HCHE Research Paper

Autor: Sabat, I.; Neumann-Böhme, S.; Stargardt, T.; Schreyögg, J.

Titel:  The European COvid Survey (ECOS): Technical Report

European COvid Survey (ECOS), a longitudinal study spanning eight European countries, was initiated early in the COVID-19 pandemic. Its purpose was to comprehend public perceptions, trust, knowledge, and behaviors related to COVID-19, including vaccination. The study aimed to enable timely monitoring and assess relationships between these variables, producing evidence for policy and research in Europe. ECOS pursued a dual objective: first, conducting quick descriptive analyses at the end of fieldwork to produce policy-relevant evidence and share timely findings on sentiments toward containment policies, vaccinations, and vaccine types through press releases and events. These findings were valuable as they were both prompt and representative of national populations. Second, ECOS aimed to address health-economic research questions for an academic audience, utilizing advanced analytic methodologies. The resulting data-based research from ECOS provided an empirical foundation to understand longitudinal phenomena and relationships, contributing to a deeper comprehension of socioeconomic processes and behaviors during the COVID-19 pandemic. Importantly, it offered informed findings for policymakers to shape effective responses and policies.

This technical report provides an account of the design, development, and methodology of 11 data collections henceforth referred to as waves of the survey, which were fielded between April
2020 and December 2022.

Research Paper Nr. 30

Autor: Hermanns, B.; Kairies-Schwarz, N.; Kokot, J.; Vomhof, M.

Titel: Heterogeneity in Health Insurance Choice: An Experimental Investigation of Consumer Choice and Feature Preferences.

We investigate heterogeneity in patterns of preferences for health insurance features using health insurance choice data from a controlled laboratory experiment. Within the experiment, participants make consecutive insurance choices based on choice sets that vary in composition and size. We keep the health risk constant and equal for everyone. In addition, we implement a treatment that entails a feature-based insurance filter, allowing us to validate feature preferences. We also account for individually elicited risk preferences. On aggregate, we find that there is considerable heterogeneity in consumer choice. Participants differ particularly (a) in their willingness to pay to insure themselves against illnesses that differ in terms of their probability of occurrence and the size of the losses to be covered and (b) in their preference to forgo deductibles. However, if we measure the quality of individuals’ decisions based on risk preferences, the heterogeneity among participants disappears. Our results suggest that heterogeneity in health insurance choices is not reflected in decision quality when we assume a rank dependent expected utility model of risk preferences

Research Paper Nr. 29

Autor: Milstein, R.; Schreyögg, J.

Titel: Activity-based funding based on diagnosis-related groups. The end of an era? A review of payment reforms in the inpatient sector in ten high-income countries.

Across the member countries of the Organisation for Economic Co-Operation and Development (OECD), policy makers are searching for new ways to pay hospitals for inpatient care. We reviewed reforms to payment systems in ten high-income countries (Australia, Austria, Canada (Ontario), Denmark, France, Germany, Norway, Poland, the United Kingdom (England), and the United States). These reforms demonstrate a shift away from activity and efficiency towards a diversified set of targets, and mirror efforts being undertaken more broadly to slow the rise in health expenditures while improving quality of care. 

Research Paper Nr. 28

Autor: Brosig-Koch, J.; Hehenkamp, B.; Kokot, J.

Titel: Who benefits from quality competition in health care? A theory and a laboratory experiment on the relevance of patient characteristics

Abstract: We study how competition between physicians affects the provision of medical care. In our theoretical model physicians are faced with a heterogeneous patient population, in which patients systematically vary with regard to both, their responsiveness to the provided quality of care and their state of health. We test the behavioral predictions derived from this model in a controlled laboratory experiment. In line with the model, we observe that competition significantly improves patient benefits as long as patients are able to respond to the quality provided. For those patients, who are not able to choose a physician, competition even decreases the patient benefit compared to a situation without competition. This decrease is in contrast to our theoretical prediction implying no change in benefits for passive patients. Deviations from patient-optimal treatment are highest for passive patients in need of a low quantity of medical services. With repetition, both, the positive effects of competition for active patients as well as the negative effects of competition for passive patients become more pronounced. Our results imply that competition can not only improve but also worsen patient outcome and that patients’ responsiveness to quality is decisive.

Research Paper Nr. 27

Autor: Messerle, R.; Schreyögg, J.

Titel: System-wide Effects of Hospital Payment Scheme Reforms: The German Introduction of Diagnosis-Related Groups

Abstract: Hospitals account for 40 % of all healthcare expenditures and play a central role in healthcare provision. Therefore, the way hospitals are payed has major implications for the care they provide. Yet the knowledge about system wide effects of payment reforms is surprisingly thin. This study analyzes the especially comprehensive German introduction of diagnosis-related groups. In Germany, diagnosis-related groups function as sole pricing, billing and budgeting system and almost exclusively determine the turnover of hospitals. The introduction of diagnosis-related groups thus completely overhauled existing payment structures. It thereby offers a unique possibility for the analysis of payment reforms. Using aggregate OECD data and recent econometric advances, we analyze hospital activity and efficiency. We find that the reform increased hospital activity – measured as the number of discharges – significantly by around 2 percent per year. In contrast to many earlier studies, we find that diagnosis-related groups do not necessarily lead to a lowering of the average length of stay.

Research Paper Nr. 26

Autor: Griebenow, M.; Kifmann, M.

Titel: Diagnostics and Treatment: On the Division of Labor between Primary Care Physicians and Specialists

Abstract: This paper analyzes the referral processes between a gatekeeping primary-care physician (PCP) and a specialist. Specialists provide superior treatment for some patients but are more costly than PCPs. Agency problems arise because diagnostic signals are private information of the physicians. Welfare optimizing contracts can call for a markup either to the PCP for treating patients without referral or to the specialist for referring patients back to the PCP. If the benefit of specialist treatment is uncertain, small markups for the specialist enhance welfare compared to a cost-based fee-for-service contract. Additionally, we consider how waiting costs for referrals affect our main results.

Research Paper Nr. 25

Autor: Hofer, F.; Birkner, B.; Spindler, M.

Titel: Power of machine learning algorithms for predicting dropouts from a German telemonitoring program using standardized claims data

Abstract:
Background: Statutory health insurers in Germany offer a variety of disease management, prevention and health promotion programs to their insurees. Identifying patients with a high probability of leaving these programs prematurely helps insurers to offer better support to those at the highest risk of dropping out, potentially reducing costs and improving health outcomes for the most vulnerable.

Objective: To evaluate whether machine learning methods outperform linear regression in predicting dropouts from a telemonitoring program.

Methods: Use of linear regression and machine learning to predict dropouts from a telemonitoring program for patients with COPD by using information derived from claims data only. Different feature sets are used to compare model performance between and within different methods. Repeated 10-fold cross-validation with downsampling followed by grid searches was applied to tune relevant hyperparameters.

Results: Random forest performed best with the highest AUC of 0.60. Applying logistic regression resulted in higher predictive power with regard to the correct classification of dropouts compared to neural networks with a sensitivity of 56%. All machine learning algorithms outperformed linear regression with respect to specificity. Overall predictive performance of all methods was only modest at best.

Conclusion: Using features derived from claims data only, machine learning methods performed similar in comparison to linear regression in predicting dropouts from a telemonitoring program. However, as our data set contained information from only 1,302 individuals, our results may not be generalizable to the broader population.

Research Paper Nr. 24

Autor: Bach, P.; Chernozhukov, V.; Spindler, M.

Titel: Insights from optimal pandemic shielding in a multi-group SEIR framework

Abstract: The COVID-19 pandemic constitutes one of the largest threats in recent decades to the health and economic welfare of populations globally. In this paper, we analyze different types of policy measures designed to fight the spread of the virus and minimize economic losses. Our analysis builds on a multi-group SEIR model, which extends the multi-group SIR model introduced by Acemoglu et al. (2020). We adjust the underlying social interaction patterns and consider an extended set of policy measures. The model is calibrated for Germany. Despite the trade-off between COVID-19 prevention and economic activity that is inherent to shielding policies, our results show that efficiency gains can be achieved by targeting such policies towards different age groups. Alternative policies such as physical distancing can be employed to reduce the degree of targeting and the intensity and duration of shielding. Our results show that a comprehensive approach that combines multiple policy measures simultaneously can effectively mitigate population mortality and economic harm.

Research Paper Nr. 23

Autor: Bäuml, M.; Kümpel, C.

Titel: Hospital responses to the Introduction of Reimbursements by Treatment Intensity in a (Presumably Lump Sum) DRG System

Abstract: Many OECD countries have replaced per- diem hospital reimbursement with lump sum payments by diagnosis- related groups (DRGs). However, modern DRG systems still allow hospitals to pass on actual treatment costs to payers, which might hinder the efficiency of heath care provision. This paper analyzes hospital responses to a large- scale refinement of reimbursement practices in Germany on January 1, 2006, in which regulating authorities introduce reimbursements by treatment intensity in the market for stroke disorder.

Research Paper Nr. 22

Autor: Boggiano, B.

Titel: Long-term effects of the Paraguayan War (1864-1870): from male scarcity to intimate partner violence.

Abstract: This paper investigates the long-term effects of the Paraguayan War (1864- 1870) on intimatepartner violence. The identification of these causal effects relies on a novel historical dataset from which I exploit the distance from municipalities to military camps during the war. Over 130 years later, the likelihood of intimate partner violence is still 5.54 percent higher than average in municipalities that were more heavily affected by the war. The loss of life among men led to female- biased sex ratios and defined Paraguay as the `country of women'. However, I show that, contrary to conventional wisdom, female-biased sex ratios are not the only driver of the long-term effects of the war. Instead, the main transmission channel is the relative status of females within the household.

Research Paper Nr. 21

Autor: Margaryan, S.

Titel: Low Emission Zones and Population Health

Abstract: Air pollution has a major detrimental impact on population health but little is known about the effectiveness of policy measures targeting pollution. I exploit the staggered implementation of low emission zones in large cities in Germany as a natural experiment to asses their health impact. Using outpatient and inpatient health care data, I demonstrate that low emission zones reduce the number of patients with cardiovascular diagnoses by 2-3 percent. This effect is particularly pronounced for the elderly above 65. The findings suggest that this kind of policies can be an efficient way to reduce air pollution and improve health.

Research Paper Nr. 20

Autor:  Bayindir, E.

Titel:  Hospital Ownership Type and Service Provision, a Structural Approach

Abstract: In this work, I estimate the valuations hospitals assign to service provision relative to the value they assign to profits by hospital ownership, (for-profit, not-for-profit or government owned) in a structural way and present evidence that valuations differ significantly by ownership type. Despite the absence of requirements, not-for-profit hospitals value services relative to profits much more than their for-profit counterparts.

Research Paper Nr. 19

Autor: Everding, J. ; Marcus, J.

Titel: The Effect of Unemployment on the Smoking Behavior of Couples

Abstract: This is the first paper to estimate effects of unemployment on the smoking behavior of both spouses. One spouse’s unemployment increases both spouses’ smoking probability and intensity. Smoking relapses and decreased smoking cessation drive the effects.

Research Paper Nr. 18

Autor:  Everding, J.

Titel: Heterogeneous Spillover Effects of Children's Education on Parental Mental Health

Abstract: Despite extensive research on nonmarket returns to education, direct and spillover effects on mental health are widely unstudied. This study is the first to analyze heterogeneous intergenerational effects of children's education on parents' mental health. Increasing children's education reduces parents' long-term probability of developing depression.

Research Paper Nr. 17

Autor: Kvasnicka, M.; Siedler, T.; Ziebarth, Nicolas R.

Titel: The Health Effects of Smoking Bans: Evidence from German Hospitalization Data

Abstract: This paper studies the short-term impact of public smoking bans on hospitalizations in Germany. It exploits the staggered implementation of smoking bans over time and across the 16 federal states along with the universe of hospitalizations from 2000-2008 and daily county-level weather and pollution data.

Research Paper Nr. 16

Autor: Bach, P.; Farbmacher, H.; Spindler, M.

Titel: Semiparametric Count Data Modeling with an Application to Health Service Demand

Abstract: Heterogeneous effects are prevalent in many economic set-tings. As the functional form between outcomes and regressors is generally unknown a priori, a semiparametric negative binomial count data model is proposed which is based on the local likelihood approach and generalized product kernels.

Research Paper Nr. 15

Autor: Himmel, K.; Schneider, U.

Titel: Ambulatory Care at the End of a Billing Period

Abstract: The ambulatory physician payment system in the German Social Health Insurance (SHI) offers incentives to reduce practice activity at the end of a billing period. Using claims data from Germany’s largest sickness fund, we find a decrease of all services limited by a threshold at the end of a billing period and an immediate increase at the beginning of the following period.

Research Paper Nr. 14

Autor: Bahrs, M.; Schumann, M.

Titel: Unlucky to Be Young? The Long-Term Effects of School Starting Age on Smoking Behaviour and Health

Abstract: In this study, we analyse the long-term effects of school starting age on smoking behaviour and health in adulthood. School entry rules combined with birth month are used as an instrument for school starting age. The analysis adopts the German Socio-Economic Panel data and employs a fuzzy regression discontinuity design.

Research Paper Nr. 13

Autor: Blome, C.; Augustin, M.

Titel: Measuring change in subjective wellbeing: Methods to quantify recall bias and recalibration response shift

Abtract: We propose to use subjective well-being (SWB) measures to determine patient-relevant treatment benefit. Benefit can be measured either prospectively (pre-post) or retrospectively, but both approaches can be biased: Prospective evaluation may be subject to response shift; retrospective evaluation may be subject to recall bias. As prospective and retrospective evaluations often differ in effect size and since there is no gold standard to compare against, the extent of the two bias needs to be determined.

Research Paper Nr. 12

Autor: Varabyova, Y.; Blankart, C.R.; Schreyögg, J.

Titel: Using nonparametric conditional approach to integrate quality into efficiency analysis: empirical evidence from cardiology departments

Abstract: We use data from 178 departments of interventional cardiology and consider three different measures of quality: patient satisfaction, risk-adjusted mortality, and patient radiation exposure. Our empirical assessment shows that the impact of quality on the production process differs according to the utilized quality measure.

Research Paper Nr. 11

Autor: Bleiber, F.; König, H.-H.

Titel: Cost-effectiveness of intravenous 5 mg zoledronic acid to prevent subsequent clinical fractures in postmenopausal women after hip fracture: a model-based analysis

Abstract: Fractures are associated with high economic costs, increased mortality and loss of health related quality of life. A clinical trial showed that a yearly dose of 5mg intravenous zoledronic acid (IZA) had a fracture-reducing effect in individuals with a prior hip fracture. As to our knowledge no evidence about the cost-effectiveness of IZA is available, the objective of this study is to evaluate the cost-effectiveness of 5mg IZA in women with a previous hip fracture in comparison to no intervention.

Research Paper Nr. 10

Autor: Milstein, R.; Schreyögg, J.

Titel: A review of pay-for-performance programs in the inpatient sector in OECD countries

Abstract: Across the member countries of the OECD, several pay-for-performance (P4P) programs have been implemented in the inpatient sector to improve the quality of care provided by hospitals. However, little is known about whether such programs can live up to expectations. We aimed to provide an overview of existing P4P programs and to assemble information on their effects.

Research Paper Nr. 09

Autor: Kifmann, M.; Siciliani, L.

Titel: Average-cost Pricing and Dynamic Selection Incentives in the Hospital Sector

Abstract: This study investigates hospitals‘ dynamic incentives to select patients when hospitals are remunerated according to a prospective payment system of the DRG type. Given that prices typically reflect past average costs, we use a discrete-time dynamic framework. Patients differ in severity within a DRG. Providers are to some extent altruistic.

Research Paper Nr. 08

Autor: Heimeshoff, M.; Schreyögg, J.

Titel: Estimation of a physician practice cost function

Abstract: This is the first study to specify a physician practice cost function with practice costs as the unit of analysis. Our study is based on the data of 3,706 physician practices for the years 2006 to 2008. We propose a model using physician practices as the unit of observation and considering the endogenous character of physician input.

Research Paper Nr. 07

Autor: Kifmann, M.; Nell, M.

Titel: Fairer Systemwettbewerb zwischen gesetzlicher und privater Krankenversicherung 

Abstract: Wir entwickeln einen Reformvorschlag, der den problematischen Selektionswettbewerb zwischen GKV und PKV beendet und zu einem fairen Systemwettbewerb führt. Jeder Bürger leistet dabei einen einkommensabhängigen Beitrag zum Gesundheitsfonds und hat bei einem Wechsel in die PKV Anspruch auf risikogerechte Zahlungen aus dem Gesundheitsfonds.

Research Paper Nr. 06

Autor: Hinz, V.; Drevs, F.; Wehner, J.

Titel: Electronic Word of Mouth about Medical Services

Abstract: Electronic word of mouth (eWOM) about medical services gains growing popularity from the part of health care users, accompanied with a high reluctance of health care providers towards existing platforms, fearing unqualified, negative reviews driven by motives of vengeance. Purpose of this research is to shed light on the characteristics, content, and motives of eWOM about medical services.

Research Paper Nr. 05

Autor: Stargardt, T.; Schreyögg, J.; Kondofersky, I.

Titel: Measuring the relationship between costs and outcomes: the example of Acute Myocardinal Infarction in German hospitals

Abstract: In this paper, we propose a methodological approach to measure the relationship between hospital costs and health outcomes. We propose to investigate the relationship for each condition or disease area using patient-level data.

Research Paper Nr. 04

Autor: Roll, K.; Stargardt, T.; Schreyögg, J.

Titel: Effect of Type of Insurance and Income on Waiting Time for Outpatient Care

Abstract: This paper analyzes the impact of type of insurance, income, and reason for appointment on waiting time for an appointment and waiting time in the physician’s practice in the outpatient sector. Data were obtained from a German patient survey conducted between 2007 and 2009. We differentiated between GP and specialist and controlled for socioeconomic, structural, and institutional characteristics as well as interactions between type of insurance and control variables.

Research Paper Nr. 03

Autor: Tiemann, O.; Schreyögg, J.

Titel: Changes in Hospital Efficiency after Privatization

Abstract: We investigated the effects of privatization on hospital efficiency in Germany. To do so, we obtained bootstrapped DEA efficiency scores in the first stage of our analysis and subsequently employed a difference-in-difference matching approach within a panel regression framework. Our findings show that conversions from public to private for-profit status were associated with an increase in efficiency of between 3.2 and 5.4%.

Research Paper Nr. 02

Autor: Kifmann, M.; Roeder, K.

Titel: Premium Subsidies and Social Insurance: Substitutes or Complements?

Abstract: Premium subsidies have been advocated as an alternative to social health insurance. These subsidies are paid if expenditure on health insurance exceeds a given share of income. In this paper, we examine whether this approach is superior to social insurance from a welfare perspective. We show that the results crucially depend on the correlation of health and productivity. For a positive correlation, we find that combining premium subsidies with social insurance is the optimal policy.

Research Paper Nr. 01