Quarterly Journal of Economics · 2021 · Liran Einav、Amy Finkelstein、Yunan Ji、Neale Mahoney
中文摘要
政府项目往往以自愿参与的方式向市场参与者提供。我们以一项医疗保险支付改革为背景，探讨这种自愿性规制的经济学问题。在该改革中，一家医疗服务提供者针对一系列相关医疗服务获得一笔预先确定的单一支付，而不再按不同服务分别获得支付。这项“捆绑支付”计划最初以一项为期5年的随机试验形式实施，被分配采用新支付模式的医院必须参加；然而，两年后，其中一半医院的参与变为自愿。利用详细的理赔层面数据，我们发现，那些无需改变行为便可增加收入的医院更有可能自愿参加（“基于水平的选择”），而在强制参与期间行为发生较大变化的医院也更有可能自愿参加（“基于斜率的选择”）。为了评估反事实制度下的结果，我们估计了一个关于医院对该项目的响应程度及其参与选择的简化模型。我们发现，现行自愿参与制度会对医院产生无效率的转移支付，而其他可行的设计能够减少这些无效率的转移支付并提高福利。我们的分析凸显了自愿性规制下需要考虑的关键设计要素。
Abstract
Government programs are often offered on an optional basis to market participants. We explore the economics of such voluntary regulation in the context of a Medicare payment reform, in which one medical provider receives a single, predetermined payment for a sequence of related healthcare services, instead of separate service-specific payments. This "bundled payment" program was originally implemented as a 5-year randomized trial, with mandatory participation by hospitals assigned to the new payment model; however, after two years, participation was made voluntary for half of these hospitals. Using detailed claim-level data, we document that voluntary participation is more likely for hospitals that can increase revenue without changing behavior ("selection on levels") and for hospitals that had large changes in behavior when participation was mandatory ("selection on slopes"). To assess outcomes under counterfactual regimes, we estimate a stylized model of responsiveness to and selection into the program. We find that the current voluntary regime generates inefficient transfers to hospitals, and that alternative (feasible) designs could reduce these inefficient transfers and raise welfare. Our analysis highlights key design elements to consider under voluntary regulation.