健康经济学（巴塔查里亚）全套完整课件.pptx

健康经济学（巴塔查里亚）全套完整课件.pptx

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CHAPTER1WHYHEALTHECONOMICS?

Whyishealtheconomicsinteresting?

Bhattacharya,HydeandTuHealthEconomics,TheU.S.healthcareeconomyismassiveandexpensive.Healthisamajorsourceofuncertaintyandrisk.Governmentsaroundtheworldaredeeplyinvolvedinfinancinghealthsystems.,TheU.S.healthcareeconomyismassiveandexpensive,Bhattacharya,HydeandTuHealthEconomics,TheU.S.GDPin2008wasapproximately$14trillion.OneoutofeverysixdollarsspentintheU.S.thatyearwasspentonhealthcare.In1960,barelyonedollaroutofeverytwentyspentintheU.S.wenttowardhealthcare.Thetrendhasbeensimilarincountriesaroundtheworld,butnocountryspendsquiteasmuchonhealthcareastheU.S.Whatdowegetforallthismoney?

HealthcareexpendituresintheUS,Bhattacharya,HydeandTuHealthEconomics,Healthisuncertainandcontagious,Bhattacharya,HydeandTuHealthEconomics,Thehealtheconomymaybehuge,buthowisitdifferentfromother,smallermarketslikethemarketforbananasandthemarketfortelevisions?

TwointerestingeconomicpropertiesUncertainty:

mostpeoplecanpredicthowmanybananasorTVstheywillbuyinthenextweek,butnothowmanyemergencyheartsurgeriestheywillneedinthenextweek.Contagiousness:

itdoesntmattertoyouifyourneighborbuysabananaoraTV,butitdoesmatterifheskipshisflushot.,Uncertaintyandinsurance,Bhattacharya,HydeandTuHealthEconomics,Anunforeseenbrokenlegorheartattackcansuddenlycreatedemandforexpensivehealthcareservices.Becausemostpeopleareriskaverse,health-relateduncertaintymotivatesindividualstodemandhealthinsurance.Thisinturncreatesproblemsthatariseininsurancemarkets:

adverseselectionandmoralhazard.Thesetwophenomenaarewhatmakehealthpolicyreallydifficult（andreallyinteresting）.,Contagiousnessandexternalities,Bhattacharya,HydeandTuHealthEconomics,ThefactthatotherpeopleshealthdecisionsaffectyoucreatesexternalitiesExamples:

VaccinationsandotherpreventativemeasurescreatepositiveexternalitiesGoingoutinpublicwithEbolaviruscreatesnegativeexternalitiesExternalitiesunderminetheefficientfunctionofmarketsandoftenrequiregovernmentintervention.,Healtheconomics=publicfinance,Bhattacharya,HydeandTuHealthEconomics,Governmentsplayahugeroleinhealthmarketsbecauseofthefeaturesjustdiscussed.IncountriesliketheUnitedKingdom,Sweden,andCanada,thegovernmentisresponsibleforthevastmajorityofhealthcareexpenditures.EvenintheUS,withitsprivatehealthcaresystem,thegovernmentisresponsibleforhalfofallhealthcarespending.,Healthcareisonlygettingbiggerand,Bhattacharya,HydeandTuHealthEconomics,moreexpensiveforgovernmentsandtaxpayersIncreasinglifeexpectanciesandgrayingpopulationsthroughoutthedevelopedworldwillplacestressonpublichealthinsurancesystems.Governmentswillhavetocopewithongoingquestionsaboutwhethertopayforexpensivenewmedicaltechnologies.Giventhesetrendswecanconfidentlyexpecthealthcaretobeanever-growinglineitemongovernmentbalancesheets.,Positivevsnormativequestions,Bhattacharya,HydeandTuHealthEconomics,NormativequestionsDoeseveryonedeserveaccesstohealthcare,eveniftheycannotpay?

Shouldpeoplebecompelledtopurchaseinsurance?

Whenisitethicaltodenycaretoadyingpatient?

Shouldthegovernmentbancertainunhealthyfoods?

PositivequestionsHowmuchwoulditcosttoprovidefreecheckupsanddrugsforeveryoneinapopulation?

Dostrictpatentprotectionsfornewdrugsspurinnovation?

Howmuchwouldconsumerssaveifdoctorswerenotrequiredtohavemedicaldegreesormedicallicenses?

Wouldataxonsaturatedfatmakeanationhealthier?

Economicreasoningcannotanswernormativequestions,butitcananswerpositivequestions,andthatcanhelpusformopinionsaboutnormativequestions.,TheuniqueUShealthcaremarket,Bhattacharya,HydeandTuHealthEconomics,IntheU.S.,patientssometimespayoutofpocketforroutinehealthcare,likeflushotsandhealthcheckups.Inmanyothercountries,includingCanadaandtheUnitedKingdom,patientsalmostneverpayoutofpocketwhentheyreceivebasichealthcare.IntheU.S.,somepeoplearenoteligibleforgovernmentinsuranceandcannotafford（ordonotwant）tobuyprivateinsurance.Inalmostalldevelopedcountries,uninsuranceisextremelyrareorevennonexistent.Insuranceiseitherprovidedforfreebythegovernment,orprovidedbyamixofpublicandprivateinsurers.,TheuniqueUShealthcaremarket,Bhattacharya,HydeandTuHealthEconomics,EventhoughtheUSmarketisuniqueinthisway,muchofourempiricalevidencewillcomefromtheUS.Thisallowsustounderstandthemaladiesthatcanoccurinprivatemarketsforhealthcare:

adverseselection,moralhazard,andmonopolisticfirms.Understandingtheseproblemsiscriticaltounderstandingwhyothercountriesapproachhealthpolicyinradicallydifferentways.,CHAPTER2DEMANDFORHEALTHCARE,Standardeconomicdemandcurvesaredownwardsloping,Asprice（P）decreases,quantity（Q）demandedincreasesExample:

P=$3,Q=4lollipopsP=$1,Q=8lollipopsP=$0.50,Q=9lollipops,Bhattacharya,HydeandTuHealthEconomics,Elasticitymeasuresthedegreeofdownward-sloping,ElasticdemandDEpricesensitive:

changesinpricegreatlyaffectthequantitydemandedInelasticdemandDIPriceinsensitive:

changesinpricedonotsignificantlychangethequantitydemanded,Bhattacharya,HydeandTuHealthEconomics,Doesthedemandcurveforhealthcareslopedownward?

Bhattacharya,HydeandTuHealthEconomics,Arepeoplesensitivetothepriceofhealthcare?

IsdemandforvaccinessuchthatP=$100,Q=1,000P=$1,Q=1,000i.e.demandisinelastic?

Isdemandforband-aidssuchthatP=$100,Q=1P=$1,Q=30i.e.demandiselastic?

Ifpeoplealwaysobeytheirdoctors,thendemandshouldbeinelastic!

Needrandomizedexperiments,Bhattacharya,HydeandTuHealthEconomics,Randomizedexperiments:

Definition:

astudythatassignstreatmentsrandomlytodifferentgroupsofstudyparticipantsIncludes:

Acontrolgroup（notreatment）PlacebogroupHelpsgenerateexperimentalgroupsthatarestatisticallysimilartoeachother,Non-randomizedexperimentscanbebiased,MeasureddemandcurveDMisbiasedcomparedtotruedemandDTPeoplegenerallychoosetheamountofinsurancetheyreceiveSickerpeoplewillchoosemoreinsurancebecausetheyknowtheywillneedmorecare,Bhattacharya,HydeandTuHealthEconomics,EvidencefromRandomizedExperiments,TwoRandomizedExperiments,Bhattacharya,HydeandTuHealthEconomics,RANDHealthInsuranceExperiment（HIE）OregonMedicaidExperiment,RANDHIE,Bhattacharya,HydeandTuHealthEconomics,Randomlyassigned2,000familiesfromsixUScitiestodifferentinsurancecoverageplansCopaymentsgroups:

Free,25%,50%,and95%Trackedutilizationofhealthcare（Q）ineachcopaymentplan（P）Copaymentactsasthemarginalcostthateachfamilyfaceswhenbuyingcare,OregonMedicaidExperiment,Bhattacharya,HydeandTuHealthEconomics,Comparedtwogroupsoflow-incomeadultsMedicaidlotterywinnersvs.lotterylosersLotterywinnersgottoapplyforpublichealthinsurancethroughMedicaidSotheyfacedlowerout-of-pocketpricesforcareLotteryloserscouldnotgetMedicaid（butmighthavepurchasedoutsideinsurance）,Results?

Bhattacharya,HydeandTuHealthEconomics,Healthcaredemandcurvesaredownwardsloping（economictheoryprevails!

）Pricechangesaffecteddemandforhealthcare,Differentmeasuresofcare,Bhattacharya,HydeandTuHealthEconomics,OutpatientCareDef:

anymedicalcarethatdoesnotinvolveanovernighthospitalstayE.g.runnynoses,twistedankles,minorbrokenbonesInpatientCareDef:

medicalcarerequiringovernightstaysE.g.MoreserioussurgeriesorconditionsthatrequireovernightrecoveryormonitoringERCareDef:

careinvolvingtheemergencyroomE.g.heartattacks,strokes,Outpatientcare,RANDHIEAspatientcost-sharing（P）increases,numberofepisodes（Q）ofoutpatientcaredecreasesHoldsforbothacuteandchronicconditions,DatafromKeeleretal.（1988）,Bhattacharya,HydeandTuHealthEconomics,Outpatientcare,Bhattacharya,HydeandTuHealthEconomics,OregonMedicaidStudyLotterywinnershavemoreoutpatientvisitsthanlotterylosersBoththeRANDHIEandtheOregonMedicaidStudyfinddownward-slopingdemandforoutpatientcare!

Inpatientcare,OregonMedicaidStudy,Nosignificantdifferenceinusageratesbetweenlotterywinnersandlotterylosers,Demandisstilldownward-slopingbutlesselasticthandemandforoutpatientcare,RANDHIE（DatafromKeeler,1988）,Bhattacharya,HydeandTuHealthEconomics,ERcare,OregonMedicaidStudy,NosignificantdifferenceinERcareforlotterywinnersvs.lotterylosersEvenforemergencyroomcarelikelythemosturgentkindthoseonthehighestcopaymentplanintheRANDHIEwerelesslikelytobuycare!

RANDHIE（DatafromNewhouse,1993）,Bhattacharya,HydeandTuHealthEconomics,Pediatriccare,PediatriccareDef:

careforinfantsorchildrenusuallypaidforbyaparentorguardianDatafromRANDHIE:

Bhattacharya,HydeandTuHealthEconomics,Mentalhealth&dentalCare（RANDHIE）,Bhattacharya,HydeandTuHealthEconomics,Prescriptiondrugs,DatafromRANDHIE,Bhattacharya,HydeandTuHealthEconomics,Non-randomizedexperimentevidence,Bhattacharya,HydeandTuHealthEconomics,U.S.MedicareCitizensareeligibleforhealthinsurancethroughMedicarewhentheyturn65butnotbeforeIfdemandforhealthcareisdownward-sloping,weexpectajumpinhealthcareusageatage65ThisisknownasadiscontinuitystudyThereisadiscontinuityinhealthinsuranceatage65,Cardetal.（2009）,Bhattacharya,HydeandTuHealthEconomics,Cardetal.havetwomainfindings:

Unplannedemergencydepartmentadmissionsfollowalineartrendaroundtheageof65Otherhospitaladmissionsjumpupattheageof65Thereisadiscontinuityinmedicalusageatthesamepoint