Impact of Health System Reforms
Sunday, Jan. 6, 2019 10:15 AM - 12:15 PM
- Chair: David Bishai, Johns Hopkins University
The Effects of Social Health Insurance Expansion and Increased Choice on Perinatal Health and Health Care Use: Lessons from the Uruguayan Health Care Reform
AbstractIn 2007 the Uruguayan government launched a reform aimed at expanding social health insurance to family-members of formal workers and retirees. The policy increased insurance generosity -relative to the safety net alternative- and increased competition by allowing new beneficiaries to choose care from a set of private providers. Exploiting the phased-in implementation and the geographic variation in the intensity of the reform, we find that the expansion of social health insurance had a negligible effect on perinatal health and health care among adolescent mothers and their newborns. Our results do not support prior research showing health care quality improvements in settings with increased choice. We hypothesize that health care rationing by private providers due to rising wages, a smaller primary care infrastructure of private providers in low-income neighborhoods, and cultural and financial barriers may have accounted for the lack of positive effects.
Fixed-Term Contracts, Decentralization, and the Quality of Primary Care: Evidence from China's Iron Rice Bowl
AbstractSeveral developing countries have sought to improve primary health care delivery through decentralization reforms granting managers of public facilities greater authority over hiring and firing and employee compensation. In this paper, we present causal estimates comparing the quality of care provided by centrally-deployed civil service physicians with physicians hired directly by facility managers on fixed-term contracts in rural China, where physicians of both types are commonly employed to provide primary care at the same facilities. We control for important sources of endogeneity by using data from interactions with unannounced standardized patients and controlling for facility fixed effects. We present two key findings. First, physicians employed on fixed term contracts substantially outperform those on civil service contracts on measures of clinical process quality and this difference increases after controlling for observable clinician characteristics. Second, we find direct evidence that these effects are due to increases in effort as civil service providers exhibit greater underperformance relative to their knowledge of appropriate clinical practice as measured by clinical vignettes matching disease cases presented by standardized patients.
Reference Pricing as a Deterrent to Entry: Evidence from the European Pharmaceutical Market
AbstractThis paper empirically and theoretically analyzes the impact of external reference pricing (ERP) on launch delays in the market for pharmaceutical products. Governments that implement ERP use prices in other countries as negotiation benchmarks in an effort to bring down the cost of prescription drugs. By doing so, they limit the ability of firms to price discriminate across countries, and create an incentive to withhold drugs from countries with lower willingness to pay. Using data on pharmaceutical sales in European countries from 2002 to 2012, we document the presence of widespread launch delays across Europe --- up to three years on average in Eastern Europe. To distinguish between strategic delays caused by ERP and delays that arise for other reasons, we develop a dynamic structural model of entry that allows for externalities in price, which we estimate using a novel moment inequality approach. We find that removing ERP would reduce delays in Eastern Europe by up to 14 months per drug. At the same time, strategic delays have a relatively small impact on firm revenue, so it would be theoretically feasible to compensate firms for their profit loss to remove strategic delays.
- I1 - Health
- P4 - Other Economic Systems