Melbourne Institute of Applied Economic and Social Research - Research Publications
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ItemNo Preview AvailableFinancial incentives and private health insurance demand on the extensive and intensive margins.(Elsevier BV, 2024-03)In countries with dual public and private healthcare systems, individuals are often incentivized to purchase private health insurance through subsidies and penalty. We use administrative data from Australia to study how high-income earners respond on both the intensive and extensive margins to the simultaneous withdrawal of a premium subsidy, and the increase of a tax penalty. We estimate regression discontinuity models by exploiting discontinuous changes in the penalty and subsidy rates. Our setting is particularly interesting because means testing creates different incentives at the extensive and intensive margins. Specifically, we could expect to see higher take-up of insurance coupled with downgrading to less expensive plans. We find evidence that the penalty - despite being large in value - only has a modest effect on take-up. Our results show little evidence of downgrading, which is consistent with a low price elasticity for the high-income earners we study.
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ItemNo Preview AvailableAge penalties and take-up of private health insurance(Melbourne Institute, 2021-12-01)Penalty mandates are used in many countries to encourage people to purchase health insurance. But are they effective? We use a large administrative dataset for a 10% random sample of all Australian tax-filers to study how people respond to a step-wise age-based mandate, and whether this has changed over time. The mandate creates discontinuities in the incentive to insure by age, which we exploit to estimate causal effects. People who do not insure before the penalty dates face higher premiums in the future, which should encourage them to bring forward purchases. We find that people respond as expected to the initial age-penalty, but not to subsequent penalties. The 2% premium loading results in a 1-4% increase in take-up, with effects increasing after an annual government letter campaign that reminds people approaching the penalty deadline about the policy. We discuss the impact of the mandate on the overall efficiency of the market, and implications of potential reforms.
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ItemEffects of Medicare Part D coverage gap closure on utilization of branded and generic drugs(WILEY, 2023-03)The Affordable Care Act included a provision to gradually eliminate the Medicare prescription drug coverage gap between 2011 and 2020, which substantially lower medication costs in the gap. Using 2007-2016 Medicare claims data, we estimate how filling the gap affects individuals' out-of-pocket spending and medication use, separately for branded and generic drugs. One important difficulty in estimating the policy impact is that around the same time, many blockbuster drugs commonly used by the Medicare population experienced patent expiration and began to see generic entry. Because generic entries affected different therapeutic classes at different times, we run difference-in-differences models by therapeutic category at the beneficiary-month level to isolate the effect of the gap closure from that of generic entry. Overall, we find that filling the gap substantially reduced out-of-pocket spending and increased the use of branded drugs, which had larger discount rates during the analysis period. Beneficiaries reaching the gap, at older ages, or with comorbidities experienced larger reduction in out-of-pocket spending. We show that without accounting for generic entry, the effect of filling the coverage gap on medication use is underestimated for branded drugs and overestimated for generic drugs.
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ItemExplaining Improved Use of High-Risk Medications in Medicare Between 2007 and 2011(WILEY-BLACKWELL, 2016-03)
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ItemANTICIPATORY BEHAVIOR IN RESPONSE TO MEDICARE PART D'S COVERAGE GAP(WILEY, 2017-03)
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ItemSimulating Variation in Families' Spending across Marketplace Plans(WILEY, 2018-08)OBJECTIVE: To examine variations in premium and cost-sharing across marketplace plans available to eligible families. DATA SOURCES: 2011-2012 Medical Expenditure Panel Survey (MEPS), 2014 health plan data from healthcare.gov, and the 2011 Medicare Part D public formulary file. STUDY DESIGN: We identified a nationally representative cohort of individuals in the MEPS who would have been eligible for marketplace coverage. For each family, we simulated the total out-of-pocket payment (premium plus cost-sharing) under each available plan in their county of residence, assuming their premarketplace use. DATA COLLECTION/EXTRACTION METHODS: Confidential state and county of residence identifiers were merged onto MEPS public use files and used to match MEPS families to the plans available in their county as reported in the publicly available data from healthcare.gov. PRINCIPAL FINDINGS: We found substantial variation in total family health care spending, especially premium component, across marketplace plans. This is true even within a plan tier of the same minimum actuarial value, and for families eligible for subsidies. Variation among families with income below 250 percent of the FPL is larger than variation among families with higher income. CONCLUSIONS: Our simulations show substantial variations in net premium and out-of-pocket payments across marketplace plans, even within a plan tier.
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ItemTemporal trends and variation in out-of-pocket expenditures and patient cost sharing: evidence from a Chinese national survey 2011-2015(BioMed Central, 2021-06-19)OBJECTIVES: This study aims to examine: (1) temporal trends in the percentage of cost-sharing and amount of out-of-pocket expenditure (OOPE) from 2011 to 2015; (2) factors associated with cost-sharing and OOPE; and (3) the relationships between province-level economic development and cost-sharing and OOPE in China. SETTING: A total of 10,316 adults aged ≥45 years from China followed-up from 2011 to 2015 were included in the analysis. We measured two main outcome variables: (1) patient cost sharing, measured by the percentage of OOPE as total healthcare expenditure, and (2) absolute amount of OOPE. RESULTS: Based on self-reported data, we did not find substantial differences in the percentage of cost sharing, but a significant increase in the absolute amount of OOPE among the middle-aged and older Chinese between 2011 and 2015. The percentage of cost-sharing was considerably higher for outpatient than inpatient care, and the majority paid more than 80% of the total cost for prescription drugs. Provinces with higher GDP per capita tend to have lower cost-sharing and a higher OOPE than their counterparts, but the relationship for OOPE became insignificant after adjusting for individual factors. CONCLUSION: Reducing out-of-pocket expenditure and patient cost sharing is required to improve financial protection from illness, especially for those with those with chronic conditions and reside in less developed regions in China. Ongoing monitoring of financial protection using data from various sources is warranted.
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ItemAssociation between telehealth use and general practitioner characteristics during COVID-19: findings from a nationally representative survey of Australian doctors(BMJ PUBLISHING GROUP, 2021)OBJECTIVE: To investigate factors associated with the use of telehealth by general practitioners (GPs) during COVID-19. DESIGN: A nationally representative longitudinal survey study of Australian doctors analysed using regression analysis. SETTING: General practice in Australia during the COVID-19 pandemic. PARTICIPANTS: 448 GPs who completed both the 11th wave (2018-2019) of the Medicine in Australia: Balancing Employment and Life (MABEL) Survey and the MABEL COVID-19 Special Online Survey (May 2020). OUTCOME MEASURES: Proportion of all consultations delivered via telephone (audio) or video (audiovisual); proportion of telehealth consultations delivered via video. RESULTS: 46.1% of GP services were provided using telehealth in early May 2020, with 6.4% of all telehealth consultations delivered via video. Higher proportions of telehealth consultations were observed in GPs in larger practices compared with solo GPs: between +0.21 (95% CI +0.07 to +0.35) and +0.28 (95% CI +0.13 to +0.44). Greater proportions of telehealth consultations were delivered through video for GPs with appropriate infrastructure and for GPs with more complex patients: +0.10 (95% CI +0.04 to +0.16) and +0.04 (95% CI +0.00 to +0.08), respectively. Lower proportions of telehealth consultations were delivered via video for GPs over 55 years old compared with GPs under 35 years old: between -0.08 (95% CI -0.02 to -0.15) and -0.15 (95% CI -0.07 to -0.22), and for GPs in postcodes with a higher proportion of patients over 65 years old: -0.005 (95% CI -0.001 to -0.008) for each percentage point increase in the population over 65 years old. CONCLUSIONS: GP characteristics are strongly associated with patterns of telehealth use in clinical work. Infrastructure support and relative pricing of different consultation modes may be useful policy instruments to encourage GPs to deliver care by the most appropriate method.
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ItemAssociation Between Preoperative Benzodiazepine Use and Postoperative Opioid Use and Health Care Costs(JAMA Network, 2020-10-27)Importance The association between preoperative benzodiazepine use and long-term postoperative outcomes is not well understood. Objective To characterize the association between preoperative benzodiazepine use and postoperative opioid use and health care costs. Design, Setting, and Participants In this cohort study, retrospective analysis of private health insurance claims data on 946 561 opioid-naive patients (no opioid prescriptions filled in the year before surgery) throughout the US was conducted. Patients underwent 1 of 11 common surgical procedures between January 1, 2004, and December 31, 2016; data analysis was performed January 9, 2020. Exposures Benzodiazepine use, defined as long term (≥10 prescriptions filled or ≥120 days supplied in the year before surgery) or intermittent (any use not meeting the criteria for long term). Main Outcomes and Measures The primary outcome was opioid use 91 to 365 days after surgery. Secondary outcomes included opioid use 0 to 90 days after surgery and health care costs 0 to 30 days after surgery. Results In this sample of 946 561 patients, the mean age was 59.8 years (range, 18-89 years); 615 065 were women (65.0%). Of these, 23 484 patients (2.5%) met the criteria for long-term preoperative benzodiazepine use and 47 669 patients (5.0%) met the criteria for intermittent use. After adjusting for confounders, long-term (odds ratio [OR], 1.59; 95% CI, 1.54-1.65; P < .001) and intermittent (OR, 1.47; 95% CI, 1.44-1.51; P < .001) benzodiazepine use were associated with an increased probability of any opioid use during postoperative days 91 to 365. For patients who used opioids in postoperative days 91 to 365, long-term benzodiazepine use was associated with a 44% increase in opioid dose (additional 0.6 mean daily morphine milligram equivalents [MMEs]; 95% CI, 0.3-0.8 MMEs; P < .001), although intermittent benzodiazepine use was not significantly different (0.0 average daily MMEs; 95% CI, −0.2 to 0.2 MMEs; P = .65). Preoperative benzodiazepine use was also associated with increased opioid use in postoperative days 0 to 90 for both long-term (32% increase, additional 1.9 average daily MMEs; 95% CI, 1.6-2.1 MMEs; P < .001) and intermittent (9% increase, additional 0.5 average daily MMEs; 95% CI, 0.4-0.6 MMEs; P < .001) users. Intermittent benzodiazepine use was associated with an increase in 30-day health care costs ($1155; 95% CI, $938-$1372; P < .001), while no significant difference was observed for long-term benzodiazepine use. Conclusions and Relevance The findings of this study suggest that, among opioid-naive patients, preoperative benzodiazepine use may be associated with an increased risk of developing long-term opioid use and increased opioid dosages postoperatively, and also may be associated with increased health care costs.