In-kind Payments Research Articles

The cost of influence: How gifts to physicians shape prescriptions and drug costs

This paper investigates the influence of gifts – monetary and in-kind payments – from drug firms to US physicians on prescription behavior and drug costs. Using causal models and machine learning, we estimate physicians’ heterogeneous responses to payments on antidiabetic prescriptions. We find that payments lead to increased prescription of brand drugs, resulting in a cost rise of $23 per dollar value of transfer received. Paid physicians show higher responses when they treat higher proportions of patients receiving a government-funded low-income subsidy that lowers out-of-pocket drug costs. We estimate that introducing a national gift ban would reduce diabetes drug costs by 2%.

Characterizing the role of informal payments in the delivery of pathology and clinical laboratory services.

Informal payments (IPs) are unofficial cash or in-kind payments for goods or services that should be covered by the health care system. They are a common but regressive method of financing health care in low- and lower-middle-income countries (LMICs). This study aims to characterize the prevalence and impact of IPs on pathology and laboratory medicine (PALM) services. From September 2021 to September 2022, PALM staff were surveyed about the frequency, determinants, and impacts of IPs in their respective workplaces. In total, 268 responses were received, and 46.6% (125/268) reported experience with IPs. These 125 participants were more likely to work in the public sector and in LMICs. Approximately 65% reported accepting IPs to perform tests or release results. Obtaining faster results was the most commonly perceived reason for patients offering IPs. Overall, participants reported that IPs had more negative than positive impacts on their workplace. This represents a first step in characterizing IPs within PALM and how this practice may affect access to these services in LMICs. Specifically, the fact that faster turnaround time was the most frequently perceived reason for offering IPs uncovers a potential barrier to improving PALM capacity in these regions.

An Analysis of Industry Payments Toward Physicians in the United States—Cryolipolysis

Background : Cryolipolysis has emerged as a nonsurgical fat reduction alternative to liposuction. Industry payments may impact how physician authors view medical devices in the literature. Under-reporting financial conflicts of interest has raised concerns about full transparency between industry and physicians. Objectives : We aim to determine the impact industry payments to physicians have on the cryolipolysis literature and whether there is under-reporting of financial conflicts of interest in the literature. Methods : We collated all articles that cite the pivotal trial in the Food and Drug Administration approval of a cryolipolysis device. Articles were read independently and coded as favourable or neutral. A separate researcher screened the Centers for Medicare & Medicaid Services Open Payments database for direct or in-kind payments and recorded financial conflicts of interest. Results : A total of 19 articles met the inclusion criteria. This included 37 unique authors across multiple specialties. Eighteen (95%) published articles had at least one author who received industry payment. Payments totalled $1,476,564.16. Twelve (63%) articles were positive, and 7 (37%) neutral. Of the 31 authors who received payments, 11 (35%) did not report a conflict of interest. The majority of industry payments assessed were for consulting fees, which totalled $980,334.86 (66.4%). Conclusions : We found the majority of published opinions on cryolipolysis from the United States were written by physicians who received industry payments. We also found financial conflicts of interest around cryolipolysis devices are under-reported in the literature.

The competitive woman: Evolutionary insights and cross-cultural evidence into finding the Femina Economica

We propose to explain the gender gap in competitiveness often found in economic experiments with a theoretical framework rooted in evolutionary psychology: Women evolved adaptations to trade off the motivation to acquire resources in competitive environments for effort dedicated to investing directly into offspring, to attract and retain mates, and to not alienate potential allomaternal allies. Such a tradeoff does not appear similarly binding for men. To begin to test this idea, we conducted a series of experiments using cash and prizes (in-kind payments dedicated to either children's needs, gender-specific interests, or gender-neutral interests for placebo tests) to reward subjects at different life stages (parents and non-parents) from countries differing in economic development and culture (novel data from Togo, Sierra Leone, Bosnia, Colombia plus China data from Cassar et al. (2016)). Our hypothesis is that different incentive types (cash or prize) may induce specific frames which activate the motivation to compete in different domains of interest, with behavioral predictions that depend on an individual's gender and life stage. Consistent with the predictions, our results on parents from China, Togo, and Sierra Leone and from non-parents from Bosnia show that, once the incentives are switched from cash to child-benefitting or gender-stereotypical goods, the gender gap in competitiveness was largely eliminated, shrinking by more than 10 percentage points, whereas placebo prizes had no impact. Importantly, economic and cultural elements matter, as not all societies exhibit a gender gap to start with (Colombia and Nana Benz of Togo). These findings indicate that competitiveness in women can be much more intense than has been observed, once we include incentives that matter to women, with implications for policies designed to promote gender equality based on labor market incentives aligned with women’ goals and respectful of the differential constraints that nature and societies put on the individual.

Who Pays for Gifts to Physicians? Heterogeneous Effects of Industry Payments on Drug Costs

This paper estimates the impact of gifts - monetary or in-kind payments - from pharmaceutical firms on physicians' prescription decisions and drug costs in the US. Using exhaustive micro data on prescriptions for anti-diabetic drugs from Medicare Part D, we find that payments cause physicians to prescribe more brand drugs. On average, for every dollar spent, payments generate a $6 increase in drug costs. We then estimate heterogeneous causal effects via machine-learning methods. We find large heterogeneity in responses to payments across physicians. Differences are predominantly explained by the insurance coverage of patients: physicians prescribe more brand drugs in response to payments when patients benefit from subsidies that reduce out-of-pocket drug costs. Finally, we estimate that a gift ban would reduce drug costs to treat diabetes by 3%.

ESSENCE AND ROLE OF STATE EXPENDITURES IN REGULATING THE DISTRIBUTION OF THE POPULATION’S INCOME

Purpose. The aim of the article is to generalize the theoretical approaches to determining the essence, classification and composition of state expenditures and substantiation of their role and mechanism in regulating the distribution of population income. Methodology of research. The theoretical and methodological basis of the research is the fundamental provisions of financial science, set forth in the works of Ukrainian and foreign scientists on the issues of formation of state expenditures. The following general scientific and special methods were used in the research process: logical analysis, synthesis, theoretical generalization (in the process of distinguishing the concepts of “budget expenditures” and “budget costs”); induction, deduction, abstract and logical (when characterizing the essence of state expenditures, state purchases and social transfers); abstraction, description, comparison (to substantiate the mechanism of influence of state expenditures on improving the financial condition of the population). Findings. It has been established that, in terms of economic essence, “budget expenditures” is a broader concept than “budget costs”, since they, under the conditions of exchange for the necessary value equivalent, can be turned into expenses. It is substantiated that public purchases and social transfers are a type of public expenditure. After all, the essence of public procurement consists in the allocation of budget funds for the purchase of goods and services necessary for the functioning of state and local authorities and the population. Instead, social transfers by their content are a system of monetary or in-kind payments to the population that are not related to their participation in economic activity at the present time or in the past. A graphical interpretation of the mechanism of influence of state expenditures on the improvement of the financial condition of the population is presented. Originality. Approaches to the classification of state expenditures have been improved. According to the method of influence on the financial condition of the population, it is proposed to divide expenses into those that directly improve the financial condition of the population, and those that improve the financial condition of the population through reproductive processes. Practical value. The results of the presented research can be used in the process of forming and implementing financial policy in terms of the use of state expenditures to improve the financial condition of the population. Keywords: state expenditures, state purchases, social transfers, population income distribution.

Information shocks and pharmaceutical firms’ marketing efforts: Evidence from the Chantix black box warning removal

We study how pharmaceutical firm marketing responds to a regulatory decision that represents a positive information shock about drug safety. In the context of the smoking cessation drug Chantix, we estimate the effects of a Food and Drug Administration (FDA) decision to remove the drug's black box warning on two forms of marketing: monetary and in-kind payments to physicians (detailing) and direct-to-consumer advertising. Using identification strategies that leverage geographic variation in latent demand for smoking cessation therapy and the targeted nature of the information shock, we find that the removal of the warning significantly increased Chantix-related detailing payments and increased expenditures on national television advertising of Chantix. Understanding these firm-level strategic promotion responses is important, as they have implications for the dissemination of new drug information and the behaviors of physicians and consumers.

A Narrative Synthesis Review of Out-of-Pocket Payments for Health Services Under Insurance Regimes: A Policy Implementation Gap Hindering Universal Health Coverage in Sub-Saharan Africa.

Background: "Achieve universal health coverage (UHC), including financial risk protection, access to quality essential healthcare services and access to safe, effective, quality and affordable essential medicines and vaccines for all" is the Sustainable Development Goal (SDG) 3.8 target. Although most high-income countries have achieved or are very close to this target, low- and middle-income countries (LMICs) especially those in sub-Saharan Africa (SSA) are still struggling with its achievement. One of the observed challenges in SSA is that even where services are supposed to be "free" at point-of-use because they are covered by a health insurance scheme, out-of-pocket fees are sometimes being made by clients. This represents a policy implementation gap. This study sought to synthesise the known evidence from the published literature on the ‘what’ and ‘why’ of this policy implementation gap in SSA. Methods: The study drew on Lipsky’s street level bureaucracy (SLB) theory, the concept of practical norms, and Taryn Vian’s framework of corruption in the health sector to explore this policy implementation gap through a narrative synthesis review. The data from selected literature were extracted and synthesized iteratively using a thematic content analysis approach. Results: Insured clients paid out-of-pocket for a wide range of services covered by insurance policies. They made formal and informal cash and in-kind payments. The reasons for the payments were complex and multifactorial, potentially explained in many but not all instances, by coping strategies of street level bureaucrats to conflicting health sector policy objectives and resource constraints. In other instances, these payments appeared to be related to structural violence and the ‘corruption complex’ governed by practical norms. Conclusion: A continued top-down approach to health financing reforms and UHC policy is likely to face implementation gaps. It is important to explore bottom-up approaches – recognizing issues related to coping behaviour and practical norms in the face of unrealistic, conflicting policy dictates.

Drug firms’ payments and physicians’ prescribing behavior in Medicare Part D

In a pervasive but controversial practice, drug firms frequently make monetary or in-kind payments to physicians in the course of promoting prescription drugs. We use a federal database on the universe of such payments between 2013 and 2015 linked to prescribing behavior in Medicare Part D. We account for the targeting of payments with fixed effects for each physician-drug combination. In an event study, we show that physicians increase prescribing of drugs for which they receive payments in the months just after payment receipt, with no evidence of differential trends between paid and unpaid physicians prior to the payment. Next, we examine five case studies of major drugs going off patent. Physicians receiving payments from the firms experiencing the patent expiry transition their patients just as quickly to generics as physicians who do not receive such payments. In addition, using hand-collected efficacy data on three major therapeutic classes, we show that drug quality is largely unaffected by the receipt of payments.

Ethics of Using and Sharing Clinical Imaging Data for Artificial Intelligence: A Proposed Framework.

In this article, the authors propose an ethical framework for using and sharing clinical data for the development of artificial intelligence (AI) applications. The philosophical premise is as follows: when clinical data are used to provide care, the primary purpose for acquiring the data is fulfilled. At that point, clinical data should be treated as a form of public good, to be used for the benefit of future patients. In their 2013 article, Faden et al argued that all who participate in the health care system, including patients, have a moral obligation to contribute to improving that system. The authors extend that framework to questions surrounding the secondary use of clinical data for AI applications. Specifically, the authors propose that all individuals and entities with access to clinical data become data stewards, with fiduciary (or trust) responsibilities to patients to carefully safeguard patient privacy, and to the public to ensure that the data are made widely available for the development of knowledge and tools to benefit future patients. According to this framework, the authors maintain that it is unethical for providers to "sell" clinical data to other parties by granting access to clinical data, especially under exclusive arrangements, in exchange for monetary or in-kind payments that exceed costs. The authors also propose that patient consent is not required before the data are used for secondary purposes when obtaining such consent is prohibitively costly or burdensome, as long as mechanisms are in place to ensure that ethical standards are strictly followed. Rather than debate whether patients or provider organizations "own" the data, the authors propose that clinical data are not owned at all in the traditional sense, but rather that all who interact with or control the data have an obligation to ensure that the data are used for the benefit of future patients and society.

Beneficiary Views on Cash and In-Kind Payments: Evidence from Ethiopia's Productive Safety Net Programme

Abstract Economists often default to the assumption that cash is always preferable to an in-kind transfer. Do beneficiaries feel the same way? This paper addresses this issue using longitudinal household data from Ethiopia, where a large-scale social safety net intervention (PSNP) operates. Even though most payments are made in cash, and even though the (temporal) transaction costs associated with food payments are higher than payments received as cash, most beneficiaries stated that they prefer their payments only or partly in food. Higher food prices induce shifts in stated preferences toward in-kind transfers. More food-secure households, those closer to food markets and to financial services are more likely to prefer cash. Though shifts occur, the stated preference for food is dominant: In no year do more than 17 percent of households prefer only cash. There is suggestive evidence that stated preferences for food are also driven by self-control concerns.

The Soviet State’s Attack on Religious Denominations: Oppression and Persecution of Clergy in the Kharkiv Region (Late 1920s to Early 1930s)

The article examines the campaign of the Soviet totalitarian state against religious confessions in the Kharkiv region in the late 1920s and early 1930s. An overview of the historiography of the problem shows that its coverage in the literature has been insufficient and even fragmentary. The author considers the causes of the Bolsheviks’ vigorous anti-religious offensive amid Stalin’s renewed military-communist assault on the country with the aim to rapidly create a non-religious socialist society. The principal directions and methods of the atheist campaign in the region are identified. “Ministers of religious cults” of all denominations without exception were stripped of voting rights, which in fact turned them into outcasts of Soviet society. Eviction of clergymen and their families from nationalized and municipal housing in the region’s cities and towns was widely practiced, often pushing this category of citizens to the brink of survival. It is shown that the harassment and administrative abuse of clergy by local authorities, often deliberately demeaning clergymen’s human dignity, became a daily occurrence during this period. The article considers the practices of illegally “re-imposing” local taxes and levies on “ministers of religious cults,” setting exorbitant rent rates for them, charging them various fees, forcing them to buy government bonds, arbitrarily extracting from them illegal in-kind payments, and the like. Furthermore, at the turn of the 1930s the State Political Directorate (DPU) significantly stepped up the persecution of groups of clergy and believers belonging to various religious denominations (Russian Orthodox Church, Ukrainian Autokephalian Orthodox Church, Protestant communities, and others). The article shows a sharp reduction in the numbers of clergy in the Kharkiv region in the early 1930s due to the massive anti-religious campaign of the Soviet government, as well as a notable intensification of the state’s control over the activities of this social group.

In-kind conservation payments crowd in environmental values and increase support for government intervention: A randomized trial in Bolivia

There is growing use of economic incentives such as Payments for Ecosystem Services (PES) to encourage sustainable land management. An important critique is that such approaches may unintentionally disrupt environmental and social values, ‘crowding out’ pre-existing motivations to conserve. Some scholars suggest that the use of in-kind payments and norm-based framing, rather than financial transfers and a market framing, can mitigate these risks. There are calls to use more robust methods for impact evaluation in environmental policy. We use one of the only Randomized Controlled Trials of a conservation incentive scheme to evaluate its impact on self-stated environmental and social values and beliefs. Data from before and after the intervention, from households in villages randomly selected to receive the program or not, demonstrate that the program increased prioritization of environmental values (evidence of crowding-in as opposed to crowding out) and altered social beliefs related to inequality and the role of government. The findings demonstrate that this conservation program had a positive impact on environmental values and increased the belief that government involvement is appropriate. The scheme, with its use of in-kind payments and reciprocity framing, offers lessons to those seeking to develop effective schemes to incentivize positive environmental stewardship.

Cross-Border Merger and Acquisition Activity and Wage Dynamics

Using detailed administrative data that link French firms and workers over the years 2002 to 2007, the authors document declines in worker-level wages ahead of the time their employer is acquired by a foreign firm that are more than offset by gains in wages that emerge after cross-border acquisition. Specifically, relative wages fall by an estimated 7.5% in the years just before foreign acquisition, and they rise by approximately 12.5% in the years afterward. Changes in workers’ earnings are evident in both wages and in-kind payments given to workers. Moreover, the authors provide theoretical foundations for the conditional mean independence assumption that underlies commonly applied empirical techniques.

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PROTOCOL: Incentives for climate mitigation in the land use sector: a mixed-methods systematic review of the effectiveness of payment for environment services (PES) on environmental and socio-economic outcomes in low- and middle-income countries.

PROTOCOL: Incentives for climate mitigation in the land use sector: a mixed-methods systematic review of the effectiveness of payment for environment services (PES) on environmental and socio-economic outcomes in low- and middle-income countries.