Generosity Of Payments Research Articles

The Impact of Incentives to Recruit and Retain Teachers in “Hard‐to‐Staff” Subjects

AbstractWe investigate the effects of a statewide program designed to increase the supply of teachers in designated “hard‐to‐staff” areas, such as special education, math, and science. Employing a difference‐in‐difference estimator we find that the loan forgiveness component of the program was effective, reducing mean attrition rates for middle and high school math and science teachers by 10.4 percent and 8.9 percent, respectively. We also find that the impact of loan forgiveness varied with the generosity of payments; when fully funded, the program reduced attrition of special education teachers by 12.3 percent, but did not have a statistically significant impact when funding was substantially reduced. A triple‐difference estimate indicates that a one‐time bonus program also had large effects, reducing the likelihood of teachers’ exit by as much as 32 percent in the short run. A back‐of‐the‐envelope cost‐benefit analysis suggests that both the loan forgiveness and the bonus program were cost effective.

Payment generosity and physician acceptance of Medicare and Medicaid patients

Using 2008 physician survey data, we estimate the relationship between the generosity of fees paid to primary care physicians under Medicaid and Medicare and his/her willingness to accept new patients covered by Medicaid, Medicare, or both programs (i.e., dually enrolled patients). Findings reveal physicians are highly responsive to fee generosity under both programs. Also, their willingness to accept patients under either program is affected by the generosity of fees under the other program, i.e., there are significant spillover effects between Medicare and Medicare fee generosity. We also simulate how physicians in 2008 would have likely responded to Medicaid and Medicare payment reforms similar to those embodied in the 2010 Affordable Care Act, had they been permanently in place in 2008. Our findings suggest that "Medicaid Parity" for primary care physicians would have likely dramatically improved physician willingness to accept new Medicaid patients while only slightly reducing their willingness to accept new Medicare patients. Also, many more primary care physicians would have been willing to treat dually enrolled patients.

PRICING DISTORTIONS IN MEDICARE'S PHYSICIAN FEE SCHEDULE AND PATIENT SATISFACTION WITH CARE QUALITY AND ACCESS

Medicare adjusts its payments to physicians for geographic differences in the cost of operating a medical practice, but the method it uses is imprecise. We measure the inaccuracy in its geographic adjustment factors and categorize beneficiaries by whether they live where Medicare's formula is favorable or unfavorable to physicians. Then, using the 2001-2003 Medicare Current Beneficiary Survey, we examine whether differences in physician payment generosity, that is, whether favorable or unfavorable, influence the satisfaction ratings Medicare seniors assign to their quality of care and access to services. We find strong evidence that they do. Many beneficiaries live in payment-unfavorable areas and receive a less satisfying quality of care and less satisfying access to services than beneficiaries who live where payments are favorable to physicians.

Medicare payment generosity and access to care

All payments to physicians under Medicare Part B are adjusted to reflect geographic differences in practice costs. The methods used for this adjustment, and temporary price floors imposed by Congress, have created longstanding systematic under and overpayment across physicians, whereby some are routinely underpaid while others are routinely overpaid. Using a nationally representative 2008 survey of physicians, this study examines whether the relative generosity of Medicare influences beneficiary access to care. We find that in areas where Medicare payments are more generous physicians are more likely to accept new Medicare patients, whereas in less generous areas, they are less likely. Our estimated models suggest that if Medicare could eliminate the systematic biases inherent its payment formula, it would see a net improvement to access to care under Medicare Part B.

The Impact of Profitability of Hospital Admissions on Mortality

Fiscal constraints faced by Medicare are leading to policies designed to reduce expenditures. Evidence of the effect of reduced reimbursement on the mortality of Medicare patients discharged from all major hospital service lines is limited. We modeled risk-adjusted 30-day mortality of patients discharged from 21 hospital service lines as a function of service line profitability, service line time trends, and hospital service line and year-fixed effects. We simulated the effect of alternative revenue-neutral reimbursement policies on mortality. Our sample included all Medicare discharges from PPS-eligible hospitals (1997, 2001, and 2005). The results reveal a statistically significant inverse relationship between changes in profitability and mortality. A $0.19 average reduction in profit per $1.00 of costs led to a 0.010-0.020 percentage-point increase in mortality rates (p<.001). Mortality in newly unprofitable service lines is significantly more sensitive to reduced payment generosity than in service lines that remain profitable. Policy simulations that target service line inequities in payment generosity result in lower mortality rates, roughly 700-13,000 fewer deaths nationally. The policy simulations raise questions about the trade-offs implicit in universal reductions in reimbursement. The effect of reduced payment generosity on mortality could be mitigated by targeting highly profitable services only for lower reimbursement.

Favorable selection, risk adjustment, and the Medicare Advantage program.

To examine the effects of changes in payment and risk adjustment on (1) the annual enrollment and switching behavior of Medicare Advantage (MA) beneficiaries, and (2) the relative costliness of MA enrollees and disenrollees. From 1999 through 2008 national Medicare claims data from the 5 percent longitudinal sample of Parts A and B expenditures. Retrospective, fixed effects regression analysis of July enrollment and year-long switching into and out of MA. Similar regression analysis of the costliness of those switching into (out of) MA in the 6 months prior to enrollment (after disenrollment) relative to nonswitchers in the same county over the same period. Payment generosity and more sophisticated risk adjustment were associated with substantial increases in MA enrollment and decreases in disenrollment. Claims experience of those newly switching into MA was not affected by any of the policy reforms, but disenrollment became increasingly concentrated among high-cost beneficiaries. Enrollment is very sensitive to payment levels. The use of more sophisticated risk adjustment did not alter favorable selection into MA, but it did affect the costliness of disenrollees.

The Impact of the Affordable Care Act on Medicare Advantage Plan Availability and Enrollment

To assess the impact of the Patient Protection and Affordable Care Act's (ACA) changes in Medicare Advantage (MA) payment rates on the availability of and enrollment in MA plans. Secondary data on MA plan offerings, contract offerings, and enrollment by state and county, in 2010-2011. We estimated regression models of the change in the number of plans, the number of contracts, and enrollment as a function of quartiles of FFS spending and pre-ACA MA payment generosity. Counties in the lowest quartile of spending are treated most generously by the ACA. Relative to counties in the highest quartile of spending, the number of plans in counties in the first, second, and third quartiles rose by 12 percent, 7.6 percent, and 5.4 percent, respectively. Counties with more generous MA payment rates before the ACA lost significantly more plans. We did not find a similar impact on the change in contracts or enrollment. The ACA-induced MA payment changes reduced the number of plan choices available for Medicare beneficiaries, but they have yet affected enrollment patterns.

The welfare implications of increasing disability insurance benefit generosity

In order to evaluate whether workers are over- or under-insured through the Disability Insurance (DI) program, we develop a framework that allows us to simulate the benefits as well as the costs associated with marginal changes in payment generosity from a representative cross-sectional sample of the population. Under the assumption that individuals are reasonably risk averse, we find that the typical worker would value increased benefits somewhat above the average costs of providing them. However, whether the benefit increases tend to lower or raise utility when we average across all individuals in our sample is sensitive to assumptions that affect the relative marginal utility of income to disabled individuals.

Hospital Reimbursement Incentives: An Empirical Analysis

Reimbursement systems for health‐care providers are very complex, like the production systems that they regulate. This complexity has led to some important misperceptions about the incentive consequences of major reimbursement reforms. One example is the prospective payment system (PPS), developed to provide “high‐powered” incentives through fixed prices for hospital admissions for the US elderly. In fact, various features of the DRG system allow reimbursement to vary with actual treatment decisions during an admission, and so are not prospective. This paper develops a general method for measuring actual reimbursement incentives in complex regulated price systems. The method uses regression techniques with variance decompositions to quantify the effects of particular features of the payment system on prospective and retrospective cost sharing, as well as overall generosity of payments. I apply this method to microdata on 20 percent of Medicare hospital admissions in 1987 and 1990 to summarize the incentives created by PPS in practice, and how the incentives are evolving over time. I show that PPS involves limited and decreasing cost sharing with hospitals, most of which is not prospective. The reimbursement incentives vary substantially across diagnoses, demographic groups, and types of intensive treatments, possibly with important implications for hospital behavior and medical expenditure growth. The techniques developed here can be used to analyze a broad range of provider reimbursement mechanisms.

The use of replacement rates in international comparisons of benefit systems

Comparative studies of social security systems have increasingly turned towards the use of replacement rates as measures of the level of benefits in different countries and therefore of the degree of social protection afforded by different welfare systems. The rationale for this is that replacement rates provide consistent measures of the relative generosity of payments and therefore indicate the “quality” of social security systems. This article reviews the use of replacement rates in comparisons of the generosity of retirement pensions and argues that they are not necessarily reliable as such measures. This reflects a number of factors, including incomplete measurement of benefit packages and differences in what must be bought out of disposable incomes. Most importantly, the article suggests that the levels of earnings in different countries are not independent of the processes of redistribution. In particular, countries which rely on social security contributions from employers appear to provide more generous benefits than those which rely on income taxes or employee contributions. This is a consequence of the fact that employer contributions do not figure specifically in the calculation of replacement rates. The relative generosity of benefit systems is overstated in countries which rely on employer social security contributions to fund benefits. The article concludes that a range of complementary indicators of social security systems should be used in future analysis of these issues.