Health insurance and the demand for medical care: evidence from a randomized experiment

We estimate how cost sharing, the portion of the bill the patient pays, affects the demand for medical services. The data come from a randomized experiment. A catastrophic insurance plan reduces expenditures 31 percent relative to zero out-of-pocket price. The price elasticity is approximately -0.2. We reject the hypothesis that less favorable coverage of outpatient services increases total expenditure (for example, by deterring preventive care or inducing hospitalization).

An economic model of teenage pregnancy decision-making

In this paper, we model unmarried teenagers’ decisions about their pregnancy outcome by considering that the teenager contrasts her expected utility (1) as a married mother, (2) as an unmarried mother, or (3) after abortion. We use crosssectional data on 297 California teenagers aged 13-19 who were pregnant for the first time between 1972 and 1974. Both Anglo and Mexican-American girls are included. We find that pregnant girls who are eligible for or are receiving public assistance are more likely to give birth and remain unmarried. Teenagers with greater time values are more likely to choose abortion, and Mexican-American girls are more likely to carry their pregnancies to term.

An economic model of teenage pregnancy decision-making

In this paper, we model unmarried teenagers' decisions about their pregnancy outcome by considering that the teenager contrasts her expected utility (1) as a married mother, (2) as an unmarried mother, or (3) after abortion. We use cross-sectional data on 297 California teenagers aged 13-19 who were pregnant for the first time between 1972 and 1974. Both Anglo and Mexican-American girls are included. We find that pregnant girls who are eligible for or are receiving public assistance are more likely to give birth and remain unmarried. Teenagers with greater time values are more likely to choose abortion, and Mexican-American girls are more likely to carry their pregnancies to term.

Effect of cost-sharing on the use of medical services by children: interim results from a randomized controlled trial

Health care expenditures of 1,136 children whose families participated in a randomized trial, The Rand Health Insurance Experiment, are reported. Children whose families were assigned to receive 100% reimbursement for health costs spent one third more per capita than children whose families paid 95% of medical expenses up to a family maximum. Outpatient use decreased as cost-sharing rose for a variety of use measures: the probability of seeing a doctor, annual expenditures, number of visits per year, and numbers of outpatient treatment episodes. Hospital expenditures did not vary significantly among children insured with varying levels of cost-sharing. Episodes of treatment for preventive care were as responsive to cost-sharing as episodes for acute or chronic illness. The results give no reason not to insure preventive care as liberally as care for acute illness.

The demand for prescription drugs as a function of cost-sharing

This paper estimates how cost-sharing affects the use of prescription drugs. The data for this analysis are derived from the Rand Health Insurance Experiment (HIE), a randomized controlled trial that randomly assigned participants to insurance plans with varying coinsurance rates and deductibles. Therefore, the cost-sharing they faced was independent of their health and demographic characteristics. The paper used HIE data from four sites to estimate how drug expenditures vary by insurance plan, and to compare the plan response for drugs with that for all ambulatory expenses. The findings show that: (1) individuals with more generous insurance buy more prescription drugs; (2) the cost-sharing response for drugs is similar to the response for all ambulatory medical services; (3) the Dayton, Ohio site had significantly greater drug expenditures per capita than the other sites studied and a significantly higher proportion of drugs sold by physicians; and (4) the proportion of brand-name drugs among all drugs purchased in pharmacies was not a function of insurance plan. In the Dayton, Ohio site, a significantly higher proportion of the drugs purchased in pharmacies were brand-name rather than generic.

A controlled trial of the effect of a prepaid group practice on use of services

Does a prepaid group practice deliver less care than the fee-for-service system when both serve comparable populations with comparable benefits? To answer this question, we randomly assigned a group of 1580 persons to receive care free of charge from either a fee-for-service physician of their choice (431 persons) or the Group Health Cooperative of Puget Sound (1149 persons). In addition, 733 prior enrollees of the Cooperative were studied as a control group. The rate of hospital admissions in both groups at the Cooperative was about 40 per cent less than in the fee-for-service group (P less than 0.01), although ambulatory-visit rates were similar. The calculated expenditure rate for all services was about 25 per cent less in the two Cooperative groups (P less than 0.01 for the experimental group, P less than 0.05 for the control group). The number of preventive visits was higher in the prepaid groups, but this difference does not explain the reduced hospitalization. The similarity of use between the two prepaid groups suggests that the mix of health risks at the Cooperative was similar to that in the fee-for-service system. The lower rate of use that we observed, along with comparable reductions found in non-controlled studies by others, suggests that the style of medicine at prepaid group practices is markedly less "hospital-intensive" and, consequently, less expensive.

A randomised controlled trial of hospice care

Terminally ill cancer patients at a Veterans Administration hospital were randomly assigned to receive hospice or conventional care. The hospice care was provided both in a special inpatient unit and at home. 137 hospice patients and 110 control patients and their familial care givers (FCGs) were followed until the patient's death. No significant differences were noted between the patient groups in measures of pain, symptoms, activities of daily living, or affect. Hospice patients expressed more satisfaction with the care they received; and hospice patients' FCGs showed somewhat more satisfaction and less anxiety than did those of controls. Hospice care was not associated with a reduced use of hospital inpatient days or therapeutic procedures and was at least as expensive as conventional care.

Factors discriminating pregnancy resolution decisions of unmarried adolescents

Pregnancy resolution decisions of unmarried adolescents were studied with the use of an expected utility decision model that included psychological, background, and economic variables. Discriminant function analysis of the decision to have an abortion or to deliver the child indicated that psychological, background, and economic variables each made significant contributions to the successful classification of teenagers (approximately 87.5% of the women were classified correctly). A four-item Abortion Approval Index, the women's perception of the prospective fathers' abortion opinion, personal knowledge of other unmarried teenagers who delivered, self-reported grade average, and receipt of state financial aid in the form of AFDC or Medicaid payments were the most powerful discriminators. For adolescents who chose to deliver, a second discriminant function indicated that only one economic factor--receipt of state financial aid--successfully discriminated those who married from those who became single mothers (approximately 72% of the women were classified correctly). Results are discussed in terms of possible decision strategies and sequences used by adolescents and the value of using a decision framework that incorporates psychological, background, and economic factors.

Some interim results from a controlled trial of cost sharing in health insurance

A total of 7706 persons are participating in a controlled trial of alternative health-insurance policies. Interim results indicate that persons fully covered for medical services spend about 50 per cent more than do similar persons with income-related catastrophe insurance. Full coverage leads to more people using services and to more services per user. Both ambulatory services and hospital admissions increase. Once patients are admitted to the hospital, however, expenditures per admission do not differ significantly among the experimental insurance plans. In addition, hospital admissions for children do not vary by plan. The income-related cost sharing in the experimental plans affects expenditure by different income groups similarly, but adults' total expenditure varies more than children's. Sufficient data are not available on whether higher use by persons with free care reflects overuse, or whether lower use by those with income-related catastrophe coverage reflects underuse. Both may well be true.

Family bequests and the derived demand for health inputs

A family investment model whereby parents allocate resources among their own consumption, health investments and financial bequests to children is specified and used to develop hypotheses which are tested on cross section data. As predicted by the model, the demand for physician visits for young children is found to 1) depend on family income only up to some level ($10,000 in 1969 $ in this case), 2) increase with maternal education, and 3) vary with price measures and family size, There is also evidence that greater health investments in young children pay off in fewer severe illnesses in young adulthood.