Health Insurance and the Demand for Medical Care - Bureau of

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Health Insurance and the Demand for Medical Care: Instrumental Variable Estimates Using Health Insurer Claims Data Abe Dunny January 28, 2015

Abstract This paper takes a di¤erent approach to estimating demand for medical care that uses the negotiated prices between insurers and providers as an instrument. The instrument is viewed as a textbook “cost shifting” instrument that impacts plan o¤erings, but is unobserved by consumers. The paper …nds a price elasticity of demand of around -0.20, matching the elasticity found in the RAND Health Insurance Experiment. The paper also studies within-market variation in demand for prescription drugs and other medical care services and obtains comparable price elasticity estimates.

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Introduction

U.S. medical care expenditures account for a large and growing share of GDP and policy-makers continue to search for mechanisms to rein in expenditure growth. In this environment, understanding the demand for medical care is critical. Estimates of the price elasticity of demand may improve our understanding of patient incentives and lead to policies to help slow the growth of the health care sector. Unfortunately, estimating medical care demand is particularly challenging. One of the central problems is that the marginal price of medical care faced by consumers is often determined by consumers through their selection of a health insurance plan. For instance, the least healthy individuals may be more likely to choose a plan with the most generous insurance coverage, leading to an overestimate of the e¤ect on medical care demand when looking at correlations between the out-of-pocket price and the utilization of medical care. Both the economic importance of measuring the elasticity of demand as well as the substantial empirical challenge caused by selection were key motivations for conducting the RAND health insurance experiment in the 1970s. The RAND experiment was speci…cally designed to address the selection problem. The key to its success was the randomization of health insurance coverage across the sample population that allowed researchers to side-step the selection issue and isolate the e¤ect of cost sharing on demand. Although it has been more than 30 years since the RAND experiment was conducted, it remains the gold standard for The views expressed in this paper are solely those of the author and do not necessarily re‡ect the views of the Bureau of Economic Analysis.

I would like to thank seminar participants at the International Health Economics Conference and

the American Society of Health Economists. I would also like to thank Ana Aizcorbe, Eli Liebman, Rashmita Basu, Adam Shapiro, Jonathan Skinner and Brett Wendling for comments. y Bureau of Economic Analysis; [email protected]

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understanding consumer responsiveness to out-of-pocket price. However, the study has several limitations. Most importantly, since the study was conducted, the share of GDP devoted to medical care has doubled and medical technologies have changed substantially. These dramatic changes suggest that the evidence from the RAND experiment may be relatively dated and there are also questions regarding medical care demand that remain unanswered in today’s environment.1 Consequently, researchers have continued to search for alternative approaches to estimating the demand for medical care. This paper takes a di¤erent approach to estimating demand, which relies on an often noted industry feature: the out-of-pocket price paid by the consumer is typically not the same as the full price paid to the medical care provider (i.e., the allowed amount). With this in mind, this paper argues that the negotiated price between insurers and medical providers in an MSA may be thought of as a textbook “cost shifter” instrument. The theoretical justi…cation is clear: the package of bene…ts o¤ered to enrollees will be a¤ected by pro…t maximizing insurers responding to the negotiated price for medical services in an area. At the same time, the negotiated price should be uncorrelated with the selection of an insurance plan, since consumers are typically unaware of the negotiated prices with providers.2 Moreover, medical provider contracts are negotiated prior to setting insurance plan o¤erings and the negotiated price is typically the same for both the least generous plans and the most generous plans, greatly reducing the possibility that the instrument would be related to plan selection. Finally, the instrument is likely to be strong, since the negotiated price di¤ers substantially across MSAs. This empirical fact is documented in detail by Dunn, Shapiro, and Liebman (2013). This can also be seen by looking at examples of speci…c price di¤erences. For instance, the average negotiated price for a 15-minute o¢ ce visit with a general MD in Minneapolis, MN, in 2007 is $82, while in Memphis, TN, the average is $63.3 This instrumental variable (IV) strategy is fundamentally di¤erent from prior work. To control for endogeneity, researchers typically look for factors that a¤ect the out-of-pocket price that are unrelated to the demand for insurance. This may be caused by randomness from an actual experiment,4 a natural experiment,5 or through another instrument that is related to the marginal price faced by a consumer, but unrelated to insurance selection.6 In contrast, the identi…cation strategy in this paper focuses on how changes in the underlying marginal cost of medical services a¤ect the incentives of insurers, which ultimately impacts the out-of-pocket prices faced by consumers. While this approach is unique to the estimation of medical care demand, this basic intuition is often the motivation behind instrumental variable strategies applied in the industrial organization literature (e.g., Hausman (1996) and Nevo (2001)). The demand model is estimated using individual micro data from the MarketScan commercial claims database for the years 2006 and 2007. The MarketScan data is a convenience sample of enrollees from insurers and large employers. The data includes the demographic information of individuals, such as the 1 Addressing

these issues by conducting another experiment may be very costly. Manning et al. (1987) report costs of a

little more than $136 million in 1984 dollars or $408 million in in‡ation-adjusted 2013 dollars. Even if another experiment is conducted, unique empirical challenges also arise in an experimental setting (see Aron-Dine, Einav, and Finkelstein (2012)). 2 This fact was highlighted in great detail in the Time magazine article “Bitter Pill: Why Medical Bills Are Killing Us” by Steven Brill. 3 These estimates were computed using MarketScan data described later in the paper. Similar di¤erences are also found looking at median price di¤erences. 4 e.g., the RAND study (see Manning et al. (1987) and Keeler and Rolph (1988)). 5 e.g., see Phelps and Newhouse (1972), Cherkin, Grothaus and Wagner (1989), and Selby, Fireman and Swain (1996), and Chandra, Gruber, and McKnight (2010). More recently, the Oregon Health Insurance Experiment (see Finkelstein et al. (2012) and Baicker et al. (2013)). 6 e.g., Kowalski (2010) and Duarte (2012).

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age, sex, and type of insurance plan. Most importantly, the data includes information on the medical conditions of the enrollees, utilization of medical care services, and expenditures. The expenditure data indicates both the amount paid out-of-pocket by the enrollee and the total allowed amount paid to the providers. Data on income, education, and health are also incorporated into the analysis. In addition to the basic features of the data just mentioned, the MarketScan data is extremely detailed and large, with more than four million enrollees in each year. These unique aspects of the data are essential for constructing an instrument that accurately re‡ects the marginal cost of insurers. The instrument is computed by building an index that isolates the variation in underlying service prices (for example, the negotiated price for of a MRI for a patient with back pain), but holding utilization constant (for example, …xing the number of MRIs for treating back pain). Accurately constructing a service price index across many MSAs requires a signi…cant amount of detailed information, since physicians and hospitals o¤er an enormous number of products and services. The main result of the paper is that the individual price elasticity of medical care utilization is about -0.20, which is similar to the estimate found in the RAND study. Following the RAND study, this paper looks at price responsiveness at the disease episode level, investigating the e¤ect of price on the intensive margin (i.e., utilization per disease episode) and the extensive margin (i.e., the number of episodes). Similar to the RAND study, price responsiveness on the intensive margin accounts for only a small fraction of the total elasticity. Most of the individual responsiveness to the out-of-pocket price is on the number of episode occurrences. These …ndings con…rm the relevance of the RAND estimates in the current environment and outside of the experimental setting. Overall, the methodology and empirical …ndings in this paper are of general interest as they uncover a new way of identifying consumer responsiveness from real world price movements. Although this paper argues that the negotiated service price in the MSA is a valid instrument, much of the analysis focuses on the potential for endogeneity to creep into the negotiated price in an MSA. For example, a bias could potentially enter the model if the service price in an MSA is related to the quality of services in the MSA. For this reason, a variety of strategies are employed. One strategy is to search for alternative IV estimates that are related to the marginal costs of insurer generosity. Following arguments similar to Hausman (1996), one alternative IV strategy uses the service price indexes from other MSAs within the same state. As another IV strategy, the demand for medical care services for those individuals enrolled in one plan type (e.g., PPO plans) are instrumented by using the negotiated service prices for individuals enrolled in another plan type (e.g., POS plans). Several other IV strategies and many robustness checks are analyzed and under many alternative speci…cations the main results of this analysis remains qualitatively unchanged. Across all the IV strategies it is assumed that the service price instruments are determined by factors exogenous to individual demand.7 This assumption is violated if there is an unobserved demand factor common across individuals in an MSA that is correlated with the service price instruments. To address potential violations of this key identifying assumption, this paper also studies within-market di¤erences in demand for two categories of medical care, prescription drugs and other medical care services (i.e., all non-prescription drug services). By studying these two markets together, market-level …xed e¤ects may be 7 This

includes supply-side cost factors and also aggregate demand factors (e.g., the population age distribution). See

Kennan (1989) and Gaynor and Vogt (2003) who both point out the exogeneity of aggregate demand variables when using micro data.

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included to control for the common unobserved demand factors (e.g., unobserved health of the population). While the determinants of individual demand for these service categories are highly correlated, the basic factors a¤ecting costs and the determination of bene…ts are unique to each. In particular, the prices of medical care services are determined by local costs, while prices for prescription drugs are driven by more national factors. The di¤erences in the costs of these medical categories leads to variation in relative bene…ts that may be used to identify demand. Based on within-market di¤erences in demand for these categories, the price elasticity ranges from -0.27 to -0.11. The next section discusses the construction of the price and utilization measures. Section 3 describes the empirical model. Section 4 presents the data and descriptive statistics. Section 5 presents the main results. Section 6 presents the results of the within-market analysis and section 7 concludes.

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De…ning Service Prices and Utilization

The analysis in this section relies on many of the basic ideas presented in Dunn, Shapiro and Liebman (2013). To begin thinking about measuring medical care utilization and prices, it is helpful to start with a simple example. Suppose there is just a single patient, i, that is seeking treatment for high blood pressure, often referred to as hypertension (h). For simplicity, the example will start by supposing that there is only one type of treatment available, the treatments are 15-minute o¢ ce visits where the patient’s blood pressure is monitored.8 Let

ch;i

= All expenditures incurred for high blood pressure (i.e., out-of-pocket expenditures plus expenditures paid by the insurer).

qh;i

= Number of 15-minute visits with the physician.

ph,i

= Price per 15-minute visit with the physician (i.e.,

ch;i ). qh;i

Also suppose that there is a reference or base group, B, so that ch;B , qh;B , and ph,B are the total expenditures, number of 15-minute visits, and price for 15-minute visits for this base group. In this example the individual service price (SPh;i ) for person i may be calculated as: SPh;i =

ph, i qh;B ph, B qh;B

=

ph, i ph, B .

This measures

the contracted price per 15-minute visit relative to the base group’s price. Di¤erences in SPh;i s across patients would re‡ect only di¤erences in the contracted prices, not the number of visits. Dividing this SPh;i into the total expenditure of the episode (ch;i ) gives the utilization measure. That is, the individual c

service utilization is SUh;i = SPh;i = ph,B qh;i . This utilization measure indicates how much the insurer h;i and patient would have paid in total for the patient’s, qh;i , 15-minute visits if the contracted price were equal to the base group price. Di¤erences in SUh;i s across patients re‡ect only di¤erences in the number of 15-minute visits. To think about this utilization measure in terms of indexes, the total expenditures for patient i relative to the base group may be written as the product of a price index and a utilization index. ch;i = ch;B 8 This

ph,i qh;i ph,B qh;i

ph,B qh;i ph,B qh;B

(1)

type of procedure may fall under the speci…c service code 99213 as de…ned by the Current Procedure Terminology

(CPT) code.

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The …rst term in equation (1) is a price index, and the second term is a utilization index. Ignoring the …xed denominator in the utilization index (ph;B qh;B ), the numerator is the individual service utilization measure, SUh;i . While this example focuses on one precisely de…ned procedure, clearly physicians perform many alternative types of procedures other than 15-minute o¢ ce visits. More generally, let qh;i be a measure of the amount of services performed, where the total amount paid is calculated by multiplying the service price times utilization, ph,i qh;i . The precise calculation of the amount of services, qh;i , will be discussed in greater detail in the data section of the paper. For those familiar with medical care payments, this measure of utilization may be thought of as a relative value unit, which re‡ects the amount of services performed and is typically used when calculating payments to physicians. Expanding on this example, now suppose that this hypertension patient may be treated with two types of services, prescription drug and physician o¢ ce services, where the service categories correspond to the subscripts (D) and (O). That is, qh;i;O and ph,i;O are the utilization and price for the physician o¢ ce visits, and qh;i;D and ph,i;D are the utilization and price for prescription drugs. Continuing with the index decomposition that is parallel to (1), but with two services, the decomposition becomes: ch;i ch;R

= =

ph;i;O qh;i;O + ph;i;D qh;i;D ph;B;O qh;B;O + ph;B;D qh;B;D ph;i;O qh;i;O + ph;i;D qh;i;D ph;B;O qh;i;O + ph;B;D qh;i;D

(2) ph;B;O qh;i;O + ph;B;D qh;i;D ph;B;O qh;B;O + ph;B;D qh;B;D

The second term of the decomposition is a utilization index, and the numerator of the index corresponds to the service utilization variable studied in this paper: SUh;i = ph;B;O qh;i;O + ph;B;D qh;i;D . The general case follows from this basic example. The medical care expenditure for the treatment of a disease episode is de…ned as the total dollar amount of medical care used until treatment is completed, including all service categories.9 Formally, denote the expenditure paid to medical providers for an episode of treating disease d for insurance enrollee i as cd;i . The individual disease expenditure, cd;i , can be divided between service price and service utilization components. This can be seen by showing that the expenditure P is calculated by totaling dollars spent on all services: cd;i = pd;s;i qd;s;i where qd;i;s and pd;i;s are the s

service utilization and service price components for diseases episode d for individual i for service type s. Following the examples, to obtain an individual service utilization measure, the base service price for service type s, pd;B;s , is multiplied by utilization amounts for di¤erent services: SUd;i =

X

qd;i;s pd;B;s :

(3)

s

An individual may have more than one disease episode. For instance, an individual may have diabetes, hypertension, and heart disease. An overall utilization measure may be calculated by summing the diseasespeci…c utilization measure over the di¤erent disease episodes for individual i: SUi =

X

SUd;i :

(4)

d2i

9 For

example, for an individual with a broken foot, the episode of treatment will be de…ned by the dollar of medical

services used to treat that condition from the …rst visit to a provider until the foot is healed. For medical conditions that are chronic, we interpret an episode as expenditure for services used to treat the chronic condition over a one year period.

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One can divide this measure of overall utilization into two distinct pieces: the amount of utilization per episode (i.e., the intensive margin) and number of disease episodes (i.e., the extensive margin). The conceptual justi…cation for measuring utilization along two dimensions is that the physician’s in‡uence along the intensive margin and extensive margin may be quite distinct. The patients may choose to seek care with a physician to treat their medical conditions, but after seeking treatment, the patient may have less control over the intensity of treatment recommended by the physician. While SUd;i is the measure of utilization per episode, the number of episodes can be calculated by P summing the number of disease episodes for each enrollee i (i.e., Episodesi = d2i 1).10 However, this

simple count may not accurately re‡ect the large di¤erences in the intensity of treatment across disease episodes. For example, the average intensity of treatment for hypertension is much lower than that of

ischemic heart disease. Speci…cally, let the average utilization measure for disease d be calculated as, P SU d =

i SUd;i Numb er of individuals with disease d .

Then it should be expected that SU heart

disease

> SU hyp ertension .

To construct a disease episode count that re‡ects the di¤erent average intensities across disease episodes, a measure of the weighted number of episodes is calculated by summing over the average utilization amounts for each disease d of individual i, EpisodesW i =

X

SU d :

(5)

d2i

The weighted number of episodes will provide the main unit of analysis for studying demand along the extensive margin. Note that the weighted number of episodes is unresponsive to changes in the amount of utilization per episode. For instance, if an individual has hypertension treated more intensively than W average, this will have no e¤ect on EpisodesW i . The only factors that a¤ect Episodesi are the number

of disease episodes and the average intensity of those episodes, as measured by SU d . The key explanatory variable in this study is the out-of-pocket price. Let ooped;i be the total out-ofpocket expenditures for individual i for disease episode d. The out-of-pocket price is just the out-of-pocket expenditure divided by utilization. Speci…cally, the equation used to compute an individual’s out-of-pocket price (OOP P ) is

P

ooped;i : (6) SUi For individuals enrolled in family plans, the average out-of-pocket price across all individuals i P P OOP Pi =

in family f is OOP Pf =

i2f P

ooped;i . SUi

d2i

i2f

d2i

The main analysis will focus on the average out-of-pocket price

faced by the family, OOP Pf .11 Some of the analysis in the following sections involves the calculation of

individual-speci…c service price indexes that are constructed in a manner similar to OOP Pi . In particular, the individual service price (SPi ) may be calculated by summing over all individual expenditures (rather P than the out-of-pocket expenditures) and dividing by the overall utilization measure: SPi =

cd;i 12 . SUi

d2i

A nice feature of the out-of-pocket price measure is that identical services are priced similarly across

markets. For example, if the out-of-pocket expenditure for a 15-minute o¢ ce visit in city A is $10 and the out-of-pocket expenditure for an identical 15-minute o¢ ce visit in city B is $15, then the out-of-pocket price measure in this paper would imply that the price for city B is 50 percent larger than city A ($15/$10=1.5) because the amount of utilization is the same, but the expenditure is 50 percent larger. In contrast, using 1 0 If

an enrollee has multiple disease episodes of the same type, this will be counted as multiple episodes. For instance, an

individual may have two episodes of a sore throat. 1 1 Alternative measures of out-of-pocket price are explored in robustness checks discussed later in the paper. 1 2 Note that this corresponds to the price component of the index in (2)

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a cost-sharing measure as the relevant price would not necessarily satisfy this property. For example, if the service price in city A were $50 and the service price in city B were $75, then the out-of-pocket prices implied by a cost-sharing measure in the two cities would be identical (i.e.,

$10 $50

=

$15 $75 ).

Therefore, an

attractive property of the out-of-pocket price measure, OOP Pf , is that the price is measured relative to a precisely de…ned unit of utilization, so that two di¤erent payment amounts for the same service will imply di¤erent price levels. As can be seen by this example, a very detailed data set is necessary to accurately price speci…c services and products (e.g., the methodology will need to distinguish between a 15-minute o¢ ce visit, a 30-minute o¢ ce visit, and an MRI).

2.1

MSA Service Price Index

An approach analogous to that described for measuring individual prices is taken to construct an MSA service price index. The average expenditure per episode of treating disease d in MSA r is denoted crd . Similar to the individual level episode expenditures, the average expenditure, crd , can be divided between service price and service utilization components. This can be seen more easily by showing that the average expenditure per episode is calculated by totaling dollars spent on all services to treat the condition and P r dividing those dollars by the number of episodes: crd = pd;s Qrd;s =Ndr , where Qrd;s is the quantity of s

services of type, s; prd;s , is the service price; and Ndr is the number of episodes treated.

To simplify notation, let qdr be a vector of the average amount of services utilized for the treatment of disease d in an MSA r, qdr = Qrd =Ndr , where the component of the utilization vector for service s is , Qrd;s =Ndr .13 Also, let prd be a vector of service prices, where the component of the vector for service s is, prd;s . The price for a particular service type and disease can be calculated by dividing its average expenditure per episode for service s by the average utilization for service s: prd;s =

crd;s r qd;s

where crd;s is

the average expenditure on disease d for service s in MSA r. For example, the price of an inpatient stay for treating heart disease is the total expenditure of an inpatient treatment for heart disease in an MSA, divided by the quantity of inpatient services for heart disease in that MSA. This decomposition allows for an MSA service price index (SP Idr ) for disease d in MSA r that is calculated as: SP Idr =

prd qdB , B pB d qd

(7)

which holds the utilization of services …xed at a base level. This MSA service price index forms the basis for the main instruments used in this paper. The service price index is intended to capture the expected marginal cost for an additional unit of a medical care services for the typical enrollee in the population. Speci…cally, assuming full insurance, the SP Idr re‡ects the marginal cost of a service for treating a patient with disease, d, in MSA r relative to the base region, B. This service price index may also be viewed as the expected marginal cost of the next service. To see this, let the probability of receiving the next service from service type s be denoted Prd;s , then the X prd;s expected relative service price is Prd;s pB . If the probability of each service is the expenditure share of s

the base group, Prd;s = 1 3 The

B pB d;s qd;s B pB q d d

d;s

X pB qB pr d;s d;s d;s , then the expected relative service price= = pB q B pB s

d

services s are service categories, such as inpatient hospital or physician o¢ ce services.

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d

d;s

prd qdB B pB d qd

= SP Idr .

To calculate a service price index, SP I r , that aggregates over diseases in MSA r, each disease-speci…c service price index, SP Idr , is weighted by the national expenditure share for that disease d for the entire U.S. Weighting by the expenditure share re‡ects the probability that the next dollar spent will be allocated to each disease.

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Empirical Model of Demand

There are three distinct measures of utilization studied in this paper. First, the study focuses on the responsiveness to overall utilization, which looks at total medical care use, regardless of the disease being treated (i.e., SUi ). Second, similar to the RAND study, utilization is broken into two pieces: the number of episodes (i.e., EpisodeW i ) and utilization per episode (i.e., SUd;i ). As argued by the RAND researchers (see Keeler and Rolph (1988)) and discussed brie‡y above, these two components of utilization likely involve di¤erent levels of control by physicians. The decision to treat an episode, such as hypertension or high cholesterol, may be thought of as a decision that is in‡uenced by the consumer, while after initiating treatment, the physician may have relatively more control. In any case, for each of these measures of utilization the role of information and the relative control of the physician and the consumer will likely di¤er, which o¤ers an important motivation for analyzing these decisions separately.

3.1 3.1.1

Components of Demand Overall Utilization

To examine overall utilization, the overall utilization measure, SUi , is regressed on the log of the out-ofpocket price, ln(OOP Pf ), and individual demographics, Zi . As is widely known in the health economics literature, medical care utilization may be highly skewed with a signi…cant fraction of individuals with no utilization. To deal with these issues, this paper follows the guidelines outlined in the health econometrics literature to test functional forms and select the appropriate estimator. Following these guidelines, discussed in greater detail in the appendix, the main speci…cation in this paper will apply a GLM model with a log link. Therefore, the empirical model of utilization is: SUi = exp( ln(OOP Pf ) + where

and

1

1 Zi

+

i)

+ ei ,

are parameters to be estimated and ei is a random error term. The potential endogeneity of

the out-of-pocket price variable is speci…ed using the unobserved variable

i.

As an example,

i

may include

unobserved illness severity, which may be related to both more generous insurance and the utilization of more services, creating a downward bias on . In addition to an omitted variable problem, the out-of-pocket price may be measured with error. For example, the constructed out-of-pocket price measure, OOP Pf , may not match the marginal out-of-pocket price, as perceived by the consumer. Both the possibility of omitted variable bias and measurement error imply that it is important to apply an IV estimator. The instrumental variable model applied in this paper is a two-stage residual inclusion model (a type of control function model).14 The basic instrument used in this analysis is the MSA service price index, 1 4 As

discussed in greater detail in Terza, Basu and Rathouz (2008), applying two-stage least squares estimation to this

type of nonlinear model may lead to inconsistent estimates. In this nonlinear setting, a residual inclusion estimation is the preferred approach.

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SP I r . The …rst-stage regression of the IV procedure is: ln(SP I r ) +

ln(OOP Pf ) =

1 Zi

+

i:

(8a)

To correct for endogeneity, the error term from the …rst-stage regression is included in the GLM model to control for the unknown factors causing movements in out-of-pocket prices, such as unobserved health and measurement error, and isolates those movements due to exogenous factors. Speci…cally, the estimate b = ln(OOP Pf ) (b ln(SP I r ) + b1 Zi ) is included in the GLM model and the second-stage regression is i SUi = exp( ln(OOP Pf ) +

+ bi ) + ei :

1 Zi

(9)

There are two key assumptions. First, the instrument, ln(SP I r ), is uncorrelated with unobserved demand, 3.1.2

i.

Second, the instrument is correlated with out-of-pocket price, ln(OOP Pf ).

Weighted Number of Episodes - Extensive Margin

The weighted number of episodes is studied in a similar fashion to overall utilization. The analysis changes by substituting the dependent variable SUi in (9) with the weighted number of treated episodes, EpisodesW i . A two-stage residual inclusion model is also applied to address endogeneity. The second-stage regression is: EpisodesW i = exp( ln(OOP Pf ) + 3.1.3

1 Zi

Utilization Per Episode - Intensive Margin

+ bi ) + ei :15

Analyzing the e¤ects of the out-of-pocket price on utilization per episode may include additional information about the speci…c disease being analyzed. The econometric model of utilization of disease d for individual i is SUd;i = exp( ln(OOP Pf ) +

1 Zi

+

2 Xd;i

+

i;d

+ vd ) + ed;i ;

where vd is a disease-severity …xed e¤ect and Xd;i is a vector of covariates that includes other disease-speci…c information of the individual, such as an interaction between the age of the individual and the disease category. Similar to the other models, the out-of-pocket price is potentially endogenous. The potential endogeneity of the out-of-pocket price is speci…ed in this model as the unobserved variable

i;d .

Again,

a two-stage residual inclusion model is applied to correct for endogeneity. Unlike the previous models, a disease-speci…c service price index may be included. In this case, the …rst-stage of the estimation is ln(OOP Pf ) =

1

ln(SP Idr ) +

2

ln(SP I r ) +

1 Zi

+

2 Xd;i

+ vd +

i;d :

The second-stage regression would then be: SUd;i = exp( ln(OOP Pf ) +

1 Zi

+

2 Xd;i

+ vd + bi;d ) + ed;i :

Note that there are important di¤erences in identi…cation when analyzing utilization along the intensive and extensive margins. When analyzing utilization along the extensive margin, an individual (or one of 1 5 In

the robustness section of the paper, an additional check uses a simple count of the number of episodes.

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their family members) could potentially develop any disease, so there is a single measure of the expected service price for the entire MSA, SP I r .16 This limits the power for identifying demand along the extensive margin. In contrast, conditional on having a disease, the relevant service price is disease-speci…c. Therefore, there are many distinct disease-speci…c prices within an MSA that may be used to identify demand along the intensive margin.17

3.2

Discussion of Empirical Issues

3.2.1

Instruments

Recall the basic motivation for the instruments applied in this paper. The negotiated prices are set prior to insurance selection by consumers. Thus, the negotiated service prices will shape the incentives of insurers when o¤ering plans, but the negotiated prices should not have a direct e¤ect on the insurance selection by consumers.18 This follows the standard cost shifter argument applied in the literature.19 Importantly, the negotiated prices are unknown to consumers and are likely determined by factors that are not directly related to an individual’s medical care utilization decisions (e.g., the wages of the health care workers and the competitive conditions in the market). Moreover, since the analysis is conducted at a micro level, the instrument may also relate to aggregate demand factors (e.g., the age distribution of the population), which may have an impact on negotiated prices, but should not have a direct e¤ect on the health care decisions of an individual.20 This IV strategy addresses a major endogeneity concern that relates to insurance selection at the individual level. However, a potential problem of this IV strategy is that the service prices could potentially be related to quality at a more aggregate level. For instance, higher service prices may be associated with greater quality and higher out-of-pocket prices. In this case, if individuals consume more medical care when it is of higher (lower) quality, these patterns would tend to decrease (increase) individual price responsiveness.21 Despite this possibility, it is not clear that quality would be related to the MSA service price index. Recall that the MSA service price index is an average service price for the entire MSA, so the estimate is likely capturing a common component of costs across a large area and a variety of di¤erent providers and services, rather than the quality of a speci…c provider.22 This greatly reduces the possibility of endogeneity bias. Moreover, several variables are included in the analysis to control for the quality of 1 6 This

is only approximately correct.

Speci…cally, an alternative measure of SP I r that is speci…c to each individual

may be calculated based on the probability that each person develop a speci…c disease based on their age, sex, and other demographic characteristics. This alternative IV strategy was studied and results did not change substantially. 1 7 Although some component of price variation is common across diseases, Dunn, Liebman, and Shapiro (2013) …nd evidence that there is a component of service price variation that is disease-speci…c. 1 8 The employer also plays a role in responding to changes in plan o¤erings. The employer could respond to changes in plan o¤erings by adjusting premium sharing with the employees or o¤ering plans with di¤erent bene…ts. Importantly, the …rst-stage estimates show a strong empirical relationship between the out-of-pocket price and service prices in an area, indicating bene…ts are a¤ected by service price changes. 1 9 Insurers reduce the risk of enrollees by transforming the linear prices that they contract with suppliers, to substantially lower prices that reduce the risk incurred by the purchasers of insurance. 2 0 See Kennan (1989) for additional discussion on estimating demand using micro data. 2 1 One could imagine the bias going in either direction. Higher quality providers may have more e¤ect on patients with a lower level of service utilization. Alternatively, higher quality treatment may involve more services. 2 2 Another reason for focusing on the average service price is to avoid any potential correlation with a particular plan. While it is generally true that insurers often negotiate a single contract with providers for multiple insurance o¤erings, it is important that the results are robust, even if this assumption fails.

10

medical care in an MSA, such as regional …xed e¤ects, the fraction of hospitals in the county associated with teaching facilities, and several other covariates. To further reduce any possibility of bias, several alternative IV strategies are applied. One alternative IV strategy uses service prices from other plan types. Speci…cally, a service price index built from non-PPO (PPO) plans is used as an instrument for the PPO (non-PPO) out-of-pocket prices. The assumption here is that the unobserved quality is unique to a particular plan type, but common costs are shared across plan types. Both of these assumptions appear plausible. Di¤erent plan types may share common costs because they both contract with providers in the same area, but the qualities of the providers that they contract with may be di¤erent. For instance, PPO plans are likely to have a network that includes many of the highest quality physicians, while POS plans tend to be more restrictive. As an additional check, another instrument is constructed which uses service prices in other MSAs in the state. The assumptions underlying this strategy are that unobserved demand shocks across markets are independent, but the prices are correlated due to common cost factors across MSAs in a state. The features of the market support these assumptions. Substantial evidence exists that consumer demand for medical care is local, with patients typically travelling just a few miles for inpatient services (e.g., Town and Vistnes (2001) and Gaynor and Vogt (2003)). However, labor market movements are more likely to be within states or across nearby states, creating a common cost component across a broad geographic area. Some regulations are also speci…c to each state (e.g., certi…cate of need laws for hospitals). This strategy is related to that proposed by Hausman (1996) that uses prices from other cities as an instrument for price when estimating demand.23 Another service price index is constructed which uses the 25th percentile of observed service prices in each MSA, rather than the average price.24 This instrumental variable strategy may be preferred if quality di¤erences across markets are associated with di¤erences in price at the high end of the price distribution, but not at the low end. For example, there may be a fraction of physicians and hospitals in an area that may be perceived as very high quality (e.g., Johns Hopkins Hospital in Baltimore), while many other providers may be of more standard quality. In this case, the 25th percentile service price index may be thought of as pricing a more homogeneous medical service across MSAs. 3.2.2

Out-of-Pocket Price

The nonlinear structure of most health insurance plans makes it challenging to estimate demand, since it is unclear which price along the nonlinear schedule invokes a response by consumers.25 For this reason, it is likely that the out-of-pocket price used in this study is only a proxy for the true out-of-pocket price. Let OOP Pf be the out-of-pocket price perceived by the consumer, and assume that the out-of-pocket price variable used in the analysis is a¤ected by error, vi , so OOP Pf = OOP Pf + vi . Much of the noise is likely created by the nonlinear nature of health insurance plans, causing vi to shift as the amount of medical care 2 3 It

should be noted that the strategy proposed here is distinct, and perhaps less likely to be endogenous than the IV

strategy applied by Hausman. The service prices in the other markets re‡ect the marginal cost of additional services for insurers in other MSAs. In contrast, the equivalent of Hausman’s instrument in this setting would be out-of-pocket prices in other markets. 2 4 Speci…cally, for each service category (e.g., outpatient hospital) and each disease (e.g., hypertension), the 25th percentile price observation is used, rather than the average. 2 5 E.g., the current price (for myopic consumers), their predicted out-of-pocket price at the end of the year (forward-looking consumers), or some average out-of-pocket price.

11

utilization changes. The IV strategy taken in this paper helps address this problem because the negotiated price between providers and insurers is typically linear and unrelated to an individual’s level of utilization, implying that cov(vi ; ln(SP I r )) = 0. In other words, the instrumental variable captures di¤erences in the out-of-pocket price related the cost of medical services in the MSA, which is uncorrelated with the individual-speci…c movements in the out-of-pocket price measure. Although the IV strategy may assist with measurement error problems, it is still necessary to select a particular measure of out-of-pocket price to include in the analysis. As described above, this paper focuses on OOP Pf , which is calculated as the realized out-of-pocket expenditure for a family divided by overall utilization for the family. There are two key advantages to using this average out-of-pocket price. First, the approach does not exclude out-of-pocket payments that may be relevant. For instance, focusing on the end-of-year expected price may capture the behavior of forward-looking consumers but miss the myopic behavior of other consumers that only respond to current prices. In contrast, focusing on current prices would ignore the response of forward-looking consumers.26 Second, the average out-of-pocket price may be easy and practical for policy-makers to apply, since it may be thought of as, roughly, the share of out-of-pocket expenditures paid by consumers.27 For example, when applying elasticities in the literature, Newhouse (1992) and Finkelstein (2007) think about the consumer’s response to out-of-pocket expenditures divided by total expenditures (i.e., an elasticity with respect to a coinsurance rate).28 Although the paper focuses on the out-of-pocket price measure, OOP Pf , it is shown that the results are robust to alternative out-of-pocket price measures. 3.2.3

Empirical Model Selection

As mentioned previously, the utilization data includes skewness, heteroskedasticity, and mass points at zero, which may create statistical problems and lead the usual least squares estimation to yield bias or imprecise estimates (see Manning and Mullahy (2001)). To address these issues, a variety of statistical models and tests have been applied to determine the appropriate estimator. This analysis suggests that a GLM model with a log link and a Gamma distributional error structure …ts the properties of the data nicely. This model is applied to each of the components of utilization. A discussion of the statistical tests and alternative speci…cations has been relegated to an appendix. However, as noted in the appendix, the key results of the paper are robust to alternative estimators, such as the application of the popular two-part model. 3.2.4

Estimating Standard Errors in a Two Stage Model

To precisely estimate standard errors of the parameters, it may be important to account for the measurement error from the …rst stage estimates. For this reason, a bootstrap approach is applied that repeats the two stage procedure using 50 random draws of the data with replacement. Due to the size of the data, 2 6 It

is unclear how consumers actually respond to nonlinear price schedules, so an average price is a simple way to include

both myopic responses and dynamic considerations, albeit in an arbitrary fashion. 2 7 The share of out-of-pocket expenditures is only roughly accurate because the measure of utilization used in the denominator will likely not equal total expenditures. Although, on average, this assumption is correct. 2 8 Of course, selecting a single price to represent a nonlinearly structured insurance plan does not uncover how individuals respond to di¤erent aspects of their nonlinear insurance structure. This alternative research question is of great importance, as it may lead to a deeper understanding of consumer behavior and also determine the optimal nonlinear insurance contract (see Aron-Dine, Einav, Finkelstein, and Cullen (2012)).

12

these random draws are taken from an initial 30 percent random sample. In this particular application, it appears that the standard errors change very little when applying the bootstrap estimator, relative to estimates that ignores the impact of the …rst stage estimates on the second stage standard errors.

4

Data

The analysis uses retrospective claims data for a sample of commercially-insured patients from the MarketScanr Research Database from Truven Health. The speci…c claims data used is the “Commercial Claims and Encounters Database,” which contains data on medical and drug claims from employer and health plan sources for several million commercially-insured individuals, including employees, their spouses, and dependents. Each observation in the data corresponds to a line item in an “explanation of bene…ts”form.29 The sample is restricted to enrollees that are not in capitated plans from the MarketScan database for the years 2006 and 2007.30 The sample is also limited to enrollees with drug bene…ts because drug purchases will not be observed for individuals without drug coverage. The MarketScan database tracks claims from all providers using a nationwide convenience sample of enrollees. Each enrollee has a unique identi…er and can be linked to a particular county. All claims have been paid and adjudicated.31 The basic idea of looking at episodes of treatment in this paper is similar to the RAND study, but the methodology for de…ning and grouping episodes is distinct. In this paper, the claims data have been processed using the Symmetry grouper 7.6 software from Optum. The grouper assigns each claim to a particular Episode Treatment Group (ETG) disease category.32 The grouper uses a proprietary algorithm, based on clinical knowledge, that is applied to the claims data to assign each record to a clinically homogenous episode of care. The episode grouper allocates all spending from individual claim records to distinct diseases.33 An advantage of using the grouper is that it can use patients’ medical history to assign diseases to drug claims, which typically do not provide a diagnosis. Another advantage is that it is replicable and the software may be applied to other data sources. Finally, the grouper algorithm is constructed by experts in the area that have a …rm grasp of current diagnostic practices. However, the algorithms are also considered a “black box” in the sense that they rely entirely on the expertise of those that developed the grouper software.34 2 9 The

decisions made for selecting the sample and de…ning utilization and episodes using these data closely follow Dunn,

Shapiro, and Liebman (2013). 3 0 A key reason for focusing on a short cross-section is that similar medical technologies are likely available in di¤erent markets, which is an assumption that is di¢ cult to justify when there is greater time variation. 3 1 Additional details about the data and the grouper used in this paper are in Dunn et al. (2010). 3 2 The ETG grouper allocates each record into one of over 500 disease groups. 3 3 All episodes are initiated using only diagnostic information, so information on services or procedures performed are not used to initiate episodes. In cases where the spending could potentially be allocated to multiple diseases, the grouper uses additional information on the claim, such as the information from the patient’s history or the types of procedures performed to allocate spending across disease episodes. 3 4 The ETG Symmetry grouper is applied in recent research looking at disease episode expenditures (e.g., Aizcorbe and Nestoriak (2012), Dunn, Shapiro and Liebman (2013), and Dunn, Liebman and Shapiro (2014)). The alternative Medical Episode Grouper (MEG) from Truven Health and other ICD9 classi…cation systems have also been applied in the literature. See Rosen and Cutler (2009) and Rosen et al. (2012) for further discussion of episode grouper methodologies. The MEG and ETG grouper methodologies appear to produce qualitatively similar patterns across geographic markets (see Dunn, Shapiro and Liebman (2013)), so it is unlikely that the choice of disease episode grouper would have a large impact on the estimates. However, in general, there is no agreed upon method for assigning disease episodes and these methods do result in disitinct disease expenditure allocations. For this reason, an additional robustness check is conducted that uses simple episode counts

13

To ensure that all claims are properly identi…ed and grouped into episodes, it is required that all individuals in the sample are fully enrolled for the entire year, plus 6 months prior enrollment (e.g., enrollment from July 2005 for enrollees in 2006) and 6 months post enrollment (e.g., enrollment until June 2008 for enrollees in 2007).35 To better control for the severity of the diagnosis, additional severity measures provided by the ETG grouper are used to further classify each episode. The availability of severity classi…cations vary by the ETG disease category, and range from 1 (the least severe) to 4 (the most severe). For instance, the most severe condition of diabetes will be given a severity level of 4 while the least severe diabetes condition will be given a severity level of 1.36

4.1

Service Utilization

This paper follows the methodology of Dunn, Shapiro, and Liebman (2013) to de…ne service quantity. Service utilization measures are created for each type of service based on the de…nition of a service within that service type. The service-type categories are inpatient hospital, outpatient hospital, general physician, specialist physician, prescription drug, and other. Measuring service utilization is not a straightforward task since the de…nition of “service” is a bit ambiguous and there are a variety of ways that one could de…ne it across various service types. Ideally, the de…nition of a speci…c service should depend on how the price of that service is typically set and paid. For example, for physician services, individuals pay a unique price for each procedure done to them (that is, the insurer and the patient together pay this amount), whereas the prices paid to facilities are often set based on the treated disease. The next section describes how the quantity of services is measured for each service type. 4.1.1

Measuring the Quantity of Service by Service Type

For each claim line in the data, it is …rst categorized by its by place of service, which determines the service-type category. For each category, the following steps describe how the amount is determined for each visit, where a visit is de…ned by the enrollee and the date of service or admission: Physician o¢ ce - Physician visits are priced based on procedures performed in a physician’s o¢ ce. Since not all procedures are equivalent, each procedure is weighted to re‡ect the intensity of the service. For the Medicare payment system, Relative Value Units (RVUs) de…ne reimbursement rates and are intended to capture the intensity of the services provided. In that spirit, the intensity of service is proxied for by using the average prices for each Current Procedural Terminology (CPT-4) code and modi…er code. The total quantity of services performed in an o¢ ce is then computed by summing over these RVU amounts. More precisely, the total amount of services from a physician o¢ ce visit is computed as P qof f ice = cpt2V isit pcpt;of f ice , where cpt 2 V isit is a complete list of CPT procedures performed during

(rather than weighted episodes), which is less reliant on expenditure allocation across diseases. The elasticity estimates

change only slightly. 3 5 About 13.8 percent of expenditures are not assigned to any ETG disease category (that is, screening for diseases and other records that cannot be assigned a category).

Those claims not assigned disease categories are removed from our analysis.

As mentioned in the robustness check section in the appendix, the main results do not change when these ungrouped claims are incorporated into the analysis. The six-month “cushion” ensures that episodes occurring at the beginning or the end of a year are not truncated.

The

results do not appear sensitive to this six-month cushion. 3 6 The ETG severity level is determined for each episode based on a variety of additional information including age, gender, comorbidities, and other potential complications.

14

the visit in an o¢ ce setting and pcpt;of f ice is the base price for procedure code, cpt. The base group price, pcpt;of f ice , is computed as the average price in the data for that procedure code and modi…er code. Since most insurers set prices from a base price schedule (e.g., 10 percent above Medicare rates), one can think of the price level in an MSA, r, as the base price multiplied by a scalar price,

r,

where prcpt =

r pcpt .

For instance, if a CPT code that equals 99213 indicating a 15-minute established patient o¢ ce visit has an average price of $100, its value will be 100 RVUs (i.e., p99213 = 100). It should be clear that the RVU amount is a measure of utilization and not price. To see this, if the fee on a 15-minute o¢ ce visit is $120 in MSA r (pr99213 = $120), then the price of the service will be calculated as $120/100RVU=1.2 $/RVU (i.e.,

r

=

prcpt 37 pcpt ).

Hospital inpatient - Inpatient hospital stays not only consist of facility fees paid to the hospital, but also fees paid to the physician. A variable in the claims data distinguishes these two types of payments. For the portion of fees paid to the hospital, the amount of services is measured as the average dollar amount for an inpatient stay for the observed disease. For the portion of fees paid to the physician, an RVU is assigned in the same way that an RVU is calculated in an o¢ ce setting. The total amount of services performed in an inpatient setting is calculated by adding the physician and facility amounts. Speci…cally, P qinpatient = pd;inpatient + cpt2V isit pcpt;inpatient where pd;inpatient is the base price for inpatient facility claims for disease d, where the base price is the average price in the data for a visit to an inpatient facility P for treating disease d. The term cpt2V isit pcpt;inpatient is the amount calculated for the physician portion

of the bill and is computed in a manner identical to the physician o¢ ce category, but is based on only physician claims in an inpatient setting. Hospital outpatient - Outpatient hospital visits are calculated in an identical fashion to the inpatient hospital visits. That is, the facility amount is calculated based on the average outpatient visit for that disease, and the doctor’s portion of the total amount is calculated based on the average payment for the procedure codes in an outpatient setting. Prescription drugs - The amount of the prescription drug varies based on the molecule, the number of pills in the bottle, the strength of the drug, and the manufacturer. An 11-digit National Drug Code (NDC) uniquely identi…es the manufacturer, the strength, dosage, formulation, package size, and type of package. To capture these di¤erences, the average price for each NDC code is calculated. This means that branded and generic products that contain the same active molecule are treated as distinct drugs. The average price for each NDC code represents the amount of the service used. Speci…cally, the amount of P drug services used is qdrug = N DC2V isit pN DC , where N DC 2 V isit is a complete list of NDC codes purchased from a visit to a pharmacy and pN DC is the base price for a speci…c NDC code. The base price

for each NDC is computed as the average price in the data. All other - The other category primarily includes ambulatory care, independent labs, and emergency room visits. For these services, if no procedure code is available, the amount of each category is measured as the average cost for a visit to that particular place of service for treating a particular disease (for example, the average cost of an ambulatory care visit to treat ischemic heart disease). For cases where procedure codes are available, the average cost of that procedure code for that place of service is used. This decomposition relies on the institutional feature that insurers and providers typical negotiate from a percentage of a base fee schedule (for example, 10 percent above Medicare rates).38 Since the measure 3 7 This

methodology for calculating utilization for physician services is identical to that conducted by Dunn and Shapiro

(2014). 3 8 In a survey of 20 health plans conducted by Dyckman & Associates, all 20 health plan fee schedules were in‡uenced by

15

of service price can be viewed as the expenditures from a visit divided by a proxy for a “RVU”, it can also be thought of as a percentage amount from a base (or average) payment— a measure close to how prices are actually set. For this reason, these measures of service quantity subsequently allow us to create service prices that correspond well with how fees are negotiated in the marketplace. In other words, this approach attempts to construct a unit value index that re‡ects the heterogeneity in how goods and services are actually priced. It can also be shown that if pricing is set based on a percentage of a set fee schedule then this approach is equivalent to pricing speci…c procedures.39

4.2

Sample and Descriptive Statistics

The sample studied in this paper is limited to those MSAs with a su¢ ciently large number of enrollees, so that the measured service prices in each market will be meaningful. The sample includes only those MSAs in the data that have an average of 15,000 enrollees per year over the 2006-2007 time period.40 The minimum sample size in each city is more than double the annual commercially-insured sample size from the Medical Expenditure Panel Survey, which is a national survey of health expenditures meant to be representative of the entire U.S. non-institutionalized population.41 This …rst selection rule leaves a sample of 103 MSAs. All disease episodes are considered when studying the e¤ects of out-of-pocket price on utilization. However, when constructing the MSA service price indexes (i.e., SP I r ) to use as instruments, only those diseases that have 15,000 episodes or more in the data are selected, which accounts for 87 percent of overall expenditures and 96 percent of the episodes. The reason for this selection rule is to make sure that the price indexes are not greatly a¤ected by infrequently observed diseases. Table 1 provides some basic descriptive statistics for the top spending disease categories. Prior to calculating these descriptive statistics, population weights are applied to adjust for di¤erences in age and sex across MSAs and to make the estimates representative of U.S. totals.42 The table reports the the Medicare fee schedule. That is, a resource-based relative value scale (RBRVS), essentially adopting Medicare’s base fee schedule. Gowrisankaran, Nevo, and Town (2013) incorporate this assumption in their bargaining study of hospital prices: “We assume that the price paid for treatment is ... the base price multiplied by the disease weight. This is essentially how most hospitals are reimbursed by Medicare, and many [Insurers] incorporate this payment structure into their hospital contracts.” 3 9 Let the the price and quantity for CPT code cpt in MSA r be denoted P cpt;r and Qcpt;r . In this case, the Laspeyres price index for MSA r for physician services may be computed as: SPILasp = pricesin MSA r

P1;r Q1;B +P2;r Q2;B :::+PN;r QN;B . Assuming that P1;B Q1;B +P2;B Q2;B :::+PN;B QN;B r can be computed as r times the base fee schedule.

physicians set prices from a base fee schedule, then the That is, P1;r =

r

P1;B , P2;r =

r

P2;B ; :::; and PN;r =

PN;B , so P1;r Q1;B +P2;r Q2;B :::+PN;r QN;B P1;B Q1;B +P2;B Q2;B :::+PN;B QN;B r (P1;B Q1;B +P2;B Q2;B :::+PB;r QN;B ) = r. P1;B Q1;B +P2;B Q2;B :::+PN;B QN;B

SPILasp = =

In this example, our index is the same as a price index that tracks

prices at the procedural level. Of course, to the extent that physicians price procedures individually, rather than based on a schedule, this result would not hold. 4 0 i.e., 30,000 enrollee-year observations. 4 1 The commercially-insured sample in the MEPS data is around 14,799 individual observations in each year. This study uses two years of data which includes more than 30,000 individual-year observations per MSA. The sample size of MSAs is larger than that used in Dunn, Shaprio, and Liebman (2013). Similar results are obtained with a smaller sample of MSAs, but more cities ensures that the estimates are representative. 4 2 Speci…cally, enrollees in each MSA are assigned weights so the weighted population has an age and sex distribution that

16

national estimates of expenditures for each disease along with the number of episodes, dollars per episode, and expenditure share. The table reveals some interesting facts about disease expenditures in these data. First, based on the ETG groupings, the top …ve disease expenditure categories include pregnancy, joint degeneration of the back, hypertension, diabetes, and ischemic heart diseases. Although there are 271 disease-severity combinations in the sample, these …ve disease categories account for 25 percent of the expenditures. In general, most of the expenditures are accounted for by a limited number of diseases with the diseases listed here accounting for 38 percent of total expenditures from the selected diseases, so the MSA service price indexes will be heavily in‡uenced by a small number of diseases. There is a wide range in the expenditure per episode across diseases. Severity 1 hypertension costs just $646 per episode, while severity 3 joint degeneration of the back costs $12,555. Table 1. Summary Statisics on Top Spending Disease Episodes

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

1

Disease Pregnancy, with delivery Pregnancy, with delivery

2

Joint degeneration, localized - back Joint degeneration, localized - back Joint degeneration, localized - back

3

Hypertension Hypertension Hypertension Hypertension Diabetes Diabetes Diabetes Diabetes Ischemic heart disease Ischemic heart disease Routine exam Mood disorder, depressed Mood disorder, depressed Mood disorder, depressed Hyperlipidemia, other

3

4 5 6

7 8

9

10

Joint degeneration, localized - neck Joint degeneration, localized - neck Joint degeneration, localized - neck

Chronic sinusitis Chronic sinusitis Chronic sinusitis Asthma Asthma Asthma Asthma Other Total

Severity

1 2 1 2 3 1 2 3 4 1 2 3 4 1 2 1 1 2 3 1 1 2 3 1 2 3 1 2 3 4

Total Dollars (Billions) 2006-07

(Thousands)

Dollars Per Episode

Share of Spending

$7.0 $3.5 $5.6 $2.5 $1.9 $5.7 $1.7 $0.9 $0.7 $5.0 $0.9 $0.9 $1.4 $4.3 $3.3 $6.7 $4.3 $0.9 $0.6 $5.2 $3.2 $0.5 $1.3 $2.7 $0.6 $1.0 $1.2 $1.7 $0.3 $0.6 $133 $208

1,493 505 6,313 1,174 302 17,638 3,836 1,573 584 6,428 716 535 469 2,373 1,195 62,047 7,208 1,152 357 15,989 4,160 372 292 10,345 1,336 888 4,231 3,431 336 288 373,029 530,598

$9,377 $13,834 $1,774 $4,270 $12,555 $646 $868 $1,090 $2,240 $1,543 $2,464 $3,287 $5,915 $3,631 $5,588 $215 $1,184 $1,575 $3,130 $649 $1,519 $2,427 $9,168 $512 $890 $2,332 $575 $980 $1,918 $3,917 $711 $785

3.4% 1.7% 2.7% 1.2% 0.9% 2.7% 0.8% 0.4% 0.3% 2.4% 0.4% 0.4% 0.7% 2.1% 1.6% 3.2% 2.0% 0.4% 0.3% 2.5% 1.5% 0.2% 0.6% 1.3% 0.3% 0.5% 0.6% 0.8% 0.2% 0.3% 63.6% 100.0%

Number of Episodes

Table 2 provides descriptive statistics on many of the variables used in the analysis at the individual is identical to that of the U.S. commercially-insured population in 2007. For constructing the MSA service price indexes, population weights are also applied to each MSA so that the service price estimates are una¤ected by the demographics of the population. Table 1 shows the disease expenditures for the two-year period of 2006 and 2007 and is based on the weighted sample of enrollees. The national weights are applied to each city and the total expenditures and episodes are divided by the number of cities in the sample, 103, times the number of years of data, 2. (Thus I divide by 206 (=103*2)). Since these …gures do not account for di¤erences in populations across cities, these estimates overcount smaller MSAs, relative to their share of the U.S. population.

17

level. The table shows that the majority of the data is from large employers, with only 24 percent of the sample contributed by insurers. The data is also comprised mostly of enrollees in PPO plans, accounting for 68 percent of the sample.43 Variables from external data source are also incorporated into the analysis to control for factors that may a¤ect medical utilization that are not contained in the MarketScan data. One data sources is the Area Resource File (ARF) database that includes several county-level variables, such as the median income, fraction of individuals with a college education, average rent,44 and the fraction of hospitals associated with a medical school in the county. Another external data source is the Behavioral Risk Factor Surveillance System (BRFSS) data that is used to construct measures of health, including estimated rates of obesity and smoking in each county.45 Table 2 also shows measures of utilization and price. Note that each of the utilization measures are highly variable and around 16.5 percent of enrollees consume zero health services. For those that do consume a positive amount of health services, the mean utilization amount is 3,967 and the standard deviation is 10,783. The utilization is also highly skewed to the right, as can be seen by comparing the mean to the median. To address the skewness of the data the demand analysis will focus on log transformations of the utilization measures. The bottom of the table reports the various price measures. One striking feature of the data is that the variation in the out-of-pocket price variable, OOP Pf , is extremely large, with a coe¢ cient of variation of about 1. The MSA service price index, SP I r , has a coe¢ cient of variation of 0.086, and the disease-speci…c service price index, SP Idr , has a coe¢ cient of variation of 0.147. Although the variation on OOP Pf appears large, this should be expected, since the out-of-pocket price is speci…c to each individual and is a¤ected by the various nonlinear characteristics of the insurance contracts and the heterogeneity of individuals selecting particular plans. In contrast, the service prices negotiated between insurers and providers are typically linear. The variation in the service price indexes is also smaller because it averages over prices for the entire MSA, eliminating di¤erences in contracted amounts within an MSA. The considerable noise contained in the OOP Pf variable implies that a substantial amount of variation in the MSA service price index may be necessary to accurately identify the relationship between the service price index and the out-of-pocket price. Fortunately, there are clear di¤erences in the MSA service price indexes across areas, ranging from 0.89 to 1.10 for the 10th and 90th percentiles. This observed variation in the service price 4 3 This

compares with 60 percent reported in the Kaiser Health Bene…t Survey in 2006. Although the share of PPOs may

appear high, recall that all capitated plans, such as HMOs, have been dropped from the analysis. Taking into account those HMO enrollees would produce estimates very similar to the Kaiser Health Bene…t Survey. 4 4 Although the average rent would not a¤ect medical care utilization directly, it may be related to the price of outside goods and services in the area. 4 5 One limitation of these supplementary variables is that they do not include individual-speci…c information, but only county-wide information. However, the inclusion of these additional variables ensures that the relationship between price and utilization across areas is not driven by these county-speci…c factors. The estimates from the BRFSS data are based on regression analysis at the individual level that are used to compute county-level estimates. To standardize the estimates, rates of obesity and smoking are computed for a standardized individual in the county (i.e., a woman of age 34 to 44). Unfotunately, the BRFSS data only includes an indicator of whether a person has insurance, and does not include information regarding the source of their coverage, such as Medicaid or employer-based insurance. Prior to estimating the regression model, those individuals that do not have insurance and also those households that earn less than $10,000 annually are removed from the analysis. Those without insurance clearly do not match with our population of commercially-insured individuals. In addition, households that earn less than $10,000 are much more likely to be enrolled in Medicaid or another public assistance program and not be included in the commercially-insured population. Additional health factors, such variables related to drinking, exercise or BMI, were included in the analysis, but had no e¤ect and potentially introduce multicollinearity with the other county-level health variables.

18

index is critical for the successful application of the IV strategy applied in this paper.46 A related point that is worth highlighting is that the elasticity is identi…ed using the range of out-of-pocket prices observed in the sample, which centers around the OOP Pf of 0.186. Measuring price elasticity around this point is useful, since the data represents a range of prices that is commonly observed across markets. However, researchers should be cautious when applying the elasticity estimates to out-of-pocket price changes that are far away from the distribution of observed prices.47 Table 2. Descriptive Statistics

Mean Age Number of Individuals in the Family Fraction with College Education (in County) Income (Median in County) Rent (Median in County) Fraction of Hosp. Med. Schools (in County) Fraction Obese (in County) Fraction Smokers (in County)

Median

s.d.

10th 90th percentile percentile

33.324 37.000 19.816 4.000 58.000 2.796 3.000 1.507 1.000 5.000 0.166 0.155 0.062 0.094 0.255 $56,607 $53,472 $13,832 $41,845 $75,460 $647 $633 $133 $492 $835 0.387 0.368 0.319 0.000 0.875 0.236 0.237 0.060 0.162 0.316 0.170 0.167 0.049 0.111 0.230

Male Data Source: Insurer Data

0.486 0.239

Plan Type PPO POS Comprehensive High Deductible Health Plan EPO & Other

0.681 0.165 0.062 0.034 0.058

Overall Service Utilization (SUi) SUi=0 SUi if SUi>0

0.1646 3967.39 1271.19 10783.99 176.48

Number of Episodes Simple Count (Episodes i) if SUi>0 Weighted Count (Episodes wi) if SUi>0

3.68

3.00

2.50

3981.91 2145.56 5396.77

9009.45

1.00

7.00

389.22

9822.67

57.70

1519.91

Service Utilzation Per Episode (SUi,d) SUi,d

740.22

196.31

2433.62

Out-of-pocket Price and Service Price Variables OOPPf

0.232

0.186

0.228

0.056

0.442

MSA Service Price (SPIr) Disease-specific, MSA Service Price (SPIrd)

1.000 1.002

0.998 0.993

0.086 0.147

0.894 0.847

1.104 1.158

Number of Individuals Number of Episodes

9,735,083 32,592,524

Notes: The data sources for the individual-level variables are from MarketScan. The county level variables are from the ARF and BRFSS data sources and are linked to the individual observations through the observed county of the individual in the MarketScan data. The total number of individuals and episode observations are reported at the bottom of the table. The total observations do not match the totals reported in the estimates, since not all the variables are observed for all individuals.

Table 2 reports nearly 10 million individuals in the sample, but not all of the variables are observed for every individual in the data, so a more limited sample is used for estimation. For the main estimates, OOP Pf , is imputed for families with zero expenditures using information from similar families in the same MSA (approximately 8 percent of the individual observations),48 although the results remain unchanged 4 6 See 4 7 For

Dunn, Shapiro, and Liebman (2013) for a more complete discussion and analysis of service price variation. instance, the estimates here may not accurately re‡ect the elasticity of demand for someone receiving insurance that

did not previously have insurance. 4 8 Speci…cally, individuals from families of the same size, age, sex, plan-type, and data contributor (employer or insurer) in

19

when the imputed observations are removed.49 The next section presents the main empirical …ndings, which show the e¤ects of out-of-pocket price on each of the measures of utilization.

5 5.1

Results Overall Utilization

Table 3 presents estimates of the overall utilization response to the out-of-pocket price. All of the estimates include the controls listed in Table 2 along with regional …xed e¤ects, although only selected parameter estimates are displayed.50 Model 1 shows the baseline results that do not control for endogeneity. The price elasticity implied by Model 1 is -0.62, which is considerably more elastic than most other estimates in the literature, suggesting a negative bias. Indeed, evidence of a negative bias is found by looking at the estimates of Model 2 that applies the MSA service price index instrument. For Model 2, the estimates show a price coe¢ cient of -0.22, which is considerably more inelastic than the estimates from Model 1. Moreover, the coe¢ cient on the residual inclusion variable (derived from the …rst-stage of the estimation routine) is negative and highly signi…cant, indicating that controlling for endogeneity is statistically important and endogeneity bias is likely a¤ecting Model 1 estimates.51 the same MSA are used for imputation. To conduct the imputation, total out-of-pocket expenditures and total utilization are calculated for each demographic category. Then the OOP Pf is imputed by dividing total out-of-pocket expenditures by total utilization for individuals of the same category. To remove the in‡uence of outliers, after conducting the imputations, those values of OOP Pf are removed by dropping the observations below the 0.25 percentile and above the 99.75 percentile. Results are robust the inclusion of these outliers. 4 9 These estimates are shown in the robustness section in the appendix. 5 0 Complete parameter estimates of selected speci…cations are shown in Table A1 of the appendix. 5 1 The full set of estimates for Models 2 is included in the appendix in Table A1.

20

Table 3. Effect of Out-of-pocket Price on Overall Service Utilization (SUi)

(1) Log(OOPPf )

Log(Median Income)

Log(Frac. Obese)

Log(Frac. Smokers)

Log(Frac. w/ College)

Instruments

(3)

(4)

(5)

(6)

-0.620*** -0.223*** -0.322*** -0.161*** -0.199*** -0.276*** (-40.33) (-3.47) (-3.99) (-2.76) (-3.75) (-2.76) 0.126 (1.63)

0.189*** 0.173*** (3.57) (3.42)

0.205***

0.198***

0.184***

(4.87)

(4.97)

(3.33)

-0.0908** -0.0346 -0.0472** -0.0172 -0.0231 -0.0425* (-2.11) (-1.50) (-2.06) (-0.70) (-0.95) (-1.67) 0.0123 (0.46)

0.0214 (1.35)

0.0191

0.0301 (0.58)

0.0368 (1.27)

0.0357

(1.33) (1.18)

0.0270

(1.62) 0.0296

(1.28)

0.0260

(1.53) 0.0287

(1.13)

0.0200

(1.28) 0.0351

(1.15)

-0.408*** -0.303*** -0.464*** -0.426*** -0.348*** (-7.01) (-3.85) (-8.64) (-9.34) (-3.71)

Residual Inclusion

Number of Observations

(2)

8979207

None

8979207

MSA Service Price

8979207

MSA Service Price Other Plans

8079984 Service Price of Other MSAs in State

8079984

8979207

Service Price of MSA Other Plans Service & Other Price, 25th MSA Price Percentile

Notes: The z-statistics are in parentheses and are clustered by MSA. The z-statistics are computed using a bootstrap estimation that accounts for the two-stage estimation strategy. One, two, and three asterisks indicate significance at the 10-percent, 5-percent, or 1-percent significance level, respectively. The coefficients on the other explanatory variables are shown in Table A1.1 for select models.

As discussed previously, one potential concern with the instrument applied in Model 2 is that the MSA service price index, ln(SP I r ), may be correlated with unobserved quality. To address this potential problem, several alternative estimates are presented that apply distinct IV strategies. Model 3 uses an MSA service price index constructed from other types of health plans in the area; and Model 4 uses a service price index constructed from other MSAs in the state. The price elasticity estimate from Model 3 is a bit more elastic than Model 2, with an elasticity of -0.32; while the estimate in Model 4 is less elastic, showing a coe¢ cient of -0.16. Model 5 presents the preferred IV strategy, which uses both of the instruments from Models 3 and 4. Model 5 strategy is preferred since both of the instruments do not rely directly on price information from the enrollee’s plan, both of the instruments contribute signi…cantly to explaining the variation in out-of-pocket prices, and both pass basic tests of validity. The …rst-stage estimates (reported in Table 6) show each of the di¤erent instrument sets applied in Table 3 are strong. Additional tests of the strength and the validity of the instruments are discussed after presenting the main results. Although Model 5 is the preferred speci…cation, another estimate is included to o¤er an additional check. The instrument used in Model 6 is identical to that of Model 2, except instead of using an instrument based on average prices, Model 6 is based on the 25th percentile price for every disease and service category.52 This strategy is distinct, but one can see the estimated elasticity in Model 6 is comparable to the other IV estimates. 5 2 For

example, the 25th percentile in prices for services in a physician o¢ ce to treat hypertension.

21

In addition to the coe¢ cient on the out-of-pocket price variable, Table 3 reports a number of other estimates of potential interest. One …nding is that the measure of county obesity rates and smoking rates are unrelated to overall utilization. This result is surprising given that obesity and smoking are related to the development of particular diseases. This may suggest that these populations may not be seeking treatment for existing medical conditions, although studying these data at the disease level shows that higher obesity rates are signi…cantly related to treatment for diabetes and hypertension.53 Another issue is that these variables are only proxies for obesity and smoking for an entire county, rather than the precise measurement for an individual person. The coe¢ cient on household median income is positive and highly signi…cant, as expected.54

5.2

Extensive Margin: Weighted Number of Episodes

Table 4 examines the e¤ect of out-of-pocket price on the weighted number of episodes.55 For nearly all of the key estimates, Models 2 through 6, the price responsiveness matches the results found in Table 3. This con…rms a key …nding from the RAND study: consumers primarily respond to out-of-pocket prices by changing the number of episodes treated, rather than the utilization per episode. That is, this …nding is consistent with a simple model of consumer behavior where individuals choose whether to be treated for a disease episode or not, but have less control over subsequent utilization. Overall, the elasticities are quite close to those of the RAND study with the key result from Model 5 matching the RAND elasticity. Another interesting …nding in Table 4 is that the income elasticity ranges from 0.10 to 0.20, a range that is comparable with the estimates reported by Phelps (1992). 5 3 This 5 4 The

is observed for the disease-speci…c estimates in Table A2 of the appendix. RAND study suggests an income elasticity of demand of 0.20 or less (see Phelps (1992)). The calculations reported

in Phelps (1992) are derived from the estimates from Keeler et al. (1988). This elasticity is likely capturing only the demand response of the consumer, and not the larger “general equilibrium” income response that includes the e¤ect of income on the adoption of new technologies, which may be considerably larger. Acemoglu, Finkelstein and Notowidigdo (2013) estimate a general equilibrium income elasticity of 0.7. 5 5 One useful by-product of modeling demand in this manner is that the data on weighted number of episodes is much less skewed than overall utilization, as shown in Table 2.

22

Table 4. Effect of Out-of-pocket Price on Weighted Number of Episodes (Episodes W i)

(1) Log(OOPPf )

Log(Frac. Obese)

Log(Frac. Smokers)

Log(Frac. w/ College)

Instruments

(4)

(-3.91)

(-4.24)

(5)

(6)

-0.197*** -0.269***

(-2.45)

(-3.19)

(-3.07)

0.106** (2.52)

0.118*** 0.110*** 0.130*** (3.70) (3.13) (3.31)

0.127***

0.111***

(3.31)

(2.97)

-0.0246 (-1.02)

-0.0151 -0.0218 0.00105 (-0.65) (-0.92) (0.05)

-0.00153 -0.0209

(-0.07)

(-0.82)

-0.00503 -0.00345 -0.00458 -0.00201 -0.00247 -0.00444 (-0.37) (-0.26) (-0.32) (-0.16) (-0.20) (-0.33) -0.0318 (-1.23)

-0.0306 -0.0314 -0.0363 -0.0364 -0.0313 (-1.32) (-1.31) (-1.56) (-1.51) (-1.26) -0.0693 -0.0201 -0.115* -0.0986* -0.0267 (-1.24) (-0.32) (-1.63) (-1.71) (-0.31)

Residual Inclusion

Number of Observations

(3)

-0.295*** -0.228*** -0.276*** -0.181**

(-36.58) Log(Median Income)

(2)

8979207

None

8979207

MSA Service Price

8979207

MSA Service Price Other Plans

8079984 Service Price of Other MSAs in State

8079984

8979207

Service MSA Price of Other Plans Service & Other Price, 25th MSA Price Percentile

Notes: The z-statistics are in parentheses and are clustered by MSA. The z-statistics are computed using a bootstrap estimation that accounts for the two-stage estimation strategy. One, two, and three asterisks indicate significance at the 10-percent, 5-percent, or 1-percent significance level, respectively. The coefficients on the other explanatory variables are shown in Table A1.1 for select models.

5.3

Intensive Margin: Utilization Per Episode

To complete the picture of demand responsiveness, Table 5 reports estimates for the e¤ect of out-of-pocket price on the utilization per episode.56 Model 1 of Table 5 shows the results of the baseline model that does not control for endogeneity. The estimates show the relationship between out-of-pocket price and utilization to be negative and highly statistically signi…cant. This estimate is dramatically di¤erent than the results of Models 2 through 6 that each correct for endogeneity and show price elasticities that are more inelastic and less statistically signi…cant. The key estimate from Model 5 suggests an elasticity of around -0.05. This result is in line with expectations based on the estimates from the previous two tables. That is, the intensive margin elasticity should be roughly equal to the overall utilization elasticity (Table 3) minus the extensive margin elasticity (Table 4). 5 6 These

estimates only focus on those diseases that are observed 15,000 times or more in the data to eliminate in‡uence

of costly and rare disease episodes.

23

Table 5. Effect of Out-of-pocket Price on Utilization per Episode (SUd,i)

(1) Log(OOPPf )

Log(Median Income)

Log(Frac. Obese)

Log(Frac. Smokers)

Log(Frac. w/ College)

(2)

(5)

(6)

-0.0494*

-0.0672*

-0.0503*

-0.0436*

(-40.84)

(-1.29)

(-1.76)

(-1.80)

(-1.80)

(-1.67)

-0.0335*

0.00644

-0.00963 -0.00411 -0.00937 0.00300

(-1.80)

(0.34)

(-0.51)

(-0.21)

(-0.48)

(0.15)

-0.0650*** -0.0374*** -0.0444*** -0.0495*** -0.0492*** -0.0405*** (-6.65)

(-4.15)

0.0134** (1.97)

0.0184*** 0.0164** (2.67) (2.36)

0.0197*** 0.0187** (2.73) (2.56)

0.0180** (2.51)

0.0288*** 0.0304*** 0.0268**

0.0293*** 0.0252**

0.0298***

(2.72)

(2.61)

(2.80)

(3.06)

(-4.51)

(2.51)

(-4.91)

(-5.02)

(2.21)

(-3.98)

-0.177*** -0.128*** -0.127*** -0.125*** -0.154*** (-9.25)

Instruments

(4)

-0.196*** -0.0252

Residual Inclusion

Number of Observations

(3)

(-4.71)

(-3.40)

(-4.59)

(-5.99)

28533369 27812331 23813449 25835792 21561379 27812331

None

MSA Service Price

MSA Service Price Other Plans

Service Price of Other MSAs in State

Service Price of MSA Other Plans Service & Other Price, 25th MSA Price Percentile

Notes: The z-statistics are in parentheses and are clustered by MSA and Major Practice Category. Due to the larger number of observations, the z-statistics are not adjusted for the two-stage estimation. However, applying a boostrap estimate that accounts for the two-stage estimation produces z-stats slightly larger than those reported in Model 5. One, two, and three asterisks indicate significance at the 10-percent, 5-percent, or 1-percent significance level, respectively. The coefficients on the other explanatory variables are shown in Table A1.2 for select models.

Table 5 contains a few additional estimates of interest. First, income has little e¤ect on utilization along the intensive margin, but the fraction of individuals with college education appears to have a positive and signi…cant e¤ect on utilization. One possible explanation may be that more highly educated individuals tend to comply with prescribed treatments.57 Second, a higher fraction of smokers in an area is associated with higher levels of utilization, perhaps due to some unobserved illness severity for this population. Surprisingly, higher obesity rates are associated with less utilization per episode. This result is unexpected, but one possible explanation is that the possible stigma associated with obesity may lead obese enrollees to avoid recommended medical care.58 Overall the estimates in Tables 3, 4, and 5 show patterns that are consistent with the RAND study. The similarity of the …ndings may be seen as somewhat surprising given the dramatic changes in health care markets in the past decades and the di¤erent approach taken to estimating demand. On the other hand, these results may simply suggest that this alternative methodology o¤ers a reasonable and accurate approach for identifying demand elasticities and the behavior of consumers has not markedly changed 5 7 Goldman

and Smith (2002) report that more educated people are more likely to comply with diabetes and AIDS treat-

ment, conditions considered highly demanding for proper compliance. 5 8 Sundmacher (2012) shows that obese individuals do not change health related behavior after a negative change in their own health (i.e., health shock). In contrast, the study …nds that smokers do change their behavior. Louis and Drury (2002) …nd that a higher body mass index is associated with an increase in the delay or avoidance of health care.

24

since the RAND study. The following subsections further investigate the robustness of these results.

5.4

Empirical Issues and Robustness Checks

The empirical strategy in this paper rests on the strength and validity of the instruments. The …rst-stage estimates are reported in Table 6. The relationship between each of the service price indexes and the out-of-pocket price is strong and statistically signi…cant.59 Looking at Model 4 in Table 6 shows that two of the key instruments, the average price from other MSAs in the state and the average price for other plan types in the MSA, are both signi…cant even when jointly included in the regression. This indicates that these instruments explain distinct components of out-of-pocket price variation. Interestingly, the …rst-stage coe¢ cient on the MSA service price index is around 2, suggesting that a disproportionate share of the service price is passed on to consumers through higher out-of-pocket prices. This coe¢ cient implies that a 10 percent increase in the service price index in an MSA tends to be associated with a 20 percent increase in the out-of-pocket price. Similar magnitudes are found using the other instruments.

Table 6. First-Stage Estimation of Log(OOPPf) on Service Price Instruments

(1) Log(MSA Service Price)

(2)

(3)

(4)

2.061*** (8.73)

Log(MSA Service Price, Other Plans)

1.654*** (6.33)

Log(Service Price of Other MSAs in State)

0.930*** (3.22) 2.265*** (7.80)

1.729*** (4.90)

Log(MSA Service Price, 25th Percentile)

Number of Observations

(5)

1.499*** (5.73) 8979207

8979207

8079984

8079984

8979207

Notes: The z-statistics are in parentheses and are clustered by MSA. The table only displays the coefficients on the insturments, with the other first-stage estimated coeffients not shown. One, two, and three asterisks indicate significance at the 10-percent, 5-percent, or 1-percent significance level, respectively.

In addition to an instrument being strong, a good instrument should be uncorrelated with the error (i.e., for an unbiased estimate, ln(SP I r ) must be uncorrelated with

i ).

Several checks are conducted to

determine whether this criteria is satis…ed. One informal check is to note that a variety of distinct IV strategies produce elasticities in a reasonably tight range, from -0.16 to -0.32 for the overall utilization elasticity. The similarity across di¤erent IV strategies implies that these distinct instruments are capturing the same economic e¤ect and that the observed di¤erences are likely driven by sampling error. As an additional check of the validity of the instruments, the residual from the key estimates (Model 5 in Tables 3) is regressed on all of the exogenous variables, including the two instruments. A joint F-test of these two instruments shows that they are statistically insigni…cant, and the R-squared is extremely low 0.0029, suggesting little correlation between the instruments and the error term.60 Checks are also performed on 5 9 The

…rst-stage F statistic exceeds 10 across IV strategies. checks are conducted by looking the relation between the MSA service price index (i.e., the instrument in

6 0 Additional

Model (1) of Table 6) and the residuals from the demand estimates using the two instruments (i.e., the instruments applied in Model (5) of Table 3). Again, there is no signi…cant correlation. Similarly, there is no correlation between the residual

25

the extensive and intensive margin with similar results.61 While basic statistical checks suggest that the instruments are appropriate, another useful exercise is to examine out-of-pocket price responsiveness for speci…c diseases.62 To check the responsiveness at the disease level, the analysis focuses on relatively common diseases that do not always require immediate treatment, such as high cholesterol, diabetes, hypertension, migraines and depression. These estimates are contrasted with the e¤ect of out-of-pocket price on the probability of treatment for appendicitis, which is a condition that arguably a- icts people more randomly and must be treated regardless of the price.63 Therefore, the price responsiveness for treating appendicitis o¤ers a falsi…cation exercise. Instrumental variable probit models are estimated to examine if treatment for these diseases is sensitive to the out-ofpocket price. The estimates are shown in Table A2 of the appendix. As expected, the probability of being treated for high cholesterol, hypertension, diabetes, migraines and depression are each negatively related to the out-of-pocket price (though insigni…cant for high cholesterol). In contrast, there appears to be no signi…cant relationship between appendicitis and out-of-pocket price, as expected. Dartmouth researchers and others studying geographic variation have documented signi…cant variation in how physicians practice medicine across geographic markets (see Skinner (2012). Therefore, one may also be concerned that the observed prices may be related to physician norms and practices across markets. For instance, it may be that high price areas are those areas where physician utilization tends to be low, causing the observed negative correlation between price and utilization. To control for this possibility, a robustness check is included in the appendix that accounts for the propensity of physicians to utilize medical services in an area. Speci…cally, information from the Medicare market is used as a control for di¤erences in geographic practices, since the same medical providers often treat both Medicare and commercial patients. Measures of expenditure and utilization in the Medicare market are available from a recently constructed public use …le from the Centers for Medicare & Medicaid Services (CMS)64 . The robustness analysis includes several county-speci…c measures including expenditures per capita, utilization per capita (which removes across-market variation in Medicare pricing), the average age of the Medicare population, as well as a measure of utilization per capita that is adjusted for the health of the Medicare population. The robustness section of the paper shows that the inclusion of these additional variables has and the MSA Service Price, 25 Percentile instrument. The MSA service price index is not used in combination with the other two instruments because the explanatory power of the MSA-speci…c instrument dominates the other instruments. Morever, the theoretical possibility of endogeneity using the MSA service price index is greater than the other instruments, implying that its greater explanatory power may be problematic. 6 1 The extensive margin check for endogeneity closely matches the results of the overall utilization test. For the intensive margin calculations, using the disease-speci…c prices as instruments produces an F-test that is statistically signi…cant, suggesting that there may be some correlation with the error term.

However, when the disease-speci…c instruments are not

used, the out-of-pocket price coe¢ cient remains very inelastic and of a similar magnitude. To improve the e¢ ciency of the estimates, the disease-speci…c prices are included in the estimation. 6 2 One must be cautious in conducting this type of analysis, since the diagnosis and treatment path may be highly nonlinear. For instance, for more serious conditions, such as for heart disease, proper treatment of high cholesterol may in‡uence the probability of heart disease appearing in the population. Therefore, a lower price in an area, leading to more high cholesterol treatment, may actually lower the probability of seeking treatment for heart disease. When analyzing the price responsiveness for speci…c diseases, the implicit assumption is that they are not a¤ected by these types of nonlinearities. 6 3 Another issues is that there may be moral hazard for individual behavior. For instance, those with more complete health insurance coverage may drive more recklessly or participate in more dangerous activity. 6 4 See http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-GeographicVariation/GV_PUF.html.

26

no e¤ect on the price elasticity estimates, strongly suggesting that provider practice patterns a¤ecting the price elasticity estimates (see robustness check number 8 in section 8.3 of appendix for additional details). Interestingly, Medicare utilization and expenditure variables are not signi…cantly related to utilization on the extensive margin, but it is positively and signi…cantly related to utilization on the intensive margin. This is consistent with the hypothesis that the intensive margin re‡ects more of the physician’s in‡uence than the extensive margin. Another important robustness check is to determine whether results are sensitive to how the out-ofpocket price is de…ned. Recall that the out-of-pocket price measure applied in this paper is calculated as the out-of-pocket expenditures for a family divided by the utilization amount for the family. This approach is useful for several reasons already mentioned. However, researchers have noted the challenges of selecting a proper measure for the out-of-pocket price (see Aron-Dine et al. (2013)), so it may be important to check the robustness of these …ndings to alternative de…nitions. One alternative measure looks at only an individual’s out-of-pocket price, ln(OOP Pi ), rather than the entire family’s out-of-pocket price, ln(OOP Pf ).65 As another alternative, an out-of-pocket price variable is constructed using two years of claims data for the same family, which may be a better proxy for the marginal price in the long run.66 For both robustness checks, the results remain unchanged. Another issue is that the nonlinearity of the health insurance contracts creates a great deal of noise in the out-of-pocket price measure, which weakens the correlation between the instruments and the outof-pocket price. As an alternative, one could look directly at the reduced form relationship between the MSA service price index and utilization to measure the full response to di¤erent service price indexes. One may view the full response involving the choices of the insurer, consumer, and employer. Although this analysis is complicated by the interpretation of the price coe¢ cient,67 a key advantage of this approach is that it removes the noise created by the nonlinear insurance contract, which arguably strengthens the identi…cation of the price response. This analysis is reported in the appendix of the paper (section 8.2). Additional robustness checks and a discussion of empirical issues are relegated to the appendix (section 8.3), including a discussion of how the empirical model is selected (section 8.1).

6

The Demand for Medical Care and Prescription Drug Services

The empirical strategy in the previous section relies on cross-sectional di¤erences in service prices and demand. Despite the numerous robustness checks employed, unobserved demand at the market-level could a¤ect these estimates. To address this issue, this section investigates within-market demand for two distinct medical care categories, prescription drugs and medical care services (i.e., all non-prescription drug services). The use of both service categories are greatly in‡uenced by the health of the patient and her propensity to seek medical treatment. Therefore, the inclusion of common MSA-level …xed e¤ects will account for a substantial share of unobserved demand for these two medical categories. However, 6 5 When

an individual’s expenditures are zero the family’s out-of-pocket price is used as the individual price. Results are

reported in Table A10 of the appendix. 6 6 This exercise implictly assumes that individuals change plans infrequently. Another reason to conduct this exercise is that several enrollees are dropped due to a lack of data on out-of-pocket expenditures or there information must be imputed. Using two years of data allows for an out-of-pocket price variable to be calculated for more individuals in the data. This result is reported in Table A10 of the appendix. 6 7 i.e., how are the insurer, employer and the consumer jointly responding?

27

underlying di¤erences in costs lead to distinct bene…t structures for prescription drugs and medical services, which allows for the identi…cation of demand. The di¤erences in the costs for these two medical care categories is apparent from the structure of these markets. Medical doctors and hospitals operate locally and negotiate prices with insurers in the area. In contrast, the same prescription drugs are sold across the United States, so the same basic cost factors and competitive environment are present across the country. Moreover, prescription drug manufacturers primarily negotiate prices with just three of the major Pharmacy Bene…t Managers who ultimately design the bene…ts of many drug insurance policies o¤ered across the country (see Berndt, McGuire and Newhouse (2011)). This industry pattern is re‡ected in statistics on price variation. Research has shown that prescription drug prices are more similar across geographic markets, relative to other medical care services (see Zhang, Baicker, and Newhouse (2010) and Dunn, Liebman, and Shapiro (2013)). The more limited variation in prices for prescription drugs also leads to a di¤erent relationship between the market price and the out-of-pocket price for these categories. Speci…cally, the generosity of bene…ts for prescription drugs is less a¤ected by across-market variation in overall medical-care prices. Another reason for studying these two markets separately is that the purchase of prescription drugs appears to be a distinct decision point for the patient. An important sign of the patient’s in‡uence over drug purchases may be inferred from the poor rate of adherence that is well known in the medical literature. As many as 50 percent of patients do not comply with their prescription-medication regimen (Osterberg and Blaschke (2005)) and the literature has documented a strong negative relationship between cost sharing and adherence (Goldman et al. (2007)).

6.1

Empirical Framework and Descriptive Statistics

The methodology for constructing the overall measures of utilization (i.e., SUi , EpisodesW i , and OOP Pf ) are applied to the two medical care categories. The key distinction is that each measure is constructed using only claims from their respective categories. Let m denote other medical care services and p denote prescription drugs, then SUim , EpisodesW;m , and OOP Pfm are measures constructed using other medicare i care services, while SUip , EpisodesW;p , and OOP Pfp are measures constructed using only prescription i drugs.68 The residual inclusion method, speci…ed in equations (8a) and (9), is applied to each of the two categories. Similar to previous analysis, the main results will apply a GLM model with a log link and a gamma distribution. The speci…cation is: (m;p)

SUi

= exp(

(m;p)

(m;p)

ln(OOP Pf

)+

(m;p) 1;(m;p) Zi

+

b(m;p) ) (m;p) i

(m;p)

+ ei

:

(10)

where there is separate parameter estimate for each service category. In the speci…cations that include prescription drugs and medical care services, only a single elasticity parameter is calculated (i.e., the pooled estimates impose the constraint

m

=

p ),

so that the instruments are su¢ ciently strong to identify a

price elasticity with the inclusion of MSA …xed e¤ects. (This assumption is relaxed at the end of this section.) Aside from the out-of-pocket price coe¢ cient, the model allows for all of the covariates in the equation, 6 8 The

(m;p) , 1;(m;p) Zi

to impact prescription drugs and medical care services in a ‡exible manner (i.e., W;(p;m)

speci…c formula for the weighted episode is Episodesi

=

P

d2i

(p;m)

SU d

: Note that the meaning of the

episode variables EpisodesW;p and EpisodesW;m change, since EpisodesW;m is zero if no medical care services are used for i i i treatment, even if prescription drugs are purchased, while EpisodesW;p is zero if no prescription drug treatments are used, i even if medical care services are provided.

28

each variable is included along with that variable interacted with a dummy variable for the prescription drug services category). A dummy variable indicating the prescription drug category is also included. Before proceeding to the estimates, Table 7 presents some basic descriptive statistics for the two categories of prescription drugs and other medical care services. The …rst line reports the share of individuals that have zero utilization in each category. The estimates show that it is common for individuals to not purchase any prescription drugs in a year, relative to other medical care services. This is consistent with the requirement that individuals obtain a doctor’s prescription prior to purchasing a drug. The level of utilization is larger for other medical care services relative to prescription drugs, and the standard deviation in utilization for both medical care categories is quite high. The coe¢ cient of variation for utilization is around 3 for both categories, while the variation in episode counts, as measured by the coe¢ cient of variation, is below 1.5. The out-of-pocket prices for both categories are similar, but with slightly more generous coverage for other medical services. The last column of the table shows a service price index for prescription drugs, SP I r;p . The prescription drug index is constructed similar to the overall service price index, but only prices and expenditures from prescription drugs are used in the calculation. This service price variable is used as an additional instrument in the within-market analysis. As additional instruments, service price indexes for prescription drugs are also constructed for other plan types in the same MSA and also for other MSAs in the state. For the MSA …xed e¤ects to meaningfully account for unobserved market demand, there must be a strong common component to demand across categories. Intuitively, the correlation should be strong, since less healthy individuals and those that seek more treatment will demand more of both service categories. This intuition is supported by the data. The correlation between log(SUip +1) and log(SUim +1) is 0.60 and signi…cant beyond the 0.0001 level. A similarly signi…cant correlation measure of around 0.60 is observed for the weighted and unweighted episode counts.69 Table 7. Descriptive Statistics by Category Prescription Drugs

Mean

Other Medical Services

Median

s.d.

Mean

287.16

2591.89

3272.05

Median

s.d.

876.75

10077.11

Overall Service Utilization (SUi) SUi=0

0.3765

SUi if SUi>0

981.37

0.1741

Number of Episodes Simple Count (Episodes i) if SUi>0

2.57

2.00

1.87

3.79

3.00

2.685191

Weighted Count (Episodes wi) if SUi>0

978.07

572.57

1370.05

3293.90

1574.75

4881.993

Out-of-pocket Price and Service Price Variables OOPPf

0.315

0.250

0.311

0.247

0.175

0.325065

MSA Service Price Drugs (SPIr)

1.008

1.022

0.073

-

-

-

Notes: The data sources for the individual-level variables are from MarketScan. The county level variables are from the ARF and BRFSS data sources and are linked to the individual observations through the observed county of the individual in the MarketScan data. The total number of individuals and episode observations are reported at the bottom of the table. The total observations do not match the totals reported in the estimates, since not all the variables are observed for all individuals.

The out-of-pocket price variables, OOP Pfm and OOP Pfp , are imputed for individuals in families with 6 9 i.e.,

log(EpisodesW;p + 1) and log(EpisodesW;m + 1) and also log(Episodespi + 1) and log(Episodesm i + 1): i i

29

zero expenditures. To impute out-of-pocket price variables for those with zero expenditures for a medical care category in a year, the imputation starts by using the values based on the full two years of expenditures for the family. Next, if the full two years of expenditures are zero for that family, information from similar individuals in the same MSA is used, but rather than using overall expenditures for imputing amounts, only the category’s expenditure information is applied.70

6.2

Instruments

Similar to the across-market analysis, the analysis in this section will also use an aggregate index of the underlying prices of all medical care goods and services in an MSA as an instrument, which includes prescription drugs. However, in addition to using the overall market price, SP I r , the analysis also uses the MSA price index for prescription drugs, SP I r;p , discussed previously. The …rst-stage estimates of the out-of-pocket prices on the instruments are shown in Table 8. Column (1) shows the relationship between the out-of-pocket price for prescription drugs, OOP Pfp , with the the overall MSA service price index (which includes both medical services and prescription drugs) and the index for prescription drug services. Interestingly, OOP Pfp is a¤ected by the overall MSA service price, but not di¤erentially impacted by prescription drugs. Column (1) should be compared to column (3) that applies the same instrument set, but the dependent variable is the out-of-pocket price for medical care services, OOP Pfm . In this case, the magnitude of the relationship between the MSA service price index and OOP Pfm is even stronger, with a coe¢ cient that is double in size, relative to prescription drugs. Also, the out-of-pocket price for medical services is less a¤ected by di¤erences in prescription drug prices in the area, as re‡ected in the signi…cant negative relationship between SP I r;p and OOP Pfm . The signi…cant and negative coe¢ cient of -0.787 may be viewed as removing the component of prescription drugs from the overall MSA price index. As expected, the prescription drug bene…ts are less sensitive to the local market prices, but are more in‡uenced by prescription drug prices in the area. This likely re‡ects the di¤erent national and local factors that impact the bene…ts for prescription drugs and medical care services. Columns (2) and (4) show the relationship between the out-of-pocket price variables and the other instruments. Speci…cally, following the strategies in the across-market analysis, prices from other plans in the market and other MSAs in the state are used to construct alternative service price indexes that are arguably more exogenous than the MSA service price index. (With the inclusion of the MSA …xed e¤ects, it is less clear that these alternative instruments are required, but it o¤ers an important robustness check.) Using these alternative instruments the …rst-stage estimates show similar patterns. Speci…cally, there is a strong and signi…cant relationship with the overall service price indexes and the out-of-pocket payment, but the relationship appears to be stronger for medical care services, relative to prescription drugs. Based on cross-sectional variation, these instruments are all strong.71 7 0 To

(m;p)

remove the in‡uence of outliers, after conducting the imputations, those values of OOP Pf

are removed by

dropping the observations below the 0.25 percentile and above the 99.75 percentile for each category. Results are robust to the inclusion of these outliers. 7 1 The joint F test exceeds 10 in all cases.

30

Table 8. First-Stage Estimation of Log(OOPP pf ) and Log(OOPP m f ) on Service Price Instruments Drug Only (Log(OOPP pf )) (1) Log(MSA Service Price)

(2)

0.854*** (4.23)

Medical Services Only(Log(OOPP m f )) (3)

(4)

2.206*** (7.48)

Log(MSA Service Price, Other Plans)

0.497*** (3.38)

0.953*** (3.22)

Log(Service Price of Other MSAs in State)

0.581** (2.23)

2.065*** (4.48)

Log(MSA Service Price Drugs)

-0.000795 (-0.00)

-0.786*** (-3.04)

Log(MSA Service Price Drugs, Other Plans)

0.145 (1.05)

0.0252 (0.08)

Log(Service Price of Drugs for Other MSAs in State)

-0.608*** (-3.71)

-1.073*** (-2.94)

Notes: The z-statistics are in parentheses and are clustered by MSA. The table only displays the coefficients on the insturments, with the other first-stage estimated coeffients not shown. One, two, and three asterisks indicate significance at the 10-percent, 5-percent, or 1-percent significance level, respectively.

Importantly, these instruments impact the out-of-pocket price in these two markets in di¤erent ways. This implies that the instruments are able to identify the relative out-of-pocket price di¤erences for prescription drugs and medical care services, while including a common MSA …xed e¤ect. The limitation of including MSA …xed e¤ects is that it soaks up much of the variation in the data, includi ng some of the explanatory power of the instruments. The instruments on service price are su¢ ciently strong to identify a single elasticity parameter along with all of the MSA …xed e¤ects, but the instruments are a bit weaker.72

6.3 6.3.1

Results Across-Market Demand

The analysis of these two medical care categories starts by focusing on demand estimates identi…ed from across-market di¤erences. That is, separately repeating the previous demand analysis but for prescription drugs and medical care services. The estimates are reported in Table 9. The …rst row of results show the demand elasticities estimated for prescription drug services. Each column explores an alternative speci…cation where the instruments or the dependent variable are distinct, as shown along the bottom of the table. The …rst column examines the overall utilization measure for prescription drugs, SUip , when no instruments are applied. One can 7 2 The

…rst stage F statistic exceeds 10 using the MSA-speci…c instruments (i.e., Table 8, Models (1) and (3)), but the F

statistic is only 8 when the alternative instrument set is applied (i.e., Table 8 Models (2) and (4)). To further investigate the strength of the instruments when …xed e¤ects are included, a linear version of the model is estimated (i.e., log(SUi + c) as a dependent variable). Using the MSA-speci…c instruments and including the MSA …xed e¤ects, the Kleibergen-Paap F statistic exceeds the Stock-Yogo critical value at the 10 percent level for maximal IV relative bias. When the alternative instrument set is applied the F statistic still exceeds the 20 percent critical value, but not the 10 percent. Similar results are found when individual-speci…c …xed e¤ects are applied.

31

see that the elasticity is negative and highly signi…cant, likely caused by a strong downward bias. Model 2 is identical to Model 1, but the MSA service price instruments are applied. One can see that the statistical signi…cance drops and the elasticity becomes much more inelastic and closer to the previously reported estimates. Next, rather than applying the overall utilization measure, a measure of the demand on the extensive margin is examined, EpisodesW;p . In this case, the elasticity is higher than the overall i elasticity and is statistically signi…cant. One possible reason for the higher elasticity is that consumers have some choice regarding whether or not to purchase a prescription drug, but they have less control over which drug is prescribed (e.g., a doctor may prescribe an expensive branded drug, even if a cheaper alternative is available). In addition, for many categories of drugs there may be a substantial variety of di¤erent prescription drugs, creating a large amount of noise in SUip at the individual level, making Model 1 elasticity di¢ cult to identify. As an alternative measure of demand, the Model 4 reports the price elasticity on a simple count of the number of episodes treated, (i.e., an unweighted episode count Episodespi ). An attractive property of the unweighted episode count is that it is similarly measured for prescription drugs and medical care services. The next three estimates, Models 5 through 7 repeat the speci…cations in the estimates 2 through 4, but use alternative instruments based on the prices from other MSAs in the state and other plan types in the market. The results are qualitatively similar, but both the statistical signi…cance of the estimates and the magnitude of the elasticities fall.73 The second row of Table 9 reports estimates that parallel the prescription drug estimates in the …rst row, but apply the analysis to medical care services. In general, the estimates are more precisely measured for medical care services, but the elasticities are in a similar range as the prescription drug estimates. The third row of Table 9 pools prescription drug and medical care services. Recall that for this speci…cation, all of the covariates are speci…c to the demand category, so that each covariate is placed in the regression along with the interaction of that covariate and an indicator of whether the service category is for prescription drug services. This includes all the covariates shown in Table A1.1 in the appendix. For example, each age variable is included in the model along with an interaction of the age variable and a dummy for prescription drugs. This allows for the use of prescription drug services and medical care services to change di¤erentially across individuals. The only coe¢ cient that does not di¤er is the response to the out-of-pocket price, which is constrained for this speci…cation.74 This is a plausible assumption given the elasticity estimates in rows 1 and 2, show a similar range of elasticities for prescription drugs and medical care services. This estimate exploits both within-market di¤erences in out-of-pocket prices (i.e., di¤erence in medical care services and prescription drug service prices) and across market di¤erences in prices (i.e., across di¤erent MSAs). The estimates show elasticity estimates with high statistical signi…cance across all of the estimates. The magnitude of the price elasticities range from -0.25 to -0.15, which is similar to the overall price elasticities reported in Table 3. Additional analysis is conducted in the appendix of the paper to formally test whether the elasticity parameter for prescription drugs is signi…cantly di¤erent from other medical care services (see the section entitled Additional Elasticities Analysis - Prescription Drug and Other Medical Care Services). Across all speci…cations, the hypothesis that the elasticities are the same cannot be rejected. The appendix of the paper also investigates whether there is a cross-price elasticity for prescription drugs and other medical 7 3 The

statistical signi…cance on the prescription drug results appears to be sensitive to functional form. When linear IV

models of these estimates are applied, statistical signi…cance of the estimates increases. 7 4 The analysis also assumes common regional dummy variables, but the results are not sensitive to this assumption.

32

Table 9. Service Specific Demand For Prescription Drugs and Medical Services

(1) Prescription Drugs Only Log(OOPP pf ) -0.865*** (-48.74)

(2)

(3)

(4)

(5)

(6)

(7)

-0.290 (-1.38)

-0.520*** (-2.58)

-0.352** (-1.73)

-0.118 (-0.65)

-0.358*** (-2.68)

-0.213 (-1.30)

8979247

8979247

8979247

8979247

8079349

8079349

8079349

-0.548*** (-36.71)

-0.220*** (-3.32)

-0.197*** (-3.88)

-0.149*** (-3.66)

-0.176*** (-4.29)

-0.158*** (-3.01)

-0.115** (-2.53)

8979138

8979138

8979138

8979138

8079541

8079541

8079541

Prescription Drug and Medical Services - Combined Log(OOPP m,pf ) -0.645*** -0.253*** -0.253*** (-51.20) (-4.33) (-4.98)

-0.189*** (-4.17)

-0.200*** (-4.16)

-0.218*** (-3.90)

-0.154*** (-2.92)

N

17958385

17958385

17958385

17958385

16158890

16158890

16158890

Dependent Variable

SUm,pi

SUm,pi

Episodes W,(m,p)i

Episodes (m,p)i

SUm,pi

Episodes W,(m,p)i

Episodes (m,p)i

MSA Drug and Medical Service Prices

MSA Drug and Medical Service Prices

N Medical Services Only Log(OOPP m f )

N

Instrument Set

None

MSA Drug and Medical Service Prices

Other Drug and Medical Service Prices

Other Drug and Medical Service Prices

Other Drug and Medical Service Prices

Notes: The z-statistics are in parentheses and are clustered by MSA. The z-statistics are computed using a bootstrap estimation that accounts for the two-stage estimation strategy. One, two, and three asterisks indicate significance at the 10-percent, 5-percent, or 1-percent significance level, respectively.

33

care services. To estimate a cross-price elasticity, another model is speci…ed that pools medical care and prescription drug services and excludes MSA …xed e¤ects. The model includes an additional parameter to be estimated, exp(

, where

(m;p) ln(OOP Pf )+

(m;p)

is the coe¢ cient on the variable, OOP Pfother in the equation SUi

(m;p) ln(OOP Pfother )+ 1;(m;p) Zi +

b(m;p) )+e(m;p) : (m;p) i i

The

OOP Pfother

=

variable

for prescription drugs (medical care services) is the out-of-pocket price for medical care (prescription drugs). Across all speci…cations, the results show

to be statistically insigni…cant, suggesting no overall cross-price

elasticity. See the appendix for additional discussion. Table 9 shows that demand may be identi…ed from cross-sectional di¤erences in price for both medical care categories. However, the identi…cation still relies on across-market di¤erences in service price. The following section reports estimates relying entirely on within-market variation. That is, after MSA …xed e¤ects are included, the elasticity is not identi…ed o¤ of across-market di¤erences in demand, but instead on within-market di¤erences in demand for prescription drugs and medical care services. 6.3.2

Within-Market Demand

Table 10 reports the estimates from the within-market analysis. The …rst row of Table 10 repeats the analysis of the third row of Table 9, but includes MSA …xed e¤ects. Since Model 1 estimates do not instrument for the out-of-pocket price, the estimates are downward biased, as expected. The next column (Model 2) applies the MSA instruments and the absolute magnitude of the elasticity falls substantially to a point estimate of -0.27, a value similar to the corresponding cross-sectional estimate in Table 9 and similar in magnitude to the overall elasticity reported in Table 3. Model 3 shows an elasticity using the weighted episode as the dependant variable. which is also negative and statistically signi…cant. The elasticities from the simple episode counts are reported in Models 4 and 7. These estimates are interesting since the dependent variables of these two categories are measured similarly and are less likely to be skewed. Similar statistically signi…cant elasticities are obtained across the two models. The only estimate that is not statistically signi…cant is Model 5. Compared to the estimates in the third row of Table 9, the results are similar in magnitude, but have a lower statistical signi…cance. Overall, the estimates fall in the range of -0.27 to -0.11, which is comparable to other demand elasticity estimates in this paper and in the literature. To account for even more unobserved di¤erences in the health of the population, the next row of Table 10 estimates a model that includes individual-level …xed e¤ects, rather than MSA …xed e¤ects. These …xed e¤ects account for all common factors that impact both prescription drug and medical care utilization at the individual level. Given the large number of …xed e¤ects, the model is estimated using linear regression techniques, rather than GLM. Speci…cally, a linear IV model is estimated where the dependant variable is speci…ed as log(SUi + c) where c is a constant determined through an initial grid search.75 The estimates using this alternative model shows more signi…cant elasticities ranging from -0.42 to -0.11. The identi…cation of elasticities in this alternative model provides additional con…rmation that unobserved common factors a¤ecting the demand for these service categories are not driving the main elasticity estimates. Although these last estimates o¤er an important robustness check, they represent a distinct elasticity that is not necessarily comparable to the others presented in this paper. The person7 5 The

constant value c was set to be $50 after conducting a crude grid search for values that minimize the root mean

squared error of observed minus predicted expenditures. This grid search was conducted in a reduced form speci…cation of the model.

34

level …xed e¤ects eliminate common movements in demand for prescription drugs and medical care service, which may be important to capture for understanding a more complete response to demand. In addition, the linear functional form tends to …nd slightly higher elasticity estimates relative to the corresponding GLM speci…cation. Table 10. Demand Estimation with MSA and Individual-Specific Fixed Effects

(1)

(2)

(3)

Prescription Drugs & Medical Care Services - MSA Fixed Effect Log(OOPPp,m f ) -0.663*** -0.271** -0.117* (-56.21) (-2.02) (-1.82) N

17958385

17958385

SUm,pi

SUm,pi

Dependent Variable

17958385

(4)

(5)

(6)

(7)

-0.124*** (-2.67)

-0.217 (-1.64)

-0.162*** (-2.37)

-0.113** (-1.99)

17958385

16158890

16158890

16158890

Episodes W,(m,p)i Episodes (m,p)i

SUm,pi

Prescription Drugs & Medical Care Services - Individual-Specific Fixed Effect - Linear Model Log(OOPPp,m f ) -0.320*** -0.419*** -0.248*** -0.113*** -0.423*** (-39.63) (-6.43) (-4.07) (-4.02) (-4.82) N

Dependent Variable

17958183

17926795

log(SUm,pi+c) log(SUm,pi+c)

Instrument Set

None

MSA Drug and Medical Service Prices

17927056

17927056

log(Episodes W,(m,p)i +c) log(Episodes (m,p)i+1)

MSA Drug and Medical Service Prices

16130182

log(SUm,pi+c)

MSA Drug and Other Drug and Medical Service Medical Service Prices Prices

Episodes W,(m,p)i Episodes (m,p)i

-0.256*** (-3.03)

-0.123*** (-3.03)

16130427

16130427

log(Episodes W,(m,p)i +c) log(Episodes (m,p)i+1)

Other Drug and Medical Service Prices

Other Drug and Medical Service Prices

Notes: The z-statistics are in parentheses and are clustered by MSA. For the residual inclusion estimates in the first row, the zstatistics are computed using a bootstrap estimation that accounts for the two-stage estimation strategy. One, two, and three asterisks indicate significance at the 10-percent, 5-percent, or 1-percent significance level, respectively.

The estimation of an elasticity that includes MSA …xed e¤ects o¤ers important evidence of identi…cation. It shows that a vastly di¤erent identi…cation strategy leads to similar elasticity estimates. Moreover, these estimates bolster the across-market …ndings. If the elasticities obtained from the across-market variation are primarily due to unobserved demand factors, then one might expect wildly di¤erent results from the within-market analysis. A simple explanation that reconciles the cross-market and within-market …ndings involves two assumptions: (1) individuals respond similarly to within-market and across-market changes in relative bene…ts; and (2) both across-market and within-market strategies are accurately identifying the price elasticity of demand.

7

Conclusion

This paper focuses on a fundamental empirical problem in the health literature: measuring consumer responsiveness to out-of-pocket price. To overcome the selection problems common in these studies, a unique approach is taken that exploits the large variation in negotiated prices of medical care services across areas. A service price index is used as an instruments that a¤ects the medical costs of insurers and ultimately in‡uences the out-of-pocket prices paid by consumers, but is not directly related to insurance selection. Applying this strategy, the demand estimates reveal that the consumer’s response to out-ofpocket price is negative, signi…cant and inelastic, with the main results mimicking those found in the 35

RAND health insurance experiment. That is, after more than 30 years, the key results of the RAND study are re‡ected in observed variations in out-of-pocket price and utilization outside of the experimental setting. Moreover, the movements in negotiated service prices are shown to be closely correlated with out-of-pocket prices, demonstrating a clear mechanism for how changes in negotiated prices ultimately a¤ect consumers and medical care utilization. The identi…cation of the price-elasticity rests on the assumption that the underlying service price instruments are determined by factors exogenous to an individual’s demand for insurance. To address concerns that unobserved demand at the market level may a¤ect the estimates, additional within-market analysis is conducted by examining the demand for prescription drugs and other medical care services. The within-market analysis accounts for an important unobserved component of demand by including MSA …xed e¤ects. The estimates of price-elasticity in the within-market analysis shows price-elasticities similar to other estimates reported in this paper and in the literature, ranging from -0.27 to -0.11. This within-market …nding greatly bolsters the main cross-sectional estimates reported in this paper.

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36

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[25] Kennan, John, (1989), “Simultaneous Equation Bias in Disaggregated Econometric Models”, The Review of Economic Studies, 56(1), pgs 337-367. [26] Keeler, Emmett and John Rolph, (1988), “The Demand for Episodes of Treatment in Health Insurance Experiment”, Journal of Health Economics, 7, pgs 151-156. [27] Kowalski, Amanda, (2010), “Censored Quantile Instrumental Variable Estimates of the Price Elasticity of Expenditure on Medical Care”, Working Paper. [28] Manning, Willard G., Joseph Newhouse, Naihua Duan, Emmett Keeler, and Arleen Leibowitz, (1987), “Health Insurance and the Demand for Medical Care: Evidence from a Randomized Experiment”, American Economic Review, 77(3) pgs 251-277. [29] Manning, Willard G. and John Mullahy, (2001), “Estimating Log Models: To Transform or Not to Transform?”, Journal of Health Economics, 20 pgs 461-494. [30] Manning, Willard, Anirban Basu, and John Mullahy, (2005), “Generalized Modeling Approaches to Risk Adjustment of Skewed Outcomes Data”, Journal of Health Economics, 24 pgs 465-488. [31] Mullahy, John, (1998), “Much ado about two: reconsidering retransformation and the two-part model in health econometrics”, Journal of Health Economics, 17 pgs 247-281. [32] Nevo, Aviv, (2001), “Measuring Market Power in the Ready-to-eat Cereal Industry”, Econometrica, 69(2) pgs 307-342. [33] Newhouse, Joseph, (1992), “Medical Care Costs: How Much Welfare Loss?”, Journal of Economic Perspectives, 6(3) pgs 3-21. [34] Newhouse, Joseph P., and the Insurance Experiment Group, (1993), Free for All? Cambridge: Harvard University Press. [35] Newhouse, Joseph and Charles Phelps, (1976), “New Estimates of Price and Income Elasticities of Medical Care Services”, The Role of Health Insurance in the Health Services Sector, Richard Rosett (ed.) (New York: Neal Watson). [36] Osterberg, L and T. Blaschke, (2005), “Adherence to Medication”, New England Journal of Medicine, 353, pgs 487-497. [37] Rosen, Allison and David Cutler, (2009), Challenges in Building Disease-Based National Health Accounts”, Medical Care, 47 Supplement pgs 7-13. [38] Rosen, Allison, Eli Liebman, Ana Aizcorbe and David Cutler, (2012), “Comparing Commercial Systems for Characterizing Episodes of Care”, BEA Working Paper. [39] Sorensen, Alan, (2003), “Insurer-Hospital Bargaining: Negotiated Discounts in Post-deregulation Connecticut”, Journal of Industrial Economics, 51(4) pgs 469-490. [40] Skinner, Jonathan, (2012), “Causes and Consequences of Regional Variations in Health Care”, Handbook of Health Economics, Chapter 2, pgs 45-93.

38

[41] Sundmacher, L, (2012), “The E¤ect of Health Shocks on Smoking and Obesity”, Europeon Journal of Health Economics, 13(4) pgs 451-465. [42] Town, Robert, and Gregory Vistnes, (2001), “Hospital Competition in HMO Networks”, Journal of Health Economics, 20 pgs 733-753. [43] Terza, Joseph, Anirban Basu, and Paul Rathouz, (2008), “Two-stage Residual Inclusion Estimation: Addressing Endogeneity in Health Econometric Modeling”, Journal of Health Economics, 27 pgs 531-543. [44] Zhang, Yuting, Katherine Baicker and Joseph Newhouse, (2010), “Geographic Variation in Medicare Drug Spending”, New England Journal of Medicine, 363(5) pgs 405-409

8

Appendix - For Online Publication

8.1

Functional Form and Modeling Assumptions

The utilization data are highly skewed for all three measures of utilization. Applying a box-cox model to test for the appropriate functional form suggests a log transformation of the data, which greatly reduces the skewness.76 Applying a least squares model may be biased in the face of heteroskedasticity, so a Park test is applied to check for the presence of heteroskedasticity. The test is applied to each of the utilization measures, which shows a clear and strong relationship between the square of the least squares residuals and several of the independent variables. This …nding suggests that heteroskedasticity is present and complex, favoring the application of GLM models. Next, tests are conducted to select the most appropriate GLM estimator. To assist in making this selection Manning and Mullahy (2001) suggest using a Park test to estimate the relationship between the mean of the predicted value and the variance of the error term. For all three components of utilization, the model suggests that the standard deviation is approximately proportional to the mean, implying a Gamma distribution, although the tests cannot reject the variance being proportional to the mean (i.e., Poisson distribution). The Park tests suggest that GLM with a Gamma distribution may be preferred, but additional tests are conducted to determine how well the GLM Gamma and Poisson models …t the data (this discussion follows ideas from Buntin and Zaslavsky (2004)). As a …rst step, the two models are estimated on a 20 percent random sample, with the …rst model assuming a Poisson distribution and the second assuming a Gamma distribution. Each model’s predicted value of utilization is computed for the remaining 80 percent of the data. Using these predicted values, the mean absolute prediction error and the mean square forecast errors are computed to determine the predictive accuracy of each model. The analysis shows that the …t of the GLM-Poisson model is considerably worse.77 Given the size of the data, this test was not repeated hundreds of times by resampling, as in Buntin and Zaslavsky (2004). However, additional random samples were selected and analyzed and results remained unchanged. Although the Gamma distribution is 7 6 For

all three utilization equations, the box cox test …nds the maximum-likelihood value of

for the dependent variable:

ISU ( ) = y 1 . The analysis shows an estimated value of near 0, indicating a log transformation. 7 7 These errors are computed using level predictions of utilization. If …t is measured using log utilization, the two models produce very similar …ts.

39

preferred in the analysis, it is worth noting that the elasticity estimated on the extensive margin remains unchanged using either distributional assumption. Another modeling decision was whether to apply a two-part model, which models two distinct decisions: (1) the decision to use any medical services; and (2) the amount of utilization to use conditional on utilizing some services. An investigation of the key estimates produced by the two-part model show that they are both quantitatively and qualitatively very similar to those produced by the GLM model using a Gamma distribution. Ultimately, the GLM model with the Gamma distribution is presented since the coe¢ cients of the model are easier to interpret and the results are essentially unchanged.

8.2

Empirical Relationship Between the Service Price Index and Utilization

Table A3 reports the e¤ect of the MSA service price index, log(SP I r ), on utilization. Model 1 looks at this relationship directly, without any instruments, and shows an elasticity of -0.47. According to the …rst-stage estimates, approximately double the service price estimate is passed onto the consumer, which appears to lead to a near doubling of the price elasticities in Table A3 relative to the elasticities reported in Table 3. Although a selection problem does not arise in this analysis, the relationship between the unobserved quality of providers in the area and the service price index is a potential problem. The estimates for Models 2 through 5 use the familiar set of instruments. The results change slightly across IV strategies, with the elasticity for the preferred IV strategy in Model 4 increasing to -0.58.78 7 8 One

may be concerned with potential measurement error, since the aggregate price may not necessarily be relevant to an

individual. As an alternative, an analysis using the estimated price paid by the family is calculated by dividing total disease P P expenditures by utilization, SPf = to this price measure.

c P i2fP d d;i . i2f d SUd;i

Qualitatively similar results are obtained when instruments are applied

40

Table A3. Effects of Log(SPIr) on Overall Utilization (SUi)

(1)

(2)

(3)

(4)

(5)

Log(SPIr)

-0.473*** -0.556*** -0.563*** -0.579*** -0.447*** (-8.42) (-4.31) (-4.61) (-5.46) (-4.94)

Log(Median Income)

0.165*** 0.158*** 0.159*** 0.158*** 0.168*** (4.29) (3.44) (3.06) (3.18) (3.74)

Log(Frac. Obese)

Log(Frac. Smokers)

Log(Frac. w/ College)

-0.00817 -0.0105 (-0.47) (-0.46) 0.0238 (1.58)

0.0220 (1.31)

0.0164 (0.63)

0.0131 (0.43)

Residual Inclusion

Number of Observations

Instruments

8979207

None

-0.00980 -0.0104 (-0.47) (-0.51) 0.0254 (1.49)

0.0251 (1.53)

-0.00347 -0.00435 (-0.15) (-0.19)

-0.00749

(-0.32) 0.0243

(1.40) 0.0174

(0.55)

0.245 (1.16)

0.139 (0.74)

0.308* (1.66)

-0.0891

8979207

8079984

8079984

8979207

MSA Service Price Other Plans

Service Price of Other MSAs in State

(-0.46)

Service Price of MSA Other Plans Service & Other Price, 25th MSA Price Percentile

Notes: The z-statistics are in parentheses and are clustered by MSA. The z-statistics are computed using a bootstrap estimation that accounts for the two-stage estimation strategy. One, two, and three asterisks indicate significance at the 10-percent, 5percent, or 1-percent significance level, respectively.

Since a large determinant of the amount an employer pays for medical care insurance will be determined by the medical service prices, one interpretation of Table A3 is that it proxies for the employer’s elasticity response with respect to the price of insurance. With this interpretation, these estimates would suggest that employers are much more elastic than individuals, suggesting that much less generous plans are selected as service prices rise. Interestingly, these estimates are quite close to those of Gruber and Lettau (2004) that estimate an elasticity of insurance spending of -0.7 for …rms. Next, the analysis turns to the relationship between the service price and the weighted number of episodes shown in Table A4. Similar to the estimates in Table A3, the estimates show a statistically strong and negative relationship between the service price index and the weighted number of episodes across each of the alternative models. Again, the magnitude of the responsiveness approximately doubles relative to the corresponding estimates in Table 4.

41

Table A4. Effects of Log(SPIr) on Weighted Number of Episodes (Episodes W i)

(1) Log(SPIr)

Log(Frac. Obese)

Log(Frac. Smokers)

Log(Frac. w/ College)

Instruments

(-5.04)

(-2.82)

0.111*** 0.106*** 0.101*** (4.39) (4.29) (2.64) 0.00686 (0.39)

(4)

(5)

(-3.73)

(-4.64)

0.107***

0.113***

(3.18)

(4.35)

0.00510 (0.27)

0.00957

0.0117

0.00753

(0.49)

(0.58)

(0.37)

-0.00738 -0.00872 (-0.58) (-0.57)

-0.0108

(-0.70)

-0.00928 -0.00688

(-0.64)

(-0.45)

-0.0458** -0.0481* -0.0614** -0.0591** -0.0447* (-2.10) (-1.95) (-2.59) (-2.55) (-1.74)

Residual Inclusion

Number of Observations

(3)

-0.494*** -0.554*** -0.624*** -0.559*** -0.469***

(-5.49) Log(Median Income)

(2)

8979207

None

0.177 (0.89)

0.252

0.261

-0.0837

(0.97)

(1.30)

(-0.53)

8979207

8079984

8079984

8979207

MSA Service Price Other Plans

Service Price of Other MSAs in State

Service Price of MSA Other Plans Service & Other Price, 25th MSA Price Percentile

Notes: The z-statistics are in parentheses and are clustered by MSA. The z-statistics are computed using a bootstrap estimation that accounts for the two-stage estimation strategy. One, two, and three asterisks indicate significance at the 10-percent, 5percent, or 1-percent significance level, respectively.

Table A5 reports the relationship between the disease-speci…c service price index and utilization per episode. Model 1 does not instrument for the service price and shows a negative and signi…cant relationship between the service price index and the amount of utilization per episode. Model 2 of Table 9 includes an additional IV strategy that is instrumented using prices on other diseases, excluding disease d.79 Models 3 through 6 contain the familiar set of instruments. Across all of the estimates, the price response along the intensive margin accounts for a relatively small fraction of the total price response. In all cases, the elasticity in Table 9 accounts for less than one …fth of the total price response reported in Table 7. 7 9 Two

price indexes are used as instruments: (1) an index built from other diseases in the same Major Practice Category

(MPC) class; and (2) an index of diseases outside the same MPC class. For hypertension, this would mean that one price index would be constructed using prices from all other cardiovascular diseases, excluding hypertension. A second index would be constructed using all MPC categories, excluding cardiology conditions.

42

Table A5. Effects of Log(SPIrd) on Utilization per Episode (SUd,i)

(1) Log(SPIrd)

Log(Median Income)

Log(Frac. Obese)

Instruments

(5)

(6)

-0.0857*** -0.103*** -0.102*** -0.0879**

(-1.94)

(-3.78)

0.00149

0.00290

-0.00727 -0.00191 -0.00874 0.00253

(0.09)

(0.16)

(-0.39)

(-2.63)

(-0.10)

(-3.67)

(-0.46)

(-2.22)

(0.14)

-0.0346*** -0.0341*** -0.0375*** -0.0407*** -0.0431*** -0.0342*** (-4.16)

(-4.20)

(-4.89)

(-4.71)

(-4.10)

0.0192*** 0.0191*** 0.0178*** 0.0212*** 0.0200*** 0.0190*** (3.02)

(2.80)

(3.24)

(2.97)

0.0311*** 0.0296*** 0.0266*** 0.0281*** 0.0244** (3.60) (3.38) (2.92) (3.09) (2.53)

Residual Inclusion

Number of Observations

(4)

(-4.37)

(3.10) Log(Frac. w/ College)

(3)

-0.0649*** -0.0833*

(-4.21) Log(Frac. Smokers)

(2)

(2.97) 0.0295*** (3.29)

0.0218

-0.00816 0.0396

0.00536

0.0276

(0.47)

(-0.33)

(0.18)

(0.66)

(1.06)

28533318 27812331 23813449 25835741 21561379 27812331

None

Diseasespecific MSA Service Prices (Other Diseases)

DiseaseSpecific MSA Service Prices Other Plans

Diseasespecific Service Prices of Other MSAs in State

Diseasespecific,Ser Diseasevice Price Specific of Other MSA Plans & Service Other MSA Price, 25th Prices Percentile

Notes: The z-statistics are in parentheses and are clustered by MSA-MPC disease category. Due to the larger number of observations, the z-statistics are not adjusted for the two-stage estimation. However, applying a boostrap estimate to Model 5 that accounts for the two-stage estimation produces z-stats very similar to those reported in Model 5. One, two, and three asterisks indicate significance at the 10-percent, 5-percent, or 1-percent significance level, respectively.

Tables A3, A4 and A5 present estimates of the relationship between the service price index and the utilization measures. The linearity of both the service price index and the instruments greatly improves identi…cation and allows for additional covariates to be incorporated into Tables A3, A4 and A5 without signi…cantly weakening the instruments. Tables A7, A8, and A9 in the appendix repeat the analysis of Tables A3, A4, and A5, but include state …xed e¤ects.80 The overall elasticity estimates reported in Table A7 are similar to those in Table 3, although a bit more inelastic and less statistically signi…cant. The results in Table A8 and A9 also change, with more of the price responsiveness shifting to the intensive margin and away from the extensive margin. The key take away from the estimates in Tables A7, A8, and A9 is that they demonstrate that price responsiveness may be identi…ed using only within-state variation in service prices. However, the results should be interpreted with some caution, since state …xed e¤ects are likely to remove important variation in the service price index across MSAs. It is also worth highlighting that identi…cation may be strengthened even further when examining utilization per episode. In particular, disease-speci…c service price indexes vary for each disease in each MSA, as documented by Dunn, Shapiro and Liebman (2013). Therefore, MSA …xed e¤ects may be included and still identify price e¤ects by using di¤erences in disease-speci…c prices across MSAs. Results using MSA …xed e¤ects are qualitatively similar to those reported in A9 of the appendix. This …nding is important, since it highlights that identi…cation may be achieved, even after removing all MSA-speci…c 8 0 The

IV strategy using other prices in the state cannot be applied in this case.

43

demand factors.

8.3

Additional Robustness Checks

Below is a numerical list of additional robustness checks: 1. The functional form may be a concern for some readers. As a check, the elasticities are estimated using a two-part model. The two-part model consists of (1) a Probit model indicating whether utilization is positive; and (2) for positive utilization, a GLM model with a log link and Gamma distribution.(Table A10, Model 1). 2. Estimate the elasticity using individual out-of-pocket price (OOP Pi ), rather than the family outof-pocket price (OOP Pf ) (Table A10, Model 2). In cases where OOP Pi is not observed, the value OOP Pf is used. 3. Estimate family out-of-pocket price using two years of claims data (Table A10, Model 3). Those individuals that have zero expenditures in both years are dropped from the analysis. 4. One concern with identifying price elasticities in a cross section is that a particular outlier MSA may greatly in‡uence the elasticity estimates. To check if this is a concern, the sample is split, approximately in half. First, the sample is split by the number of enrollees in the MSA and results are qualitatively similar in each subsample (Table A10, Models 4 and 5). Next, the sample is split by region and, again, results are qualitatively similar in each subsample (Table A10, Models 6 and 7). The one anomaly is the low elasticity on the extensive margin when looking at the South and West region in Model 7. Upon further investigation, it appears that the low elasticity is caused by the inclusion of regional …xed e¤ects that removes much of the variation necessary to identify an elasticity in this smaller subsample. When the regional …xed e¤ects are removed, the elasticity estimates fall in the expected range and are signi…cant in this subsample. 5. The inclusion of regional dummies controls for region-speci…c utilization di¤erences, but also removes across-region variation in service prices from the analysis. As another check, region …xed e¤ects are removed from the speci…cation and the main results are unchanged (Table A10, Model 8). 6. The MSA service price instrument, SP I r , is calculated the same for all individuals in the data. However, the age and sex of individuals may make the expected disease treatment individual-speci…c. For instance, individuals in their 20s are less likely to have expenditures on heart-related conditions. An individual-speci…c MSA service price index is calculated for each individual, where the diseasespeci…c service prices are weighted by the expenditure share of each disease for each individual’s age, sex and family size category. The results are qualitatively similar to the other estimates (Table A10, Model 9). 7. For approximately eight percent of the individuals where expenditure information is not observed, the out-of-pocket price is imputed using expenditures from other individuals in the market. The individual categories used for the imputation include age, sex, plan-type, size of family, and data contributor for each MSA. The estimates that remove these imputations are qualitatively unchanged (Table 10, Model 10). Also note, that the estimates using two years of claims data to compute

44

OOP Pf , (Table 10, Model 3), do not apply any imputation and results are also similar to the other estimates. 8. One may be concerned that the e¤ects are identi…ed in a cross-section, so the price variable used as an instrument may be spuriously correlated with how physicians practice medicine across geographic markets. For instance, the instrument could be related to provider practice norms, capacity constraints, or regulations. Note that these factors that impact utilization across geographic markets are also likely to a¤ect utilization in the Medicare market. Therefore, to address this concern, utilization and expenditure patterns from the Medicare market are included in the analysis. The county-speci…c variables used in this robustness check are from the 2008 Geographic Variation Public Use File that was constructed by CMS.81 The data includes a couple of simple measures, such as expenditures per capita and the average age of the Medicare population. However, it also includes a standardized utilization measure that accounts for the geographic price di¤erences in the Medicare markets, where the measure of utilization may be viewed as similar to that used in this paper, essentially removing geographic di¤erences in payments for identical services. Finally, the analysis also includes a standardized utilization measure that accounts for di¤erences in the health risk across Medicare markets. In all cases, the inclusion of the additional Medicare control variables has little e¤ect on the price elasticity estimates. The di¤erent Medicare per capita expenditure and utilization measures are not signi…cantly related to overall utilization or utilization along the extensive margin (see Table A10, Model 11). The Medicare utilization measures do have signi…cant e¤ects on the intensive margin (Table A11, Model 7). However, the interpretation of the variables in the intensive margin estimate is unclear, since some utilization measures are positive and signi…cant, while others are negative and signi…cant. A simple model that includes only the standardized Medicare utilization measure shows a positive and signi…cant relationship between Medicare utilization and SUd;i . Note that the Medicare variables are not included in the main analysis, since these variables are potentially endogenous. In particular, the utilization in Medicare markets may also be impacted by across-market di¤erences in costs, since payments in the Medicare market are set to re‡ect across-market di¤erences in costs. 9. Around 13.8 percent of expenditures in the claims data are ungrouped and excluded from much of the analysis. As a check on whether dropping these expenditures has an e¤ect, an alternative methodology for calculating utilization is applied that includes ungrouped expenditures. Speci…cally, overall utilization is calculated by dividing total expenditures by the individual-speci…c price index, 0 X 1 SPi , (i.e., Adj:SUi =

@

d2i

cd A+ungroup ed exp enditures SPi

) to obtain a measure of utilization that includes

the ungrouped claims. Using this alternative measure of utilization, similar elasticity estimates are obtained (Table A11, Model 1). 10. Apply a simple episode count (Episodesi ) rather than the weighted episode count (Episodesw i ) (Table A11, Model 2). 11. Tables 7 and 8 look at the direct relationship between price indexes and utilization. One possible concern with looking at an overall price index is that it may capture the availability or adoption of 8 1 Medicare

utilization information was not available for 2007 or 2006, but it is unlikely that practice patterns changed

substantially in a single year. In addition, similar results are found when 2007 and 2006 Medicare per capita expenditures are included.

45

di¤erent technologies in di¤erent areas. Given the variety of instruments applied this seems unlikely, but an additional robustness check is conducted using a “low-tech”service. Speci…cally, the average negotiated price for a 15-minute o¢ ce visit to a general MD is used as an instrument for the MSA service price index. The results of Tables 7 and 8 remain qualitatively unchanged (Table A11, Models 3 and 4). 12. To check for the importance of controlling for illness severity, controls are included to account for comorbidities and severity when analyzing utilization along the intensive margin, SUd;i . The controls include dummy variables for the number of comorbidities (Table A11, Model 5). 13. MSA …xed e¤ects are included in the analysis studying the e¤ects of SP Id;i on SUd;i (Table A11, Model 6). 14. One might be concerned that a selection issue arises because individuals or …rms may choose to be uninsured in markets with higher service prices. To check for this possibility, the county unemployment rate and the fraction of uninsured individuals were included in the analysis. There was no e¤ect on the main results and each of these coe¢ cients were insigni…cant. The e¤ects were so small they are not included in the robustness tables. 15. The analysis in this paper excludes HMOs, since HMO plans often have capitated services and expenditure information is not observed for capitated services. HMO enrollees represent only about 20 to 25 percent of the enrollees in the market in 2006 and 2007.82 However, one may be concerned that omitting HMO enrollees could introduce a systematic bias in the estimates caused by a relationship between service price levels, utilization, and the presence of HMOs in the area. As a check on this potential bias, enrollment information from the MarketScan data is used to measure the share of HMO enrollment in each county and the share of HMO enrollment is used as an additional independent variable in the analysis. In the …rst-stage estimation, there is no relationship between HMO enrollment and the out-of-pocket price. In the second-stage, the inclusion of the HMO share does not change the elasticity estimates, as is shown in Table A11, Model 12. 16. Given the heteroskedacitisty and the prevalence of zeros in the data, both GLM models and two-part models are preferred to linear demand models. However, as a robustness check on the functional form, the zero observations are dropped and a log-linear model is applied. One advantage of this approach is that a linear IV model may be applied, rather than applying a control function approach. Of course, the disadvantage is that 0 observations are dropped. Using this alternative strategy only changes the estimated coe¢ cients slightly (Table A11, Model 12). Similar estimates are found when the dependent variable is transformed to log(SUi + c) or log(EpisodesW i + c) where c is set at 75, so that zeros may be included in the model. Although c is often arbitrarily set to 1, the value c is actually a parameter that should be estimated. The value of 75 was selected because it produced the lowest mean squared error of observed minus predicted expenditures based on a grid search using increments of 25 (i.e., 1, 25, 50, 75, 100, etc). Given that the speci…cation is linear, a KleibergenPaap rk F statistic is computed to test for weak instruments. The value of the test statistic is 48, which is an amount that far exceeds the Stock-Yogo 10 percent critical value of 20. 8 2 The

approximate 20 percent enrollment in HMOs is observed in Kaiser Family Foundation Employer Health Bene…ts

Survey, 2007. The amount is 25 percent in the MarketScan data.

46

8.4

Reported Full Estimates Table A1.1 Effects of Out-of-pocket-price on Utilization - Full Estimates

Overall Utilization (SUi)

Weighted Num. of W Episodes (Episodes i)

(1)

(2)

(3)

(4)

Log(OOPCf)

-0.223***

-0.199***

-0.228***

-0.197***

(-3.47)

(-3.75)

(-3.91)

(-3.19)

Log(Median Income)

0.189*** (3.57)

0.198*** (4.97)

0.118*** (3.70)

Log(Frac. Obese)

-0.0346 (-1.50)

-0.0231 (-0.95)

Log(Frac. Smokers)

0.0214 (1.35)

Log(Frac. w/ College)

(Continued)

(1)

(2)

(3)

(4)

Frac. of Hosp. Med. Schools

-0.0228

-0.0125

-0.0107

-0.00124

(-1.26)

(-0.64)

(-0.60)

(-0.07)

0.127*** (3.31)

Data Source: Insurer Data

0.0114 (0.58)

0.0124 (0.63)

0.0399*** (2.59)

0.0369** (2.51)

-0.0151 (-0.65)

-0.00153 (-0.07)

PPO

-0.140*** (-3.85)

-0.154*** (-5.26)

-0.125*** (-3.79)

-0.136*** (-5.19)

0.0260 (1.53)

-0.00345 (-0.26)

-0.00247 (-0.20)

POS

-0.244*** (-7.44)

-0.260*** (-8.87)

-0.206*** (-7.72)

-0.213*** (-9.18)

0.0368 (1.27)

0.0287 (1.13)

-0.0306 (-1.32)

-0.0364 (-1.51)

Comprehensive

Residual Inclusion

-0.408*** (-7.01)

-0.426*** (-9.34)

-0.0693 (-1.24)

-0.0986* (-1.71)

Log(Rent)

-0.0964 (-1.22)

-0.0739 (-1.19)

0.0467 (0.75)

0.0645 (1.06)

Male

0.103*** (16.72)

0.102*** (16.72)

Age 17 to 24

0.326*** (35.36)

Age 25 to 34

-0.0991*** -0.116*** -0.0849*** -0.0961*** (-2.95) (-4.25) (-3.02) (-3.80)

High Deductible Health Plan -0.198*** (-5.06)

-0.226*** (-7.36)

-0.258*** (-7.46)

-0.283*** (-8.11)

Family Size=2

0.0704*** 0.0714*** 0.0465*** 0.0471*** (8.01) (8.56) (6.01) (6.01)

0.0635*** 0.0624*** (18.79) (14.96)

Family Size=3

0.0270*** 0.0297*** (3.61) (4.09)

0.320*** (30.19)

0.312*** (28.11)

0.303*** (29.42)

Family Size=4

-0.0680*** -0.0655*** -0.0553*** -0.0531*** (-9.02) (-7.75) (-7.54) (-5.82)

0.795*** (74.30)

0.794*** (65.08)

0.766*** (64.92)

0.762*** (69.91)

Family Size>=5

-0.164*** (-21.72)

-0.160*** (-20.03)

-0.154*** (-18.36)

Age 35 to 44

0.832*** (84.98)

0.830*** (84.61)

0.752*** (72.31)

0.750*** (94.94)

Year

0.0261*** (3.20)

0.0233** (2.44)

0.0217*** 0.0194*** (3.88) (3.27)

Age 45 to 54

1.023*** (81.84)

1.021*** (85.80)

0.964*** (79.67)

0.965*** (104.89)

New England

0.0585* (1.70)

0.0613 (1.62)

0.0302 (0.77)

0.0249 (0.57)

Age 55 to 64

1.272*** (85.37)

1.270*** (88.81)

1.252*** (88.17)

1.251*** (118.02)

Mid-Atlantic

0.0501** (2.01)

0.0494** (2.18)

0.0616* (1.66)

0.0575* (1.87)

Age 17 to 24 * Male

-0.546*** (-33.09)

-0.539*** (-30.98)

-0.602*** (-43.00)

-0.593*** (-53.91)

East North Central

0.0409 (1.38)

0.0466* (1.86)

0.0492 (1.27)

0.0521 (1.24)

Age 25 to 34 * Male

-0.942*** (-73.02)

-0.943*** (-73.67)

-0.897*** (-76.02)

-0.895*** (-77.83)

West North Central

0.0112 (0.33)

0.0429 (1.14)

0.0250 (0.67)

0.0377 (1.06)

Age 35 to 44 * Male

-0.587*** (-51.49)

-0.586*** (-56.89)

-0.511*** (-75.26)

-0.509*** (-76.77)

South Atlantic

Age 45 to 54 * Male

-0.356*** (-38.28)

-0.354*** (-35.79)

-0.311*** (-43.86)

-0.310*** (-43.06)

East South Central

0.117* (1.82)

0.117 (1.57)

0.145*** (3.30)

0.133*** (3.28)

Age 55 to 64 * Male

-0.174*** (-14.50)

-0.174*** (-16.89)

-0.150*** (-24.31)

-0.150*** (-22.97)

West South Central

0.0944*** (4.20)

0.0924** (3.34)

0.0680** (2.49)

0.0614** (2.41)

Number of Observations 8979207

8079984

8979207

8079984

47

0.0145** (1.99)

0.0157** (2.05)

-0.150*** (-18.20)

0.0783*** 0.0775*** 0.0955*** 0.0914*** (3.66) (3.64) (3.00) (3.92)

Table A1.2 Effects of Out-of-pocket-price on Utilization - Full Estimates Service Utilization Per Episode (SUi,d)

(1)

(2)

Log(OOPCf)

-0.0252 (-1.29)

-0.0503* (-1.80)

Log(Median Income)

0.00644 (0.34)

-0.00937 (-0.48)

Log(Frac. Obese)

(Continued)

(1)

(2)

-0.0175** -0.0190* (-2.04) (-1.79)

Frac. of Hosp. Med. Schools

Data Source: Insurer Data -0.0854*** -0.0772*** (-15.11) (-12.17)

-0.0374*** -0.0492*** (-4.15) (-5.02)

PPO

-0.0923*** -0.0895*** (-9.45) (-7.67)

Log(Frac. Smokers)

0.0184*** 0.0187** (2.67) (2.56)

POS

-0.111*** (-12.10)

Log(Frac. w/ College)

0.0304*** 0.0252** (3.06) (2.21)

Comprehensive

Residual Inclusion

Log(Rent)

-0.177*** (-9.25)

-0.125*** (-4.59)

-0.115*** (-11.27)

-0.0721*** -0.0746*** (-6.77) (-6.16)

High Deductible Health Plan -0.0457*** -0.0411** (-3.75) (-2.55)

-0.0637** -0.0386 (-2.18) (-1.20)

Family Size=2

-0.00309 (-1.41)

-0.00797*** (-2.73)

Male

0.0208*** 0.0193*** (6.72) (5.66)

Family Size=3

-0.0299*** -0.0335*** (-11.77) (-9.71)

Age 17 to 24

0.0611*** 0.0677*** (10.18) (9.52)

Family Size=4

-0.0571*** -0.0605*** (-21.36) (-17.27)

Age 25 to 34

0.0462*** 0.0541*** (4.95) (4.84)

Family Size>=5

-0.0636*** -0.0713*** (-19.67) (-15.89)

Age 35 to 44

0.140*** (10.13)

0.151*** (9.07)

Year

0.0159*** 0.0184*** (6.72) (6.07)

Age 45 to 54

0.172*** (9.31)

0.187*** (8.29)

New England

Age 55 to 64

0.175*** (7.73)

0.188*** (6.85)

Age 17 to 24 * Male

-0.00520 (-1.01)

-0.0116** (-2.09)

Age 25 to 34 * Male

-0.000374 0.0118* (-0.07) (1.84)

Age 35 to 44 * Male

0.0387** (1.97)

0.0475** (1.98)

Mid-Atlantic

0.0128 (0.74)

0.0220 (1.18)

East North Central

0.0270 (1.57)

0.0338 (1.61)

West North Central

0.0160 (0.93)

0.0364* (1.90)

-0.0294*** -0.0175*** (-7.27) (-3.81)

South Atlantic

0.00455 (0.36)

0.0133 (0.94)

Age 45 to 54 * Male

-0.0179*** -0.0122** (-4.41) (-2.50)

East South Central

0.0114 (0.69)

0.0304* (1.66)

Age 55 to 64 * Male

0.00142 (0.38)

West South Central

0.0454*** 0.0563*** (3.13) (3.45)

0.00458 (1.09)

Number of Observations

27812331 21561379

Instruments

Service Price of Other Plans & MSA Service Other MSA Price Price

Notes: The z-statistics are in parentheses and are clustered by MSA-MPC disease category. Due to the larger number of observations, the z-statistics are not adjusted for the two-stage estimation. However, applying a boostrap estimate to Model 5 that accounts for the two-stage estimation produces z-stats very similar to those reported in Model 5. One, two, and three asterisks indicate significance at the 10-percent, 5-percent, or 1-percent significance level, respectively.

8.5

Disease-Speci…c Out-of-pocket Price Response Table A2. Effect of Out-of-pocket Price on Utilization - Probit Model

High

Diabetes Hypertension Cholesterol Depression Migraine Appendicitis Log(OOPPf)

-0.0517**

-0.112**

-0.107*

(-2.20)

(-2.43)

(-1.76)

-0.132*** -0.0887** (-2.95)

(-2.43)

0.0211 (0.56)

Notes: The z-statistics are in parentheses and are clustered by MSA. One, two, and three asterisks indicate significance at the 10-percent, 5-percent, or 1-percent significance level, respectively.

48

8.6

Estimates with State Fixed E¤ects r

Table A7. Relationship Between Log(SPI ) and Overall Utilization (SUi) with State FE

(1) r

Log(SPI )

Log(Median Income)

Log(Frac. Obese)

Log(Frac. Smokers)

Log(Frac. w/ College)

(2)

(3)

-0.290*** (-2.67)

-0.304**

-0.355***

(-2.29)

(-3.20)

0.186*** (4.61)

0.185***

0.183***

(5.04)

(5.20)

-0.0174 (-1.05)

-0.0172

-0.0164

(-0.91)

(-0.92)

0.0337*** (2.65)

0.0336**

0.0331**

0.00399 (0.17)

0.00397

0.00385

(0.20)

(0.19)

Residual Inclusion

Number of Observations

Instruments

8979207

None

(2.02)

(2.04)

0.0201

0.210

(0.10)

(1.22)

8979207

8979207

MSA Service MSA Service Price Other Price, 25th Plans Percentile

Notes: The z-statistics are in parentheses and are clustered by MSA. The z-statistics are computed using a bootstrap estimation that accounts for the two-stage estimation strategy. One, two, and three asterisks indicate significance at the 10-percent, 5-percent, or 1percent significance level, respectively.

49

r

Table A8. Relationship Between Log(SPI ) and Weighted W Number of Episodes (Episodes i) with State FE

(1) r

Log(SPI )

-0.147* (-1.65)

(2)

(3)

-0.135 (-1.39)

-0.120 (-1.28)

Log(Median Income)

0.166*** (5.37)

0.167*** (5.86)

0.167*** (5.80)

Log(Frac. Obese)

-0.00426 (-0.29)

-0.00444 (-0.39)

-0.00464 (-0.43)

Log(Frac. Smokers)

0.0191** (2.11)

0.0192** (1.99)

0.0193** (2.11)

-0.0137 (-0.77)

-0.0137 (-1.20)

-0.0136 (-1.17)

-0.0177 (-0.14)

-0.0867 (-0.61)

8979207

8979207

Log(Frac. w/ College)

Residual Inclusion

Number of Observations

Instruments

8979207

None

MSA Service MSA Service Price Other Price, 25th Plans Percentile

Notes: The z-statistics are in parentheses and are clustered by MSA. The z-statistics are computed using a bootstrap estimation that accounts for the two-stage estimation strategy. One, two, and three asterisks indicate significance at the 10-percent, 5-percent, or 1percent significance level, respectively.

50

r

Table A9. Relationship between Log(SPI ) and Utilization per Episode (SUd,i) with State FE

(1) r

Log(SPI )

Log(Median Income)

Log(Frac. Obese)

(2)

(3)

(4)

(5)

(6)

-0.0802*** -0.162*** (-4.88) (-2.92)

-0.108*** (-4.06)

-0.182*** (-3.67)

-0.132*** (-4.21)

-0.242*** (-4.08)

-0.00468 (-0.28)

-0.0115 (-0.63)

-0.00631 (-0.36)

-0.0112 (-0.60)

-0.00749 (-0.44)

-0.00536 (-0.31)

-0.0304*** -0.0291*** -0.0324*** -0.0313*** -0.0339*** -0.0284*** (-4.31) (-4.09) (-4.25) (-4.29) (-4.30) (-4.02)

Log(Frac. Smokers)

0.00584 (1.17)

0.00600 (1.17)

0.00571 (1.08)

0.00624 (1.19)

0.00621 (1.11)

0.00579 (1.14)

Log(Frac. w/ College)

0.0149* (1.75)

0.0132 (1.52)

0.0136 (1.51)

0.0164* (1.84)

0.0150 (1.60)

0.0135 (1.56)

0.0880 (1.48)

-0.0125 (-0.56)

0.110** (2.44)

0.0176 (0.62)

0.176*** (2.94)

Residual Inclusion

Number of Observations

Instruments

28533318 27812331 23813449 25835741 21561379 27812331

None

DiseaseDiseaseDiseasespecific, specific MSA Diseasespecific Service DiseaseService Specific Service Price of Specific MSA Prices MSA Service Prices of Other Plans Service (Other Prices Other Other MSAs & Other Price, 25th Diseases) Plans in State MSA Prices Percentile

Notes: The z-statistics are in parentheses and are clustered by MSA-MPC disease category. The zstatistics are computed using a bootstrap estimation that accounts for the two-stage estimation strategy. One, two, and three asterisks indicate significance at the 10-percent, 5-percent, or 1-percent significance level, respectively.

51

Table A10. Estimated Robustness Checks on SUi and Episodewi

Price Elasticity Estimate on SUi

Price Elasticity Estimate on Episodewi

-0.141*** (-2.87)

-0.141*** (-2.87)

GLM (log link & gamm distribution)

-0.156** (-2.25)

-0.151*** (-3.09)

Combined Effect

-0.198*** (-2.79)

-0.192*** (-3.78)

2. Individual Out-of-pocket Price: Effect of Log(OOPP i)

-0.158** (-2.18)

-0.194*** (-3.29)

3. Family Out-of-pocket Price Two Years: Effect of Log(OOPP i)

-0.249***

-0.191***

1. Two-Part Model: Effect of Log(OOPP f ) Probit

(-3.73)

(-4.07)

4. MSAs Large Enrollment (over 40,000): Effect of Log(OOPP f )

-0.176** (-2.34)

-0.227*** (-3.49)

5. MSAs Small Enrollment (under 40,000): Effect of Log(OOPP f )

-0.241* (-1.85)

-0.181** (-2.38)

-0.213*** (-2.62)

-0.257*** (-4.05)

-0.223* (-1.75)

-0.0903 (-1.19)

8. Exclude Regional Fixed Effects: Effect of Log(OOPP f )

-0.251*** (-3.00)

-0.270*** (-5.63)

9. Individual-Specific Expected SPIr: Effect of Log(OOPPf )

-0.280*** (-3.67)

-0.275*** (-6.83)

10. No OOPPf imputation: Effect of Log(OOPPf )

-0.179** (-2.52)

-0.177*** (-3.30)

11. Include log(Medicare Exp. Per Capita): Effect of Log(OOPP f )

-0.186** (-2.87)

-0.188*** (-3.39)

Coefficient on Log(Medicare Exp. Per Capita)

-0.0937 (-0.44)

0.230 (1.55)

Coefficient on Log(Standardized Exp. Per Capita)

0.196 (0.59)

-0.305 (-1.38)

Coefficient on Log(Risk Adj., Stand. Exp. Per Capita)

0.0709 (0.26)

0.236 (1.47)

Coefficient on Log(Average Age Medicare Population)

-0.589 (-1.05)

-0.152 (-0.37)

12. Include the Share of HMO Enrollees in the County

-0.209*** (-3.50)

-0.204*** (-4.14)

13. Linear IV Regression on Log of Dependent Variable

-0.257*** (-6.13)

-0.273*** (-4.35)

6. Regions NE and MW: Effect of Log(OOPP f )

7. Regions S and W: Effect of Log(OOPP f )

52

Table A11. Additional Robustness Checks Price Elasticity Estimate

1. Include Ungrouped Expenditures: Effect of Log(OOPP f ) on Adjusted SUi

-0.280*** (-2.79)

2. Effect of Log(OOPPf ) on Simple Episode Count (Episodei)

-0.141*** (-3.00)

3. Average 15-minute Visit Price Instrument: Effect of Log(SPIr) on SUi

-0.554*** (-3.43)

4. Average 15-minute Visit Price Instrument: Effect of Log(SPIr) on Episodewi

-0.678*** (-3.73)

5. Include Additional Severity Controls: Effect of Log(OOPP f ) on SUd,i

6. Include MSA Fixed-Effects: Effect of Log(SPIdr) on SUd,i

7. Include log(Medicare Exp. Per Capita): Effect of Log(OOPP f ) on SUd,i

-0.0261 (-0.89) -0.122*** (-4.13) -0.0218 (-0.78)

Coefficient on Log(Medicare Exp. Per Capita)

-0.307*** (-4.07)

Coefficient on Log(Standardized Exp. Per Capita)

0.559*** (5.50)

Coefficient on Log(Risk Adj., Stand. Exp. Per Capita)

-0.186** (-2.61)

Coefficient on Log(Average Age Medicare Population)

-0.521** (-2.64)

Notes: The z-statistics are in parentheses and are clustered by MSA. One, two, and three asterisks indicate significance at the 10-percent, 5-percent, or 1-percent significance level, respectively. Unless specified otherwise, the IV strategy will include two instruments: (1) a price index constructed from prices of other plans in the MSA and (2) a price index constructed from prices in other MSAs in the state. These estimates are based on a 30 percent random sample of the data. The estimated z-statistics are not adjusted for the first stage estimates of the residual inclusion. Accounting for the first stage estimates when calculating standard errors had only very small effects on the z-statistic estimates.

8.7

Additional Elasticities Analysis - Prescription Drug and Other Medical Care Services

The pooled results presented in Tables 9 and 10 restrict the out-of-pocket price coe¢ cient to be the same across both categories. This is justi…ed by the observation that similar elasticities are observed for these two categories when they are run separately in Table 9. This section attempts to measure separate elasticity parameter for prescription drugs and other medical care services in a pooled analysis and also tries to identify a cross-market elasticity (i.e., the e¤ect of prescription drug prices on medical care). These elasticities provider further insight into the price-responsiveness of individuals, but they are empirically challenging to identify. When only one price coe¢ cient is included in the model the instruments are quite strong, as discussed previously. However, for additional price coe¢ cients to be identi…ed requires that the instruments are strong enough to identify two separate price elasticities. Not surprisingly, the inclusion of the MSA …xed e¤ects eliminates much of the variation in the data, making it impossible to identify additional elasticities. Therefore, this section will concentrate only on pooled regressions with regional …xed e¤ects. Table A12 presents the results. The …rst row repeats the pooled results of Table 9, but includes an interaction of a drug dummy variable with the out-of-pocket price variable as an additional covariate. In this case, there are two endogenous regressors. Model 1 does not correct for endogeneity and the elasticity estimates are quite high. Next, the residual inclusion method is applied to correct for the endogeneity. In

53

all of the estimates, the null hypothesis that the prescription drug and the non-prescription drug services have the same elasticity cannot be rejected. The Model 5 estimate that does show higher signi…cance is also more likely to have a weak instrument problem, relative to Model 2 that shows no signi…cant di¤erence.83 Overall, these estimates support the assumption of a common elasticity for both categories. Table A12. Demand Estimation with Drug-Specific Elasticity or Cross-Price Effect

(1)

(2)

(3)

Prescription Drugs & Medical Care Services - Drug Specific Elasticity Log(OOPP p,m f ) -0.550*** -0.254*** -0.240*** (-37.85) (-5.03) (-5.40)

(4)

(5)

(6)

(7)

-0.184*** (-4.57)

-0.218*** (-4.97)

-0.221*** (-4.39)

-0.166*** (-3.37)

Log(OOPP p,m f )*Drug

-0.311*** (-14.92)

0.118 (0.42)

-0.157 (-0.83)

-0.0558 (-0.33)

0.263 (1.64)

0.0317 (0.27)

0.102 (0.73)

N

17958385

17958385

17958385

17958385

16158890

16158890

16158890

Prescription Drugs & Medical Care Services - Cross-Price Effect Log(OOPP p,m f ) -0.636*** -0.307*** -0.219*** (-52.58) (-4.39) (-5.83)

-0.178*** (-6.04)

-0.285*** (-4.14)

-0.223*** (-4.98)

-0.173*** (-4.04)

Log(OOPP other(p,m)f )

-0.0584*** (-6.87)

0.0799 (1.17)

-0.0614 (-1.37)

-0.0182 (-0.36)

0.108 (1.57)

0.00191 (0.03)

0.0248 (0.41)

N

17957883

17957883

17957883

17957883

16158487

16158487

16158487

SUm,pi

SUm,pi

None

MSA Drug and Medical Service Prices

Dependent Variable

Instrument Set

Episodes W,(m,p)i Episodes (m,p)i MSA Drug and Medical Service Prices

SUm,pi

MSA Drug and Other Drug and Medical Service Medical Service Prices Prices

Episodes W,(m,p)i Episodes (m,p)i Other Drug and Medical Service Prices

Other Drug and Medical Service Prices

Notes: The z-statistics are in parentheses and are clustered by MSA. The z-statistics are computed using a bootstrap estimation that accounts for the two-stage estimation strategy. One, two, and three asterisks indicate significance at the 10-percent, 5-percent, or 1percent significance level, respectively.

Another price elasticity of interest is a cross-price elasticity between prescription drugs and other medical care services. To estimate a cross-price elasticity, another model is speci…ed. The model includes an additional parameter to be estimated, , where (m;p)

equation SUi OOP Pfother

(m;p)

= exp( ln(OOP Pf

is the coe¢ cient on the variable, OOP Pfother in the

)+ ln(OOP Pfother )+

(m;p) (m;p) (m;p) + (m;p)bi )+ei : 1;(m;p) Zi

The

variable for the prescription drugs (medical care service) observation is the out-of-pocket price

for medical care services (prescription drugs). Across all speci…cations, the results show

to be statistically

insigni…cant, suggesting no overall cross price elasticity. Note that it is possible for this cross-price to be positive for some treatments and negative for others, potentially canceling out. For this speci…cation the instruments strength is reasonable, although weaker than the analysis including only a out-of-pocket price variable.84 8 3 Linear

variable).

versions of these models are run to investigate the strength of the instruments (i.e., log(SUi + c) as a dependent For Models 5 through 7 a the F-test statistic does not exceeds the Stock-Yogo critical value at the 30 percent

level for maximal IV relative bias. The instruments applied in Models 2 through 4 are less likely a¤ected by weak instrument bias. In Models 2 through 4 the F-test statistic exceeds the Stock-Yogo critical value at the 20 percent level for maximal IV relative bias, but the F statistic does not exceed the 10 percent level. 8 4 For Models 5 through 7 the F-test statistic exceeds the Stock-Yogo critical value at the 20 percent level for maximal IV

54

relative bias. The instruments applied in Models 2 through 4 exceede the Stock-Yogo critical value at the 10 percent level for maximal IV relative bias.

55

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