Econometrica · 2018 · Liran Einav、Amy N. Finkelstein、Neale Mahoney
中文摘要
我们研究急性期后照护环境中的供方激励设计——这是医疗体系中风险极高但研究不足的环节。我们关注长期照护医院（LTCHs）以及当患者住院天数达到阈值时，其获得的Medicare支付出现的大幅（约13,500美元）跳跃。阈值之后的出院率大幅增加，边际出院患者的健康状况相对更好。尽管在高死亡率人群中存在巨大的财务激励和行为反应，我们未能检测到任何关于对患者死亡率产生影响的令人信服的证据。为了评估反事实支付方案下的供方行为，我们估计了LTCH出院决策的简单动态离散选择模型。当我们保守地将自己限定在使LTCH免受损失的替代契约时，我们发现一项替代契约可为每例入院产生约2,100美元的Medicare结余，约占支付总额的5%。更为激进的支付改革能产生大得多的结余，但伴随而来的LTCH利润减少可能产生样本外后果。我们的结果突显了改善财务激励如何能够在不对行业利润或患者健康产生负面后果的情况下降低医疗支出。
Abstract
We study the design of provider incentives in the post-acute care setting - a high-stakes but under-studied segment of the healthcare system. We focus on long-term care hospitals (LTCHs) and the large (approximately $13,500) jump in Medicare payments they receive when a patient s stay reaches a threshold number of days. Discharges increase substantially after the threshold, with the marginal discharged patient in relatively better health. Despite the large financial incentives and behavioral response in a high mortality population, we are unable to detect any compelling evidence of an impact on patient mortality. To assess provider behavior under counterfactual payment schedules, we estimate a simple dynamic discrete choice model of LTCH discharge decisions. When we conservatively limit ourselves to alternative contracts that hold the LTCH harmless, we find that an alternative contract can generate Medicare savings of about $2,100 per admission, or about 5% of total payments. More aggressive payment reforms can generate substantially greater savings, but the accompanying reduction in LTCH profits has potential out-of-sample consequences. Our results highlight how improved financial incentives may be able to reduce healthcare spending, without negative consequences for industry profits or patient health.