Karen Eggleston joined the Walter H. Shorenstein Asia-Pacific Research Center in the summer of 2007 to lead the center's Asia Health Policy Program. She is also a Fellow with the Center for Innovation in Global Health (CIGH) at Stanford University School of Medicine, a fellow at Stanford's Center for Health Policy/Primary Care and Outcomes Research (CHP/PCOR), and a Faculty Research Fellow of the National Bureau of Economic Research (NBER). Her research focuses on comparative healthcare systems and health reform in Asia, especially China; government and market roles in the health sector; payment incentives; healthcare productivity; and the economics of the demographic transition. Eggleston teaches through Stanford's East Asian studies and International Policy Studies programs and is also affiliated with Stanford's public policy program.
Eggleston earned her PhD in public policy from Harvard University in 1999. She has MA degrees in economics and Asian studies from the University of Hawaii (August 1995 and May 1992, respectively), and earned a BA in Asian studies summa cum laude (valedictorian) from Dartmouth College in 1988. Eggleston studied in China for two years and was a Fulbright scholar in Korea. She was a consultant to the World Bank on their project on health service delivery in rural China in 2004, to China's Ministry of Finance and the Asian Development Bank from 2010 to 2011 for an evaluation of China's health reforms, and to the World Bank/WHO/Government of China 2015 report on China's health service delivery system. She is a member of the Strategic Technical Advisory Committee for the Asia Pacific Observatory on Health Systems and Policies.
Senior Fellow, Freeman Spogli Institute for International Studies
Honors & Awards
Hewlett Faculty Grant for participation in “Strengthening Public Health Systems in the Pacific Rim”, Freeman Spogli Institute for International Studies (June 2008)
Invited keynote speaker, Western Economics Association International conference in Beijing, PRC (January 14, 2007)
World Bank Beijing Office Grant, World Bank Beijing Office (April-December, 2005)
Grant, The Robert Wood Johnson Foundation’s Health Care Financing and Organization Initiative (June 2004 -November 2005)
Research Grant, Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services (July 2003-June 2004)
Grant, The Robert Wood Johnson Foundation’s Health Care Financing and Organization Initiative (December 2002-May 2004)
Fellowship, Economics of Aging, National Bureau of Economic Research (NBER) (1998)
Fellowship, East-West Center, Honolulu/Manoa, Hawaii (1990-1992)
Fulbright Scholarship, Yonsei University, Seoul, Korea (1989-1990)
Reynolds Scholarship, Johns Hopkins-Nanjing University Center for Chinese and American Studies (1988-1989)
Boards, Advisory Committees, Professional Organizations
Faculty Research Fellow, National Bureau of Economic Research (2012 - Present)
Advisory Board Member, Aging and Health Research Center, Xi'an Jiaotong University, Xi'an, China (2012 - Present)
Editorial Board, Journal of the Economics of Aging (2012 - Present)
Strategic Technical Advisory Committee, Asia Pacific Observatory on Health Systems and Policies (2011 - Present)
Academic Program Coordinator, Harvard University Kennedy School of Government Health Care Delivery Policy Program (2001 - 2008)
Research Associate, Harvard University Kennedy School of Government (1999 - 2006)
Global Fellow, International Institute, University of California, Los Angeles (2006 - 2007)
Center for East Asian Studies
Ph.D., Harvard University, Public Policy (1999)
M.A., University of Hawaii, Economics (1995)
M.A., University of Hawaii, Asian Studies (1992)
B.A., Dartmouth College, Asian Studies (Valedictorian) (1988)
Current Research and Scholarly Interests
Health reform in China; comparative healthcare systems in Asia; government and market roles in the health sector; payment incentives; healthcare productivity; and economic implications of demographic change.
The Impact of Health Insurance on Survival: Evidence from NCMS in Rural China, China CDC and Stanford (Asia Health Policy Program and School of Medicine colleagues)
The Net Value of Health Screening and Incentives for Management of Diabetes and Hypertension in Japan, 2005-2012, Stanford University and University of Tokyo collaborators
Trends in Disability in a Super-Aging Society: Adapting the Future Elderly Model to Japan, Stanford University and University of Tokyo collaborators
Disparities in Health and Healthcare in Myanmar
Diabetes Prevalence and Risk Factors among Vietnamese Adults
The Economics of Population Aging in China and India, Stanford and Harvard colleagues
Managing Chronic Disease in Rural China: Will lowering drug copayments enhance adherence and improve outcomes?, Stanford Asia Health Policy Program and Shandong Province Department of Health
The Educational Gradient in Health: Evidence from China, Stanford University and China Academy of Social Science collaborators
Mortality outcomes for Chinese and Japanese immigrants in the USA and countries of origin (Hong Kong, Japan): a comparative analysis using national mortality records from 2003 to 2011.
2016; 6 (10)
With immigration and minority populations rapidly growing in the USA, it is critical to assess how these populations fare after immigration, and in subsequent generations. Our aim is to compare death rates and cause of death across foreign-born, US-born and country of origin Chinese and Japanese populations.We analysed all-cause and cause-specific age-standardised mortality rates and trends using 2003-2011 US death record data for Chinese and Japanese decedents aged 25 or older by nativity status and sex, and used the WHO Mortality Database for Hong Kong and Japan decedents in the same years. Characteristics such as age at death, absolute number of deaths by cause and educational attainment were also reported.We examined a total of 10 458 849 deaths. All-cause mortality was highest in Hong Kong and Japan, intermediate for foreign-born, and lowest for US-born decedents. Improved mortality outcomes and higher educational attainment among foreign-born were observed compared with developed Asia counterparts. Lower rates in US-born decedents were due to decreased cancer and communicable disease mortality rates in the US heart disease mortality was either similar or slightly higher among Chinese-Americans and Japanese-Americans compared with those in developed Asia counterparts.Mortality advantages in the USA were largely due to improvements in cancer and communicable disease mortality outcomes. Mortality advantages and higher educational attainments for foreign-born populations compared with developed Asia counterparts may suggest selective migration. Findings add to our limited understanding of the racial and environmental contributions to immigrant health disparities.
View details for DOI 10.1136/bmjopen-2016-012201
View details for PubMedID 27793837
Prevalence and determinants of diabetes and prediabetes among Vietnamese adults.
Diabetes research and clinical practice
2016; 113: 116-124
We estimated the prevalence of diabetes and prediabetes among Vietnamese adults, and quantitatively evaluated association with known risk factors.Subjects were 5602 men and 10,680 women in North Vietnam aged 30-69 years participating in community diabetes screening programs during 2011-2013. We calculated standardized prevalence rates and demographic projections for 2035, and used multinomial regression analysis to examine the associations of multiple risk factors with diabetes and prediabetes.The age-, sex- and area of residence-standardized prevalence of diabetes was 6.0% and of prediabetes was 13.5%, with higher prevalence among men than women. Population aging is projected to raise the prevalence of diabetes to 7.0% and of prediabetes to 15.7% by 2035. Older age, obesity, large waist-to-hip ratio and hypertension were each associated with higher prevalence of diabetes, whereas the opposite direction of association was observed for underweight and minority ethnicity. In addition, diabetes was positively associated with family history of diabetes in women, but inversely related to physically heavy work among men.One in 17 and one in 7 adults had diabetes and prediabetes, respectively, in Vietnam. Urbanization, population aging, increased adiposity, hypertension and sedentary work are associated with the increasing prevalence of diabetes.
View details for DOI 10.1016/j.diabres.2015.12.009
View details for PubMedID 26795973
- Out-of-pocket health expenditures and antimicrobial resistance in low-income and middle-income countries: an economic analysis LANCET INFECTIOUS DISEASES 2015; 15 (10): 1203-1210
- Leading Causes of Death among Asian American Subgroups (2003-2011) PLOS ONE 2015; 10 (4)
An exploration of China's mortality decline under Mao: A provincial analysis, 1950-80
POPULATION STUDIES-A JOURNAL OF DEMOGRAPHY
2015; 69 (1): 39-56
Between 1950 and 1980, China experienced the most rapid sustained increase in life expectancy of any population in documented global history. We know of no study that has quantitatively assessed the relative importance of the various explanations proposed for this gain in survival. We have created and analysed a new, province-level panel data set spanning the decades between 1950 and 1980 by combining historical information from China's public health archives, official provincial yearbooks, and infant and child mortality records contained in the 1988 National Survey of Fertility and Contraception. Although exploratory, our results suggest that gains in school enrolment and public health campaigns together are associated with 55-70 per cent of China's dramatic reductions in infant and under-5 mortality during our study period. These results underscore the importance of non-medical determinants of population health, and suggest that, in some circumstances, general education of the population may amplify the effectiveness of public health interventions. Supplementary material for this article (Babiarz et al. 2014, Suppl.) is available at: http://dx.doi.org/10.1080/00324728.2014.972432.
View details for DOI 10.1080/00324728.2014.972432
View details for Web of Science ID 000349446200001
View details for PubMedID 25495509
Cardiovascular Disease Mortality in Asian Americans
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
2014; 64 (23): 2486-2494
Asian Americans are a rapidly growing racial/ethnic group in the United States. Our current understanding of Asian-American cardiovascular disease mortality patterns is distorted by the aggregation of distinct subgroups.The purpose of the study was to examine heart disease and stroke mortality rates in Asian-American subgroups to determine racial/ethnic differences in cardiovascular disease mortality within the United States.We examined heart disease and stroke mortality rates for the 6 largest Asian-American subgroups (Asian Indian, Chinese, Filipino, Japanese, Korean, and Vietnamese) from 2003 to 2010. U.S. death records were used to identify race/ethnicity and cause of death by International Classification of Diseases-10th revision coding. Using both U.S. Census data and death record data, standardized mortality ratios (SMRs), relative SMRs (rSMRs), and proportional mortality ratios were calculated for each sex and ethnic group relative to non-Hispanic whites (NHWs).In this study, 10,442,034 death records were examined. Whereas NHW men and women had the highest overall mortality rates, Asian Indian men and women and Filipino men had greater proportionate mortality burden from ischemic heart disease. The proportionate mortality burden of hypertensive heart disease and cerebrovascular disease, especially hemorrhagic stroke, was higher in every Asian-American subgroup compared with NHWs.The heterogeneity in cardiovascular disease mortality patterns among diverse Asian-American subgroups calls attention to the need for more research to help direct more specific treatment and prevention efforts, in particular with hypertension and stroke, to reduce health disparities for this growing population.
View details for DOI 10.1016/j.jacc.2014.08.048
View details for Web of Science ID 000345962400007
View details for PubMedID 25500233
An observational study of socioeconomic and clinical gradients among diabetes patients hospitalized for avoidable causes: evidence of underlying health disparities in China?
INTERNATIONAL JOURNAL FOR EQUITY IN HEALTH
Diabetes is an ambulatory care sensitive condition that can generally be managed in outpatient settings with little or no need for inpatient care. As a preliminary step to investigate whether health disparities can be detected in the inpatient setting in China, we study how diabetic patients hospitalized without prior primary care contact or with greater severity of illness differ from other diabetic inpatients along socioeconomic and clinical dimensions.We conduct an observational study using three years of clinical data for more than 1,800 adult patients with diabetes at two tertiary hospitals in East China. Univariate analysis and probit regression are used to characterize the differences in socioeconomic and clinical factors between patients hospitalized for diabetes with no prior primary care contact and those hospitalized with previous treatment experience. Secondarily, we use ordinary least squares regression to estimate the socioeconomic and clinical differences associated with poor serum glucose control at admission.We find that compared with patients hospitalized after prior treatment experience, inpatients with no previous primary care contact for diabetes have worse clinical laboratory values, are more likely to be young and male, to have lower education attainment, and to have poorer blood sugar control. Insurance, urban residence, and previous use of diabetic medication are in turn negatively correlated with HbA1c levels upon admission.Among hospitalized diabetic patients, socioeconomic factors such as lower education attainment, rural residence and lack of full insurance are associated with avoidable hospitalizations or worse indicators of health. Although we cannot definitively rule out selection bias, these findings are consistent with health disparities observable even at the inpatient level. Future studies should study the underlying mechanism by which traditionally vulnerable groups are more likely to be hospitalized for avoidable causes and with greater severity of illness.
View details for DOI 10.1186/1475-9276-13-9
View details for Web of Science ID 000332938900002
View details for PubMedID 24479633
- Will Demographic Change Slow China's Rise? JOURNAL OF ASIAN STUDIES 2013; 72 (3): 505-518
Contracting with private providers for primary care services: evidence from urban China.
Health economics review
2013; 3 (1): 1-?
Controversy surrounds the role of the private sector in health service delivery, including primary care and population health services. China's recent health reforms call for non-discrimination against private providers and emphasize strengthening primary care, but formal contracting-out initiatives remain few, and the associated empirical evidence is very limited. This paper presents a case study of contracting with private providers for urban primary and preventive health services in Shandong Province, China. The case study draws on three primary sources of data: administrative records; a household survey of over 1600 community residents in Weifang and City Y; and a provider survey of over 1000 staff at community health stations (CHS) in both Weifang and City Y. We supplement the quantitative data with one-on-one, in-depth interviews with key informants, including local officials in charge of public health and government finance.We find significant differences in patient mix: Residents in the communities served by private community health stations are of lower socioeconomic status (more likely to be uninsured and to report poor health), compared to residents in communities served by a government-owned CHS. Analysis of a household survey of 1013 residents shows that they are more willing to do a routine health exam at their neighborhood CHS if they are of low socioeconomic status (as measured either by education or income). Government and private community health stations in Weifang did not statistically differ in their performance on contracted dimensions, after controlling for size and other CHS characteristics. In contrast, the comparison City Y had lower performance and a large gap between public and private providers. We discuss why these patterns arose and what policymakers and residents considered to be the main issues and concerns regarding primary care services.
View details for DOI 10.1186/2191-1991-3-1
View details for PubMedID 23327666
- Risk adjustment and prevention CANADIAN JOURNAL OF ECONOMICS-REVUE CANADIENNE D ECONOMIQUE 2012; 45 (4): 1586-1607
Soil-Transmitted Helminth Infections and Correlated Risk Factors in Preschool and School-Aged Children in Rural Southwest China
2012; 7 (9)
We conducted a survey of 1707 children in 141 impoverished rural areas of Guizhou and Sichuan Provinces in Southwest China. Kato-Katz smear testing of stool samples elucidated the prevalence of ascariasis, trichuriasis and hookworm infections in pre-school and school aged children. Demographic, hygiene, household and anthropometric data were collected to better understand risks for infection in this population. 21.2 percent of pre-school children and 22.9 percent of school aged children were infected with at least one of the three types of STH. In Guizhou, 33.9 percent of pre-school children were infected, as were 40.1 percent of school aged children. In Sichuan, these numbers were 9.7 percent and 6.6 percent, respectively. Number of siblings, maternal education, consumption of uncooked meat, consumption of unboiled water, and livestock ownership all correlated significantly with STH infection. Through decomposition analysis, we determined that these correlates made up 26.7 percent of the difference in STH infection between the two provinces. Multivariate analysis showed that STH infection is associated with significantly lower weight-for-age and height-for-age z-scores; moreover, older children infected with STHs lag further behind on the international growth scales than younger children.
View details for DOI 10.1371/journal.pone.0045939
View details for Web of Science ID 000309517500047
View details for PubMedID 23029330
- The New Demographic Transition: Most Gains in Life Expectancy Now Realized Late in Life JOURNAL OF ECONOMIC PERSPECTIVES 2012; 26 (3): 137-156
- Prescribing institutions: Explaining the evolution of physician dispensing JOURNAL OF INSTITUTIONAL ECONOMICS 2012; 8 (2): 247-270
Socioeconomic Correlates of Inpatient Spending for Patients with Type 2 Diabetes Mellitus in China: Evidence from Hangzhou
EXPERIMENTAL AND CLINICAL ENDOCRINOLOGY & DIABETES
2012; 120 (1): 35-44
We evaluated the factors associated with inpatient costs including total costs, pharmaceutical costs and laboratory costs for diabetes-related admissions.Using data for 960 adult patients admitted between May 2005 and April 2008 with a primary or secondary diagnosis of type 2 diabetes mellitus (DM) at Sir Run Run Shaw Hospital affiliated with Zhejiang University Medical School (SRRSH) in Hangzhou, China, we evaluate the association between patient characteristics and inpatient costs with multivariable regression analyses.Total inpatient costs were positively associated with age, higher UKPDS stroke risk score, and presence of any complication. A regression that included patient socioeconomic and clinical characteristics explained 21.5% of the variation in total inpatient costs; regression estimates indicate that patients with coronary artery disease, retinopathy, nephropathy, neuropathy, and diabetic foot had inpatient costs that were respectively 93.7%, 14.0%, 17.5%, 11.5% and 89.0% higher than otherwise similar patients without those complications. Pharmaceutical costs did not differ by insurance coverage. Insured patients spent 7-16% more on laboratory tests than otherwise similar patients did.Clinical factors, especially presence of diabetes-related complications, appear to be the primary determinants of variation in inpatient costs for patients with type 2 DM in China. To mitigate the health costs increases associated with China's DM epidemic, policymakers should focus on cost-effective ways to manage patients in outpatient settings to prevent the complications associated with diabetes.
View details for DOI 10.1055/s-0031-1291178
View details for Web of Science ID 000299495600006
View details for PubMedID 22237582
- Demographic Change, Intergeneration al Transfers, and the Challenges to Social Protection Systems in China Aging, Economic Growth, and Old - Age Security in Asia Edward Elgar . 2012
- Health, Education, and China’s Demographic Tra nsition Since 1950 The Chinese Economy : A New Transition International Economics Association, Palgrave-MacMillian . 2012: 150-165
- Children of China's Future YaleGlobal Online 2012
Educational disparities in quality of diabetes care in a universal health insurance system: evidence from the 2005 Korea National Health and Nutrition Examination Survey
INTERNATIONAL JOURNAL FOR QUALITY IN HEALTH CARE
2011; 23 (4): 397-404
To investigate educational disparities in the care process and health outcomes among patients with diabetes in the context of South Korea's universal health insurance system.Bivariate and multiple regression analyses of data from a cross-sectional health survey.A nationally representative and population-based survey, the 2005 Korea National Health and Nutrition Examination Survey.Respondents aged 40 or older who self-reported prior diagnosis with diabetes (n= 1418).Seven measures of the care process and health outcomes, namely (i) receiving medical treatment for diabetes, (ii) ever received diabetes education, (iii) received dilated eye examination in the past year, (iv) received microalbuminuria test in the past year, (v) having activity limitation due to diabetes, (vi) poor self-rated health and (vii) self-rated health on a visual analog scale.Except for receiving medical care for diabetes, overall process quality was low, with only 25% having ever received diabetes education, 39% having received a dilated eye examination in the past year and 51% having received a microalbuminuria test in the past year. Lower education level was associated with both poorer care processes and poorer health outcomes, whereas lower income level was only associated with poorer health outcomes.While South Korea's universal health insurance system may have succeeded in substantially reducing financial barriers related to diabetes care, the quality of diabetes care is low overall and varies by education level. System-level quality improvement efforts are required to address the weaknesses of the health system, thereby mitigating educational disparities in diabetes care quality.
View details for DOI 10.1093/intqhc/mzr035
View details for Web of Science ID 000292834300006
View details for PubMedID 21705771
- Quality Adjustment for Health Care Spending on Chronic Disease: Evidence from Diabetes Treatment, 1999-2009 AMERICAN ECONOMIC REVIEW 2011; 101 (3): 206-211
- Soft budget constraints and ownership: Empirical evidence from US hospitals ECONOMICS LETTERS 2011; 110 (1): 7-11
The Global Challenge of Antimicrobial Resistance: Insights from Economic Analysis
INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH
2010; 7 (8): 3141-3149
The prevalence of antimicrobial resistance (AR) limits the therapeutic options for treatment of infections, and increases the social benefit from disease prevention. Like an environmental resource, antimicrobials require stewardship. The effectiveness of an antimicrobial agent is a global public good. We argue for greater use of economic analysis as an input to policy discussion about AR, including for understanding the incentives underlying health behaviors that spawn AR, and to supplement other methods of tracing the evolution of AR internationally. We also discuss integrating antimicrobial stewardship into global health governance.
View details for DOI 10.3390/ijerph7083141
View details for Web of Science ID 000281411100011
View details for PubMedID 20948953
Comparing public and private hospitals in China: Evidence from Guangdong
BMC HEALTH SERVICES RESEARCH
The literature comparing private not-for-profit, for-profit, and government providers mostly relies on empirical evidence from high-income and established market economies. Studies from developing and transitional economies remain scarce, especially regarding patient case-mix and quality of care in public and private hospitals, even though countries such as China have expanded a mixed-ownership approach to service delivery. The purpose of this study is to compare the operations and performance of public and private hospitals in Guangdong Province, China, focusing on differences in patient case-mix and quality of care.We analyze survey data collected from 362 government-owned and private hospitals in Guangdong Province in 2005, combining mandatorily reported administrative data with a survey instrument designed for this study. We use univariate and multi-variate regression analyses to compare hospital characteristics and to identify factors associated with simple measures of structural quality and patient outcomes.Compared to private hospitals, government hospitals have a higher average value of total assets, more pieces of expensive medical equipment, more employees, and more physicians (controlling for hospital beds, urban location, insurance network, and university affiliation). Government and for-profit private hospitals do not statistically differ in total staffing, although for-profits have proportionally more support staff and fewer medical professionals. Mortality rates for non-government non-profit and for-profit hospitals do not statistically differ from those of government hospitals of similar size, accreditation level, and patient mix.In combination with other evidence on health service delivery in China, our results suggest that changes in ownership type alone are unlikely to dramatically improve or harm overall quality. System incentives need to be designed to reward desired hospital performance and protect vulnerable patients, regardless of hospital ownership type.
View details for DOI 10.1186/1472-6963-10-76
View details for Web of Science ID 000277049800001
View details for PubMedID 20331886
- PRESCRIBING CULTURES AND PHARMACEUTICAL POLICIES IN THE ASIA-PACIFIC (Book Review) HEALTH AFFAIRS 2010; 29 (2): 329-330
Inpatient treatment of diabetic patients in Asia: evidence from India, China, Thailand and Malaysia
2010; 27 (1): 101-108
The prevalence of Type 2 diabetes mellitus (DM) has grown rapidly, but little is known about the drivers of inpatient spending in low- and middle-income countries. This study aims to compare the clinical presentation and expenditure on hospital admission for inpatients with a primary diagnosis of Type 2 DM in India, China, Thailand and Malaysia.We analysed data on adult, Type 2 DM patients admitted between 2005 and 2008 to five tertiary hospitals in the four countries, reporting expenditures relative to income per capita in 2007.Hospital admission spending for diabetic inpatients with no complications ranged from 11 to 75% of per-capita income. Spending for patients with complications ranged from 6% to over 300% more than spending for patients without complications treated at the same hospital. Glycated haemoglobin was significantly higher for the uninsured patients, compared with insured patients, in India (8.6 vs. 8.1%), Hangzhou, China (9.0 vs. 8.1%), and Shandong, China (10.9 vs. 9.9%). When the hospital admission expenditures of the insured and uninsured patients were statistically different in India and China, the uninsured always spent less than the insured patients.With the rising prevalence of DM, households and health systems in these countries will face greater economic burdens. The returns to investment in preventing diabetic complications appear substantial. Countries with large out-of-pocket financing burdens such as India and China are associated with the widest gaps in resource use between insured and uninsured patients. This probably reflects both overuse by the insured and underuse by the uninsured.
View details for DOI 10.1111/j.1464-5491.2009.02874.x
View details for Web of Science ID 000273451900015
View details for PubMedID 20121896
- "Kan Bing Nan, Kan Bing Gui": Challenges for China’s Healthcare System Thirty Years into Reform Growing Pains: Tensions and Opportunities in China’s Transformation Walter H. Shorenstein Asia - Pacif ic Research Center. 2010
- The Diabetes Epidemic in the Asia - Pacific Aging Asia: Economic and Social Implications of Rapid Demographic Change in China, Japan, and South Korea Walter H. Shorenstein Asia - Pacific Research Center series with Brookings Institution Press. 2010
- Introduction Aging Asia: Economic and Social Implications of Rapid Demographic Change in China, Japan, and South Korea Walter H. Shorenstein Asia - Pacific Research Center series with Brookings Institution Press. 2010
- Aging Asia: The Economic and Social Implications of Rapid Demographic Change in China, Japan, and South Korea Book Brooking Institution Press. 2010
- Jobs and Kids: Female Employment and Fertility in Rural China VoxEU.org 2010
The Net Value of Health Care for Patients With Type 2 Diabetes, 1997 to 2005
ANNALS OF INTERNAL MEDICINE
2009; 151 (6): 386-W127
The net economic value of increased health care spending remains unclear, especially for chronic diseases.To assess the net value of health care for patients with type 2 diabetes.Economic analysis of observational cohort data.Mayo Clinic, Rochester, Minnesota, a not-for-profit integrated health care delivery system.613 patients with type 2 diabetes.Changes in inflation-adjusted annual health care spending and in health status between 1997 and 2005 (with health status defined as 10-year cardiovascular risk), holding age and diabetes duration constant across the observation period ("modifiable risk"), and simulated outcomes for all diabetes complications based on the UKPDS (United Kingdom Perspective Diabetes Study) Outcomes Model. Net value was estimated as the present discounted monetary value of improved survival and avoided treatment spending for coronary heart disease minus the increase in annual spending per patient.Assuming that 1 life-year is worth $200,000 and accounting for changes in modifiable cardiovascular risk, the net value of changes in health care for patients with type 2 diabetes was $10,911 per patient (95% CI, -$8480 to $33,402) between 1997 and 2005, a positive dollar value that suggests the value of health care has improved despite increased spending. A second approach based on diabetes complications yielded a net value of $6931 per patient (CI, -$186,901 to $211,980).The patient population was homogeneous and small, and the wide CIs of the estimates are compatible with a decrease as well as an increase in value.The economic value of improvements in health status for patients with type 2 diabetes seems to exceed or equal increases in health care spending, suggesting that those increases were worth the extra cost. However, the possibility that society is getting less value for its money could not be statistically excluded, and there is opportunity to improve the value of diabetes-related health care.None.
View details for Web of Science ID 000270390100003
View details for PubMedID 19755364
- Human Resource Management Technology Diffusion through Global Supply Chains: Buyer-directed Factory-based Health Care in India WORLD DEVELOPMENT 2009; 37 (9): 1484-1493
- Provider payment incentives: international comparisons INTERNATIONAL JOURNAL OF HEALTH CARE FINANCE & ECONOMICS 2009; 9 (2): 113-115
The effect of soft budget constraints on access and quality in hospital care
INTERNATIONAL JOURNAL OF HEALTH CARE FINANCE & ECONOMICS
2009; 9 (2): 211-232
Given an increasingly complex web of financial pressures on providers, studies have examined how hospitals' overall financial health affects different aspects of hospital operations. In our study, we develop an empirical proxy for the concept of soft budget constraint (SBC, Kornai, Kyklos 39:3-30, 1986) as an alternative financial measure of a hospital's overall financial health and offer an initial estimate of the effect of SBCs on hospital access and quality. An organization has a SBC if it can expect to be bailed out rather than shut down. Our conceptual model predicts that hospitals facing softer budget constraints will be associated with less aggressive cost control, and their quality may be better or worse, depending on the scope for damage to quality from noncontractible aspects of cost control. We find that hospitals with softer budget constraints are less likely to shut down safety net services. In addition, hospitals with softer budget constraints appear to have better mortality outcomes for elderly heart attack patients.
View details for DOI 10.1007/s10754-009-9066-2
View details for Web of Science ID 000265963900008
View details for PubMedID 19408114
Soft budget constraints in China: Evidence from the Guangdong hospital industry
INTERNATIONAL JOURNAL OF HEALTH CARE FINANCE & ECONOMICS
2009; 9 (2): 233-242
Using data from 276 general acute hospitals in the Pearl River Delta region of Guangdong Province from 2002 and 2004, we construct a preliminary metric of budget constraint softness. We find that, controlling for hospital size, ownership, and other factors, a Chinese hospital's probability of receiving government financial support is inversely associated with the hospital's previous net revenue, an association consistent with soft budget constraints.
View details for DOI 10.1007/s10754-009-9067-1
View details for Web of Science ID 000265963900009
View details for PubMedID 19399608
- Measuring Selection Incentives in Managed Care: Evidence From the Massachusetts State Employee Insurance Program JOURNAL OF RISK AND INSURANCE 2009; 76 (1): 159-175
- Introduction Prescribing Cultures and Pharmaceutical Policy in the Asia - Pacific Walter H. Shorenstein Asia - Pacific Research Center series with Brookings Institution Press. 2009
- Physician s and pharmacists in comparative historical perspective: The ca se of South Korea Prescribing Cultures and Pharmaceutical Policy in the Asia Pacific Shorenstein Asia - Pacific Research Center series with Brookings Institution Press. 2009 : 267-280
HOSPITAL OWNERSHIP AND QUALITY OF CARE: WHAT EXPLAIN'S THE DIFFERENT RESULTS IN THE LITERATURE?
2008; 17 (12): 1345-1362
This systematic review examines what factors explain the diversity of findings regarding hospital ownership and quality. We identified 31 observational studies written in English since 1990 that used multivariate analysis to examine quality of care at nonfederal general acute, short-stay US hospitals. We find that pooled estimates of ownership effects are sensitive to the subset of studies included and the extent of overlap among hospitals analyzed in the underlying studies. Ownership does appear to be systematically related to differences in quality among hospitals in several contexts. Whether studies find for-profit and government-controlled hospitals to have higher mortality rates or rates of adverse events than their nonprofit counterparts depends on data sources, time period, and region covered. Policymakers should be aware of the underlying reasons for conflicting evidence in this literature, and the strengths and weaknesses of meta-analytic synthesis. The 'true' effect of ownership appears to depend on institutional context, including differences across regions, markets, and over time.
View details for DOI 10.1002/hec.1333
View details for Web of Science ID 000261635300003
View details for PubMedID 18186547
- Soft budget constraints and the property rights theory of ownership ECONOMICS LETTERS 2008; 100 (3): 425-427
Pharmaceutical policy in China
2008; 27 (4): 1042-1050
Contradictory goals plague China's pharmaceutical policy. The government wants to develop the domestic pharmaceutical industry and has used drug pricing to cross-subsidize public hospitals. Yet the government also aims to control drug spending through price caps and profit-margin regulations to guarantee access even for poor patients. The resulting system has distorted market incentives, increased consumers' costs, and financially rewarded inappropriate prescribing, thus undermining public health. Pharmaceuticals account for about half of total health spending in China, representing 43 percent of spending per inpatient episode and 51 percent of spending per outpatient visit. Yet some essential medicines are unavailable or of questionable quality.
View details for DOI 10.1377/hlthaff.27.4.1042
View details for Web of Science ID 000257635900018
View details for PubMedID 18607039
- Emerging health economics and outcomes research in the Asia-Pacific region VALUE IN HEALTH 2008; 11: S1-S2
Health service delivery in China: A literature review
2008; 17 (2): 149-165
We report the results of a review of the Chinese- and English-language literatures on service delivery in China, asking how well China's health-care providers perform and what determines their performance. Although data and methodological limitations suggest caution in drawing conclusions, a critical reading of the available evidence suggests that current health service delivery in China leaves room for improvement, in terms of quality, responsiveness to patients, efficiency, cost escalation, and equity. The literature suggests that these problems will not be solved by simply shifting ownership to the private sector or by simply encouraging providers -- public and private -- to compete with one another for individual patients. By contrast, substantial improvements could be (and in some places have already been) made by changing the way providers are paid -- shifting away from fee-for-service and the distorted price schedule. Other elements of 'active purchasing' by insurers could further improve outcomes. Rigorous evaluations, based on richer micro-level data, could considerably strengthen the evidence base for service delivery policy in China.
View details for DOI 10.1002/hec.1306
View details for Web of Science ID 000253239400001
View details for PubMedID 17880024
- Developing Commercial Health Insurance in China Field Note in Perspectives: China and the World 2008; 10 (3): 141-155
- From Plan to Market in the Health Sector? China's Experience Journal of Asian Economics 2008; 19: 400-412
- Healthcare Reforms in Central and Eastern Europe: Overview and Possible Implications of China Bijao (Comparative Studies) 2007; 32: 119-132
Physician dual practice
2006; 78 (2-3): 157-166
Physicians employed in government clinics and hospitals also frequently have private practices. The economic theory of such dual practice is relatively limited and recent. We provide a summary and comparison of five models of dual practice, including one we have developed based on total compensation theory and contracting limitations. We also discuss whether theoretical predictions are consistent with empirical evidence from developed and developing countries. We argue that the social trade-off between the benefits and costs of dual practice hinge on the quality of a country's contracting institutions. The conclusion outlines a proposed research agenda for better understanding this widespread phenomenon in the health sector and in other segments of society.
View details for DOI 10.1016/j.healthpol.2005.09.007
View details for Web of Science ID 000240837500005
View details for PubMedID 16253383
Provider choice of quality and surplus.
International journal of health care finance & economics
2006; 6 (2): 103-117
We study the quality choices of institutional health-care providers, such as hospitals, assuming that the utility function of the key organizational decision maker includes both quality of care and financial surplus. We are primarily concerned with how changes in outside claims--particularly proportional outside claims--on the provider's financial surplus affect his choice of quality. We use the term "rate of surplus retention" to refer to the fraction of surplus remaining after deducting all such claims. Using the Arrow-Pratt coefficient of relative risk aversion as a measure of curvature of the provider's utility-from-money function, we show that increasing the surplus retention rate increases (decreases) quality if the provider's coefficient of relative risk aversion is greater than (less than) 1.
View details for PubMedID 16783504
- Ownership and performance of health service organizations: Evidence from hospitals Global Forum Update on Research for Health 2006; 3: 142-145
- Antibiotic resistance as a global threat: Evidence from China, Kuwait and the United States GLOBALIZATION AND HEALTH 2006; 2
Multitasking and mixed systems for provider payment
JOURNAL OF HEALTH ECONOMICS
2005; 24 (1): 211-223
The problem of multitasking refers to the challenge of designing incentives to motivate appropriate effort across multiple tasks when the desired outcomes for some tasks are more difficult to measure than others. Multitasking is pervasive in health care. I use a simple model to show that the problem of multitasking further strengthens conventional arguments for mixed payment systems such as partial capitation. When pay-for-performance metrics are imperfect for rewarding service-specific quality efforts, using mixed payment helps to balance incentives for quality effort across services.
View details for DOI 10.1016/j.jhealeco.2004.09.001
View details for Web of Science ID 000226272400010
View details for PubMedID 15617795
Hospital competition under regulated prices: application to urban health sector reforms in China.
International journal of health care finance & economics
2004; 4 (4): 343-368
We develop a model of public-private hospital competition under regulated prices, recognizing that hospitals are multi-service firms and that equilibria depend on the interactions of patients, hospital administrators, and physicians. We then use data from China to calibrate a simulation model of the impact of China's recent payment and organizational reforms on cost, quality and access. Both the analytic and simulation results show how providing implicit insurance through distorted prices leads to over/under use of services by profitability, which in turn fuels cost escalation and reduces access for those who cannot afford to self-pay for care. Simulations reveal the benefits of mixed payment and expanded insurance cover for mitigating these distortions.
View details for PubMedID 15467409
Addressing government and market failures with payment incentives: Hospital reimbursement reform in Hainan, China
SOCIAL SCIENCE & MEDICINE
2004; 58 (2): 267-277
This paper examines the role of provider payment policy as an instrument for addressing government and market failures and controlling costs in the health sector, particularly in developing countries. We empirically evaluate the impact of provider payment reform in Hainan province, China, on expenditures for different categories of services that had been subject to distorted prices under fee-for-service. Using a pre-post study design with a control group, we analyze two years of claims data to assess the impact of a January 1997 change to prospective payment for a sub-sample of the hospitals. This difference-in-difference empirical strategy allows us to isolate the supply-side payment reform effects from demand-side policy interventions. We find that prepayment is associated with a slower increase in spending on expensive drugs and high technology services, compared to fee-for-service. The fact that payment reform is associated with reduced growth in spending on the most expensive drugs is particularly encouraging, given that drugs account for a remarkably high percentage of both the level and growth of aggregate health expenditure in China. Payment reform can be an effective policy instrument for correcting market failures and adverse side effects of government health sector interventions (such as distorted prices to assure access to basic services), both of which can lead to excessive health care expenditure growth. Such health spending growth can have a particularly high opportunity cost for developing countries.
View details for DOI 10.1016/S0277-9536(03)00010-8
View details for Web of Science ID 000187743100006
View details for PubMedID 14604613
Healthcare payment incentives: a comparative analysis of reforms in Taiwan, South Korea and China.
Applied health economics and health policy
2004; 3 (1): 47-56
Payment incentives to both consumers and providers have significant consequences for the equity and efficiency of a healthcare system, and have recently come to the fore in health policy reforms. This review first discusses the economic rationale for the apparent international convergence toward payment systems with mixed demand- and supply-side cost sharing. The recent payment reforms undertaken in Taiwan, South Korea and China are then summarised. Available evidence clearly indicates that payment incentives matter, and, in particular, that supply-side cost sharing can improve efficiency without undermining equity. Further study and monitoring of health service quality and risk selection is warranted.
View details for PubMedID 15702940
- Zhuangui Zhong De Fuli, Xuanze He Yizhixing (Welfare, Choice and Solidarity in Transition -- Chinese edition) CITIC Publishing House. 2003
Provider payment reform in China: The case of hospital reimbursement in Hainan Province
2001; 10 (4): 325-339
This paper develops a simple model of payment incentives and empirically evaluates provider payment reform in Hainan Province, China. We use a pre-post study design with a control group to analyse two years of claims data to assess the impact of a January 1997 change to prospective payment for a sub-sample of the hospitals. This difference-in-difference empirical strategy allows us to isolate the supply-side payment reform effects from demand-side changes, in contrast with previous studies of China's reforms. Our results validate the theory that Chinese providers' behavioural response to payment incentives is similar to that reported in the literature derived from the experience of industrialized countries. We find that prepayment is associated with a slower rate of growth of overall expenditures, programme spending and patient co-payments per inpatient admission, compared to fee-for-service (FFS). These findings suggest cautious optimism regarding the effectiveness of prospective payment for controlling costs and should be encouraging for policymakers in developing and transitional economies considering replacement of FFS with more aggregated forms of provider payment.
View details for Web of Science ID 000169548000006
View details for PubMedID 11400255
- Welfare, Choice and Solidarity in Transition: Reforming the Health Sector in Eastern Europe Cambridge University Press. 2001
The design and interpretation of contracts: Why complexity matters
NORTHWESTERN UNIVERSITY LAW REVIEW
2000; 95 (1): 91-132
View details for Web of Science ID 000165397100002