Provider payment incentives: Evidence from the U.S. hospice industry
Journal of Public Economics · 2025 · Norma B. Coe、David A Rosenkranz
中文摘要
将按人头付费与医疗服务提供者平均收入上限相结合，可以减少配置无效率。但该上限可能被那些频繁调整患者名册的医疗服务提供者所削弱。我们利用美国临终关怀行业来考察这一可能性——在该行业中，联邦医疗保险（Medicare）按固定日费率向临终关怀项目付费，但对其年均收入设置上限。通过利用该上限非线性设计以及财政年度交替所产生的变异，我们发现，预计将超过上限的项目在第四季度将入院率提高了5.8%，将存活出院率提高了4.3%。但这种患者调整远不足以消除其经济处罚：其至多仅相当于平均项目超额收入的10%。边际入组患者平均而言剩余寿命更长，且临终关怀服务期更为碎片化，这表明他们对临终关怀服务的内在需求较弱。我们讨论了该上限对市场结构的影响。
Abstract
Combining capitation with a cap on health care providers’ average revenue can reduce allocative inefficiency. But the cap may be undercut by health care providers who churn their patient censuses. We investigate this possibility in the U.S. hospice industry, where Medicare pays hospice programs fixed daily rates but caps their average annual revenue. By leveraging variation generated by the cap’s nonlinear design and the transition between fiscal years, we find that programs on track to exceed the cap raise enrollment rates by 5.8 % and live discharge rates by 4.3 % in the fourth quarter. But this churning falls far short of eliminating their financial penalties: it amounts to 10 % of an average program’s excess revenue at most. Marginal enrollees have longer remaining lifetimes and more fragmented hospice spells on average, suggesting weaker intrinsic demand for hospice care. We discuss the cap’s implications for market structure.