Leroux; Grégory Ponthiere
  19. Heterogeneous Impacts of the Affordable Care Act on Labor Markets By Chao Fu; Naoki Aizawa
  20. Steps States Can Take to Help Workers Keep Their Jobs after Injury, Illness, or Disability By Yonatan Ben-Shalom
  21. Behavioral Interventions to Promote Job Retention after Injury or Illness By Kara Contreary; Irma Perez-Johnson
  22. The More Children You Have the More Likely You Are to Smoke? Evidence from Vietnam By Mohamed Arouri; Adel Ben Youssef; Cuong Nguyen-Viet
  23. Cost-Effectiveness Of Treatments For Mild-To-Moderate Obstructive Sleep Apnea In France By Anne-Isabelle Poullié; Magali Cognet; Aline Gauthier; Marine Clementz; Sylvain Druais; Hans-Martin Späth; Lionel Perrier; Oliver Scemama; Catherine Rumeau Pichon; Jean-Luc Harousseau

  1. By: Schwärzler, Marion Cornelia; Kronenberg, Tobias
    Abstract: The National Health Account for Germany is a standard reporting tool for the sector’s contribution to economic growth, employment and international trade. Its compilation is based on the supply and use tables of national accounts. Consequently, it refers to a satellite system of the health economy within the overall German economy. It further contains a health input-output table (HIOT) enabling the calculation of multiplier effects. The HIOT is fully consistent with the official input-output table, but it facilitates a more thorough analysis of this heterogeneous inter-sectoral industry, dividing the economy into a number of ‘core’ health sectors, ‘extended’ health sectors, and ‘non-health’ sectors. Concepts and methodology have been developed within projects on behalf of the Federal Ministry of Economic Affairs and Energy of Germany over several years. This paper describes underlying approaches for the compilation of the National Health Account with special emphasis on recent developments due to revisions of statistical standards in the con-text of supply and use tables, NACE 2008 and ESA 2010. Consequently, its contribution to existing scientific research is the methodological point of view the paper addresses, which has not been discussed in detail before. The sector’s relevance for export activities is evaluated as an exemplary field of application of the National Health Account by conducting input-output analysis.
    Keywords: Input-Output analysis, economic footprint, health economy, Germany
    JEL: C67 E01 I11 I18
    Date: 2016–09–08
  2. By: Cervellati, Matteo; Esposito, Elena; Sunde, Uwe; Valmori, Simona
    Abstract: Using high-resolution data from Africa over the period 1998-2012, this paper investigates the hypothesis that a higher exposure to malaria increases the incidence of civil violence. The econometric identification exploits exogenous monthly within-grid-cell variation in weather conditions that are particularly suitable for malaria transmission and compares the effect across cells with different latent malaria exposure, which affects the resistance and immunity of the population. By conditioning on cell-year and month fixed effects, the empirical specification accounts for most complementary determinants of violence that have been identified in the existing literature. The results document a robust effect of the occurrence of suitable conditions for malaria on civil violence. The effect is shown to be highest in areas with low levels of immunity and to affect unorganized violence in terms of riots and protests and confrontations between militias and civilians, instead of geo-strategic violence. The effect spikes during short harvesting periods of staple crops that are particularly important for the subsistence of the population. The paper ends with an exploration of the role of anti-malarial policies.
    Keywords: Malaria Risk; Civil Violence; Weather Shocks; Immunity; Cell-level Data; Africa
    Date: 2016–09
  3. By: Zack Cooper; Stephen Gibbons; Matthew Skellern
    Abstract: This paper examines the impact of competition from government-facilitated entry of private, specialty surgical centres on the efficiency and case mix of incumbent public hospitals within the English NHS. We exploit the fact that the government chose the location of these surgical centres (Independent Sector Treatment Centres or ISTCs) based on nearby public hospitals’ waiting times – not length of stay or clinical quality – to construct treatment and control groups that are comparable with respect to key outcome variables of interest. Using a difference-in-difference estimation strategy, we find that ISTC entry led to greater efficiency – measured by presurgery length of stay for hip and knee replacements – at nearby public hospitals. However, these new entrants took on healthier patients and left incumbent hospitals treating patients who were sicker, and who stayed in hospital longer after surgery.
    Keywords: Hospital Competition; Public-Private Competition; Market Entry; Market Structure; Outsourcing; Hospital Efficiency; Risk Selection; Cherry Picking
    JEL: C23 H57 I11 L1 L33 R12
    Date: 2016–06
  4. By: Mark Shepard
    Abstract: Health insurers increasingly compete on their covered networks of medical providers. Using data from Massachusetts’ pioneer insurance exchange, I find substantial adverse selection against plans covering the most prestigious and expensive “star” hospitals. I highlight a theoretically distinct selection channel: these plans attract consumers loyal to the star hospitals and who tend to use their high-price care when sick. Using a structural model, I show that selection creates a strong incentive to exclude star hospitals but that standard policy solutions do not improve net welfare. A key reason is the connection between selection and moral hazard in star hospital use.
    JEL: I11 I13 I18 L13
    Date: 2016–09
  5. By: Bahrs, Michael; Schumann, Mathias
    Abstract: In this study, we analyse the long-term effects of school starting age on smoking behaviour and health in adulthood. School entry rules combined with birth month are used as an instrument for school starting age. The analysis adopts the German Socio- Economic Panel data and employs a fuzzy regression discontinuity design. The results reveal that school starting age reduces the long-term risk to smoke, improves long-term health, and affects physical rather than mental health. In addition, we find that the relative age composition of peers and the school environment are important mechanisms.
    Keywords: smoking,health,peer effects,education,school starting age,regression discontinuity design
    JEL: I12 I21 I28
    Date: 2016
  6. By: Hentschker, C.; Wübker, A.
    Abstract: Medical technological progress has been shown to be the main driver of health care costs. A key policy question is whether new treatment options are worth the additional costs. In this paper we assess the causal effect of percutaneous transluminal coronary angioplasty (PTCA), a major new heart attack treatment, on mortality. We use a full sample of administrative hospital data from Germany for the years 2005 to 2007. To account for non-random treatment assignment of PTCA, instrumental variable approaches are implemented that aim to randomize patients to different likelihoods of getting PTCA independent of heart attack severity. Instruments include differential distances to PTCA hospitals and regional PTCA rates. Our results suggest a 4.5 percentage point mortality reduction for patients who have access to this new treatment compared to patients receiving only conservative treatment. We relate mortality reduction to the additional costs for this treatment and conclude that this new treatment option is cost-effective in lowering mortality for AMI patients at reasonable cost-e ectiveness thresholds.
    Keywords: acute myocardial infarction; instrumental variables; mortality;
    JEL: I11 I12 I18
    Date: 2016–08
  7. By: Huixia Wang (Hunan University, School of Economy and Trade); Chenggang Wang (University of Hawaii at Manoa, Department of Economics); Timothy Halliday (University of Hawaii at Manoa, Department of Economics, University of Hawaii Economic Research Organization)
    Abstract: We employ granular information on local macro-economic conditions from the Panel Study of Income Dynamics to estimate the impact of the Great Recession on health and health-related behaviors. Among working-aged adults, a one percentage point increase in the county-level unemployment rate resulted in a 2.4-3.2 percent increase in chronic drinking, a 1.8-1.9 percent decrease in mental health status, and a 7.8-8.9 percent increase in reports of poor health. Notably, there was heterogeneity in the impact of the recession across socioeconomic groups. Particularly, obesity and overweight rates increased for blacks and high school educated people, while there is weak evidence that they decreased for whites and the college educated. Along some dimensions, the Great Recession may have widened some socioeconomic health disparities in the United States.
    Keywords: Great Recession, Health Behaviors, Health Outcomes, Obesity, Inequality
  8. By: Calara, Paul Samuel (The Swedish Institute for Health Economics (IHE)); Gerdtham, Ulf-G (Department of Economics, Lund University); Petrie, Dennis (Centre for Health Economics, Monash University)
    Abstract: This study compares the evolution of income-related health inequality (IRHI) in Australia (2001–2006) and in Great Britain (1999–2004) by exploring patterns of morbidity- and mortality-related health changes across income groups. Using Australian longitudinal data, the change in health inequality is decomposed into those changes related to health changes (income-related health mobility) and income changes (health-related income mobility), and compared with recent results from Great Britain. Absolute IRHI increased for both sexes, indicating greater absolute health inequality in Australia over this period, similar to that seen in Great Britain. The income-related health mobility indicates that this was due to health losses over this period being concentrated in those initially poor who were significantly more likely to die. The health-related income mobility further indicates that those who moved up the income distribution during the period were more likely to be those who were healthy. Australian estimates of mobility measures are similar, if not greater, in magnitude than for Great Britain. While reducing health inequality remains high on the political agenda in Great Britain, it has received less attention in Australia even though the evidence provided here suggests it should receive more attention.
    Keywords: HILDA; BHPS; income-related health inequality; longitudinal analysis; vertical equity
    JEL: D39 D63 I18
    Date: 2016–09–14
  9. By: Kayleigh Barnes; Arnab Mukherji; Patrick Mullen; Neeraj Sood
    Abstract: This paper estimates the impact of social health insurance on financial risk reduction by utilizing data from a natural experiment created by the phased roll out of a social health insurance program for the poor in India. We estimate the impact of insurance on the distribution of out-of-pocket costs, frequency and amount of money borrowed for health reasons, and the likelihood of incurring catastrophic health expenditures. We use a stylized expected utility model to compute the welfare effects associated with changes due to insurance in the distribution of out-of-pocket costs. We adjust the standard model to account for the unique conditions of a developing country by incorporating consumption floors, informal borrowing, and selling of assets. These adjustments allow us to estimate the value of financial risk reduction from both consumption smoothing and asset protection channels. Our results show that social insurance reduces out-of-pocket costs with larger effects in the higher quantiles of the out-of-pocket cost distribution. In addition, we find a reduction in the frequency and amount of money borrowed for health reasons. Finally, we find that the value of financial risk reduction outweighs the total per household cost of the social insurance program by two to five times.
    JEL: H0 H4 H51 I1 I13 I15 I3
    Date: 2016–09
  10. By: Titeca, Hannes
    Abstract: Healthcare systems differ greatly across the world, however, it appears that the extent of public insurance (publicly/government funded healthcare) is the only institutional characteristic that plays a significant role in accounting for the large disparities in total healthcare spending. Other factors, such as whether healthcare services are provided by the private or public sector, play much less of a role, highlighting the important distinction between how services are provided and how those services are funded. A regression analysis is conducted utilising an existing categorisation of the predominately high-income countries of the OECD in 2009. It is found that more public insurance and less private insurance is associated with significantly lower spending after controlling for differences in income through GDP and healthcare quality/outcomes through life expectancy. This result is robust to the inclusion of additional controls for lifestyle factors and the proportion of the population aged 65 and over, as well as the inclusion or exclusion of the US that could otherwise be seen as some kind of outlier. A typical country relying largely on private provision and insurance, such as the Netherlands, Germany or the US, could reduce total healthcare spending by around a third by moving to a system with extensive public insurance whilst retaining extensive private provision of services, a situation typical of some countries such as Austria, Greece and Japan.
    Keywords: healthcare systems; healthcare spending; healthcare expenditure; healthcare institutions; international comparison; regression analysis; private; public; health insurance; institutional differences; health care spending; health care institutions; health care expenditure
    JEL: D02 H51 I1 I11 I13 I18
    Date: 2016
  11. By: Quan-Hoang Vuong
    Abstract: Background: Patients have to acquire information to support their decision on choosing a suitable healthcare provider. But in developing countries like Vietnam, accessibility issues remain an obstacle, thus adversely affect both quality and costliness of healthcare information. Vietnamese use both sources from health professionals and friends/relatives, especially when quality of the Internet-based cheaper sources appear to be still questionable. The search of information from both professionals and friends/relatives incurs some cost, which can be viewed as low or high depending low or high accessibility to the sources. These views potentially affect their choices.Aim & Objectives: To investigate the effects that medical / health services information on perceived expensiveness of patients’ labor costs. Two related objectives are: i) establishing empirical relations between accessibility to sources and expensiveness; and, ii) probabilistic trends of probabilities for perceived expensiveness.Results: There is evidence for established relations among the variables “Convexp” and “Convrel” (all p’s
    Keywords: Healthcare provider; Quality of information; Health data; Consumer behavior; Vietnam
    JEL: I18
    Date: 2016–09–15
  12. By: Cecilia Speroni; Nan Maxwell
    Abstract: To better prepare students for jobs in health care, Virginia’s TAACCCT grant included seven strategies to improve student outcomes. This study examines the implementation of each of the strategies and the challenges, successes, sustainability approaches, and lessons learned across the strategies.
    Keywords: Community college, TAACCCT, career coaches, online education, workforce development, health careers
    JEL: I J
  13. By: Margaret Sullivan; Brittany English; Alyson Burnett; Jillian Berk
    Abstract: To better prepare students for jobs in health care, Virginia’s TAACCCT grant included seven strategies to improve student outcomes. This study examines the implementation of each of the strategies and the challenges, successes, sustainability approaches, and lessons learned across the strategies.
    Keywords: Community college, TAACCCT, career coaches, online education, workforce development, health careers
    JEL: I J
  14. By: Alvaro S Almeida (CEF.UP and Faculdade de Economia, Universidade do Porto)
    Abstract: The national health services (NHS) of England, Portugal, Finland and other single-payer universalist systems financed by general taxation, are based on the theoretical principle of an integrated public sector payer-provider. However, in practice one can find different forms of participation of non-public healthcare providers in those NHS, including private for profit providers, but also third sector non-profit organizations (NPO). This paper reviews the role of non-public non-profit healthcare organizations in NHS systems. By crossing a literature review on privatization of national health services with a literature review on the comparative performance of non-profit and for-profit healthcare organizations, this paper assesses the impact of contracting private non-profit healthcare organizations on the efficiency, quality and responsiveness of services, in public universal health care systems. The results of the review were then compared to the existing evidence on the Portuguese hospital devolution to NPO program. The evidence in this paper suggests that NHS health system reforms that transfer some public sector hospitals to NPO should deliver improvements to the health system with minimal downside risks. The very limited existing evidence on the Portuguese hospital devolution program suggests it improved efficiency and access, without sacrificing quality.
    Keywords: health systems, non-profit organizations, privatization
    JEL: I11 I18
    Date: 2016–09
  15. By: Doug Johnson; Jorge Ugaz
    Abstract: Using mystery client surveys of 927 private health facilities in Lagos State in Nigeria, we determine what variables are associated with quality of family planning counseling. Key strong predictors include cadre of provider, location, fees charged for the service, facility type, among others.
    Keywords: Contraception, family planning, counseling, Nigeria, private providers
    JEL: F Z
  16. By: Rina Na (Department of Economics, The University of Kansas); David J.G. Slusky (Department of Economics, The University of Kansas;)
    Abstract: We estimate the effects of the ACA’s Medicaid expansion on health outcomes with a difference-in-differences approach, using restricted geotagged NHANES data from 2007 to 2014. Our results show that the partial Medicaid expansion in 2014 is significantly associated with a decrease of 8.465 mg / dL (4.3%) in total cholesterol and decrease of 5.569 mmHg in systolic blood pressure (4.7%). These are both likely the result of an increase in the use of cholesterol lowering medications, which can affect both of these measures, as there is no corresponding increase in the use of blood pressure medication. Contrastingly, we find no statistically significant effects for diabetes prescriptions or measures.
    Keywords: Medicaid Expansion, Health, NHANES, Cholesterol, Blood Pressure, Diabetes
    JEL: H20 H42 I12 I13 I28
    Date: 2016–09
  17. By: John L. Czajka; Amang Sukasih; Alyssa Maccarone
    Abstract: This report is intended to assist agencies within the Department of Health and Human Services and the broader federal statistical community in making more effective use of small area estimates to address data gaps for small geographic areas and populations.
    Keywords: Small area estimates, data analytics, design, survey, statistics
  18. By: Marie-Louise Leroux; Grégory Ponthiere
    Abstract: The family plays a central role in decisions relative to the provision of long term care (LTC). We develop a model of family bargaining to study the impact of the distribution of bargaining power within the family on the choices of nursing homes, and on the location and prices chosen by nursing homes in a Hotelling economy. We show that, if the dependent parent only cares about the distance, whereas his child cares also about the price, the mark up rate of nursing homes is increasing in the bargaining power of the dependent parent. We contrast the laissez-faire with the social optimum, and we show how the social optimum can be decentralized in a first-best setting and in a second-best setting (i.e. when the government cannot force location). Finally, we explore the robustness of our results to considering families with more than one child, and to introducing a wealth accumulation motive within a dynamic OLG model, which allows us to study the joint dynamics of wealth and nursing home prices. We show that a higher capital stock raises the price of nursing homes through higher mark up rates.
    Keywords: Family bargaining, long term care, nursing homes, spacial competitition, optimal policy, OLG models.
    JEL: D10 I11 I18
    Date: 2016
  19. By: Chao Fu (University of Wisconsin - Madison); Naoki Aizawa (University of Minnesota)
    Abstract: We study the heterogeneous impacts of the Affordable Care Act (ACA) across households, firms and local labor markets. We develop and estimate a competitive labor market equilibrium model, with rich heterogeneities across local markets, workers and firms. We estimate the model via indirect inference, exploring variations in the policy environments across markets and across policy eras (before/after ACA). We use the estimated model to study the counterfactual changes in various components of the ACA.
    Date: 2016
  20. By: Yonatan Ben-Shalom
    Abstract: This is one of three policy action papers prepared in Year 3 of the Stay-at-Work/Return-to-Work Policy Collaborative, an initiative funded by the Office of Disability Employment Policy in the U.S. Department of Labor.
    Keywords: Stay at work, return to work, disability, injury, illness
    JEL: I J
  21. By: Kara Contreary; Irma Perez-Johnson
    Abstract: This is one of three policy action papers prepared in Year 3 of the Stay-at-Work/Return-to-Work Policy Collaborative, an initiative funded by the Office of Disability Employment Policy in the U.S. Department of Labor.
    Keywords: disability, stay at work, return to work, behavioral interventions, job retention, injury, illness
    JEL: I J
  22. By: Mohamed Arouri (LEO - Laboratoire d'économie d'Orleans - UO - Université d'Orléans - CNRS - Centre National de la Recherche Scientifique); Adel Ben Youssef (GREDEG - Groupe de Recherche en Droit, Economie et Gestion - UNS - Université Nice Sophia Antipolis - CNRS - Centre National de la Recherche Scientifique); Cuong Nguyen-Viet (Chercheur Indépendant)
    Abstract: There is no doubt that parental smoking can cause health problems for children. It is expected that parents who are aware of the harmful effect of secondhand smoke would decrease parental smoking when having more children. Yet, using instrumental variable regressions and data from the 2006 and 2008 Vietnam Household Living Standard Surveys , we find a very strongly positive and significant effect of the number of children on the probability of households smoking tobacco in Vietnam. Having an additional child increases the probability of households consuming tobacco by approximately 15 percent. These findings imply low awareness levels regarding the harmful effects of secondhand smoke on children " s health in Vietnam and indicate the need for policy action that disseminates knowledge on the harmful effects of smoking.
    Keywords: I31,parental smoking behaviors, children,health, instrumental variable regressions JEL Classifications: I12,O1
    Date: 2016–01–12
  23. By: Anne-Isabelle Poullié (HAS - Haute Autorité de Santé [Saint-Denis La Plaine]); Magali Cognet (Amaris - Amaris - Amaris London); Aline Gauthier (Amaris - Amaris - Amaris London); Marine Clementz (Amaris - Amaris - Amaris London); Sylvain Druais (Amaris - Amaris - Amaris London); Hans-Martin Späth (UCBL - Université Claude Bernard Lyon 1); Lionel Perrier (Centre Léon Bérard [Lyon], GATE Lyon Saint-Étienne - Groupe d'analyse et de théorie économique - ENS Lyon - École normale supérieure - Lyon - UL2 - Université Lumière - Lyon 2 - UCBL - Université Claude Bernard Lyon 1 - Université Jean Monnet - Saint-Etienne - PRES Université de Lyon - CNRS - Centre National de la Recherche Scientifique); Oliver Scemama (HAS - Haute Autorité de Santé [Saint-Denis La Plaine]); Catherine Rumeau Pichon (HAS - Haute Autorité de Santé [Saint-Denis La Plaine]); Jean-Luc Harousseau (HAS - Haute Autorité de Santé [Saint-Denis La Plaine])
    Abstract: Objectives: Untreated obstructive sleep apnea-hypopnea syndrome (OSAHS) is associated with excessive daytime sleepiness, increased risk of cardiovascular (CV) disease, and road traffic accidents (RTAs), which impact survival and health-related quality of life. This study, funded by the French National Authority for Health (HAS), aimed to assess the cost-effectiveness of different treatments (i.e., continuous positive airway pressure [CPAP], dental devices, lifestyle advice, and no treatment) in patients with mild-to-moderate OSAHS in France. Methods: A Markov model was developed to simulate the progression of two cohorts, stratified by CV risk, over a lifetime horizon. Daytime sleepiness and RTAs were taken into account for all patients while CV events were only considered for patients with high CV risk. Results: For patients with low CV risk, incremental cost-effectiveness ratio (ICER) of dental devices versus no treatment varied between 32,976 EUR (moderate OSAHS) and 45,579 EUR (mild OSAHS) per quality-adjusted life-year (QALY), and CPAP versus dental devices, above 256,000 EUR/QALY. For patients with high CV risk, CPAP was associated with a gain of 0.62 QALY compared with no treatment, resulting in an ICER of 10,128 EUR/QALY. Conclusion: The analysis suggests that it is efficient to treat all OSAHS patients with high CV risk with CPAP and that dental devices are more efficient than CPAP for mild-to-moderate OSAHS with low CV risk. However, out-of-pocket costs are currently much higher for dental devices than for CPAP (i.e., 3,326 EUR versus 2,430 EUR) as orthodontic treatment is mainly non-refundable in France.
    Keywords: Continuous positive airway pressure, Dental devices, Obstructive sleep apnea, Cost-effectiveness analysis
    Date: 2016

This nep-hea issue is ©2016 by Yong Yin. It is provided as is without any express or implied warranty. It may be freely redistributed in whole or in part for any purpose. If distributed in part, please include this notice.
General information on the NEP project can be found at For comments please write to the director of NEP, Marco Novarese at <>. Put “NEP” in the subject, otherwise your mail may be rejected.
NEP’s infrastructure is sponsored by the School of Economics and Finance of Massey University in New Zealand.