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David A. Hyman and Charles Silver
Medical malpractice is the best studied aspect of the civil justice system. But the subject is complicated, and there are heated disputes about basic facts. For example, are premium spikes driven by factors that are internal (i.e., number of claims, payout per claim, and damage costs) or external to the system? How large (or small) is the impact of a damages cap? Do caps have a bigger impact on the number of cases that are brought or the payment in the cases that remain? Do blockbuster verdicts cause defendants to settle cases for more than they are worth? Do caps attract physicians? Do caps reduce healthcare spending—and by how much? How much does it cost to resolve the high percentage of cases in which no damages are recovered? What is the comparative impact of a cap on noneconomic damages versus a cap on total damages?
Other disputes involve normative questions. Is there too much med mal litigation or not enough? Are damage caps fair? Is the real problem bad doctors or predatory lawyers—or some combination of both?
This article summarizes the empirical research on the performance of the med mal system, and highlights some areas for future research.
Syed Abdul Hamid
Health microinsurance (HMI) has been used around the globe since the early 1990s for financial risk protection against health shocks in poverty-stricken rural populations in low-income countries. However, there is much debate in the literature on its impact on financial risk protection. There is also no clear answer to the critical policy question about whether HMI is a viable route to provide healthcare to the people of the informal economy, especially in the rural areas. Findings show that HMI schemes are concentrated widely in the low-income countries, especially in South Asia (about 43%) and East Africa (about 25.4%). India accounts for 30% of HMI schemes. Bangladesh and Kenya also possess a good number of schemes. There is some evidence that HMI increases access to healthcare or utilization of healthcare. One set of the literature shows that HMI provides financial protection against the costs of illness to its enrollees by reducing out-of-pocket payments and/or catastrophic spending. On the contrary, a large body of literature with strong methodological rigor shows that HMI fails to provide financial protection against health shocks to its clients. Some of the studies in the latter group rather find that HMI contributes to the decline of financial risk protection. These findings seem to be logical as there is a high copayment and a lack of continuum of care in most cases. The findings also show that scale and dependence on subsidy are the major concerns. Low enrollment and low renewal are common concerns of the voluntary HMI schemes in South Asian countries. In addition, the declining trend of donor subsidies makes the HMI schemes supported by external donors more vulnerable. These challenges and constraints restrict the scale and profitability of HMI initiatives, especially those that are voluntary. Consequently, the existing organizations may cease HMI activities.
Overall, although HMI can increase access to healthcare, it fails to provide financial risk protection against health shocks. The existing HMI practices in South Asia, especially in the HMIs owned by nongovernmental organizations and microfinance institutions, are not a viable route to provide healthcare to the rural population of the informal economy. However, HMI schemes may play some supportive role in implementation of a nationalized scheme, if there is one. There is also concern about the institutional viability of the HMI organizations (e.g., ownership and management efficiency). Future research may address this issue.
The majority of econometric models ignore the fact that many economic time series are sampled at different frequencies. A burgeoning literature pertains to econometric methods explicitly designed to handle data sampled at different frequencies. Broadly speaking these methods fall into two categories: (a) parameter driven, typically involving a state space representation, and (b) data driven, usually based on a mixed-data sampling (MIDAS)-type regression setting or related methods. The realm of applications of the class of mixed frequency models includes nowcasting—which is defined as the prediction of the present—as well as forecasting—typically the very near future—taking advantage of mixed frequency data structures. For multiple horizon forecasting, the topic of MIDAS regressions also relates to research regarding direct versus iterated forecasting.
Pieter van Baal and Hendriek Boshuizen
In most countries, non-communicable diseases have taken over infectious diseases as the most important causes of death. Many non-communicable diseases that were previously lethal diseases have become chronic, and this has changed the healthcare landscape in terms of treatment and prevention options. Currently, a large part of healthcare spending is targeted at curing and caring for the elderly, who have multiple chronic diseases. In this context prevention plays an important role as there are many risk factors amenable to prevention policies that are related to multiple chronic diseases.
This article discusses the use of simulation modeling to better understand the relations between chronic diseases and their risk factors with the aim to inform health policy. Simulation modeling sheds light on important policy questions related to population aging and priority setting. The focus is on the modeling of multiple chronic diseases in the general population and how to consistently model the relations between chronic diseases and their risk factors by combining various data sources. Methodological issues in chronic disease modeling and how these relate to the availability of data are discussed. Here, a distinction is made between (a) issues related to the construction of the epidemiological simulation model and (b) issues related to linking outcomes of the epidemiological simulation model to economic relevant outcomes such as quality of life, healthcare spending and labor market participation. Based on this distinction, several simulation models are discussed that link risk factors to multiple chronic diseases in order to explore how these issues are handled in practice. Recommendations for future research are provided.
Audrey Laporte and Brian S. Ferguson
One of the implications of the human capital literature of the 1960s was that a great many decisions individuals make that have consequences not just for the point in time when the decision is being made but also for the future can be thought of as involving investments in certain types of capital. In health economics, this led Michael Grossman to propose the concept of health capital, which refers not just to the individual’s illness status at any point in time, but to the more fundamental factors that affect the likelihood that she will be ill at any point in her life and also affect her life expectancy at each age. In Grossman’s model, an individual purchased health-related commodities that act through a health production function to improve her health. These commodities could be medical care, which could be seen as repair expenditures, or factors such as diet and exercise, which could be seen as ongoing additions to her health—the counterparts of adding savings to her financial capital on a regular basis. The individual was assumed to make decisions about her level of consumption of these commodities as part of an intertemporal utility-maximizing process that incorporated, through a budget constraint, the need to make tradeoffs between health-related goods and goods that had no health consequences. Pauline Ippolito showed that the same analytical techniques could be used to consider goods that were bad for health in the long run—bad diet and smoking, for example—still within the context of lifetime utility maximization. This raised the possibility that an individual might rationally take actions that were bad for her health in the long run. The logical extension of considering smoking as bad was adding recognition that smoking and other bad health habits were addictive. The notion of addictive commodities was already present in the literature on consumer behavior, but the consensus in that literature was that it was extremely difficult, if not impossible, to distinguish between a rational addict and a completely myopic consumer of addictive goods. Gary Becker and Kevin Murphy proposed an alternative approach to modeling a forward-looking, utility-maximizing consumer’s consumption of addictive commodities, based on the argument that an individual’s degree of addiction could be modeled as addiction capital, and which could be used to tackle the empirical problems that the consumer expenditure literature had experienced. That model has become the most widely used framework for empirical research by economists into the consumption of addictive goods, and, while the concept of rationality in addiction remains controversial, the Becker-Murphy framework also provides a basis for testing various alternative models of the consumption of addictive commodities, most notably those based on versions of time-inconsistent intertemporal decision making.
Paul Hansen and Nancy Devlin
Multi-criteria decision analysis (MCDA) is increasingly used to support healthcare decision-making. MCDA involves decision makers evaluating the alternatives under consideration based on the explicit weighting of criteria relevant to the overarching decision—in order to, depending on the application, rank (or prioritize) or choose between the alternatives. A prominent example of MCDA applied to healthcare decision-making that has received a lot of attention in recent years and is the main subject of this article is choosing which health “technologies” (i.e., drugs, devices, procedures, etc.) to fund—a process known as health technology assessment (HTA). Other applications include prioritizing patients for surgery, prioritizing diseases for R&D, and decision-making about licensing treatments. Most applications are based on weighted-sum models. Such models involve explicitly weighting the criteria and rating the alternatives on the criteria, with each alternative’s “performance” on the criteria aggregated using a linear (i.e., additive) equation to produce the alternative’s “total score,” by which the alternatives are ranked. The steps involved in a MCDA process are explained, including an overview of methods for scoring alternatives on the criteria and weighting the criteria. The steps are: structuring the decision problem being addressed, specifying criteria, measuring alternatives’ performance, scoring alternatives on the criteria and weighting the criteria, applying the scores and weights to rank the alternatives, and presenting the MCDA results, including sensitivity analysis, to decision makers to support their decision-making. Arguments recently advanced against using MCDA for HTA and counterarguments are also considered. Finally, five questions associated with how MCDA for HTA is operationalized are discussed: Whose preferences are relevant for MCDA? Should criteria and weights be decision-specific or identical for repeated applications? How should cost or cost-effectiveness be included in MCDA? How can the opportunity cost of decisions be captured in MCDA? How can uncertainty be incorporated into MCDA?
Chao Gu, Han Han, and Randall Wright
This article provides an introduction to New Monetarist Economics. This branch of macro and monetary theory emphasizes imperfect commitment, information problems, and sometimes spatial (endogenously) separation as key frictions in the economy to derive endogenously institutions like monetary exchange or financial intermediation. We present three generations of models in development of New Monetarism. The first model studies an environment in which agents meet bilaterally and lack commitment, which allows money to be valued endogenously as means of payment. In this setup both goods and money are indivisible to keep things tractable. Second-generation models relax the assumption of indivisible goods and use bargaining theory (or related mechanisms) to endogenize prices. Variations of these models are applied to financial asset markets and intermediation. Assets and goods are both divisible in third-generation models, which makes them better suited to policy analysis and empirical work. This framework can also be used to help understand financial markets and liquidity.
Vincenzo Atella and Joanna Kopinska
New sanitation and health technology applied to treatments, procedures, and devices is constantly revolutionizing epidemiological patterns. Since the early 1900s it has been responsible for significant improvements in population health by turning once-deadly diseases into curable or preventable conditions, by expanding the existing cures to more patients and diseases, and by simplifying procedures for both medical and organizational practices. Notwithstanding the benefits of technological progress for the population health, the innovation process is also an important driver of health expenditure growth across all countries. The technological progress generates additional financial burden and expands the volume of services provided, which constitutes a concern from an economic point of view. Moreover, the evolution of technology costs and their impact on healthcare spending is difficult to predict due to the revolutionary nature of many innovations and their adoption. In this respect, the challenge for policymakers is to discourage overadoption of ineffective, unnecessary, and inappropriate technologies. This task has been long carried out through regulation, which according to standard economic theory is the only response to market failures and socially undesirable outcomes of healthcare markets left on their own. The potential welfare loss of a market failure must be confronted with the costs of regulatory activities. While health technology evolution delivers important value for patients and societies, it will continue to pose important challenges for already overextended public finances.
Karla DiazOrdaz and Richard Grieve
Health economic evaluations face the issues of noncompliance and missing data. Here, noncompliance is defined as non-adherence to a specific treatment, and occurs within randomized controlled trials (RCTs) when participants depart from their random assignment. Missing data arises if, for example, there is loss-to-follow-up, survey non-response, or the information available from routine data sources is incomplete. Appropriate statistical methods for handling noncompliance and missing data have been developed, but they have rarely been applied in health economics studies. Here, we illustrate the issues and outline some of the appropriate methods with which to handle these with application to health economic evaluation that uses data from an RCT.
In an RCT the random assignment can be used as an instrument-for-treatment receipt, to obtain consistent estimates of the complier average causal effect, provided the underlying assumptions are met. Instrumental variable methods can accommodate essential features of the health economic context such as the correlation between individuals’ costs and outcomes in cost-effectiveness studies. Methodological guidance for handling missing data encourages approaches such as multiple imputation or inverse probability weighting, which assume the data are Missing At Random, but also sensitivity analyses that recognize the data may be missing according to the true, unobserved values, that is, Missing Not at Random.
Future studies should subject the assumptions behind methods for handling noncompliance and missing data to thorough sensitivity analyses. Modern machine-learning methods can help reduce reliance on correct model specification. Further research is required to develop flexible methods for handling more complex forms of noncompliance and missing data.
Many nonlinear time series models have been around for a long time and have originated outside of time series econometrics. The stochastic models popular univariate, dynamic single-equation, and vector autoregressive are presented and their properties considered. Deterministic nonlinear models are not reviewed. The use of nonlinear vector autoregressive models in macroeconometrics seems to be increasing, and because this may be viewed as a rather recent development, they receive somewhat more attention than their univariate counterparts. Vector threshold autoregressive, smooth transition autoregressive, Markov-switching, and random coefficient autoregressive models are covered along with nonlinear generalizations of vector autoregressive models with cointegrated variables. Two nonlinear panel models, although they cannot be argued to be typically macroeconometric models, have, however, been frequently applied to macroeconomic data as well. The use of all these models in macroeconomics is highlighted with applications in which model selection, an often difficult issue in nonlinear models, has received due attention. Given the large amount of nonlinear time series models, no unique best method of choosing between them seems to be available.
The literature on optimum currency areas differs from that on other topics in economic theory in a number of notable respects. Most obviously, the theory is framed in verbal rather than mathematical terms. Mundell’s seminal article coining the term and setting out the theory’s basic propositions relied entirely on words rather than equations. The same was true of subsequent contributions focusing on the sectoral composition of activity and the role of fiscal flows. A handful of more recent articles specified and analyzed formal mathematical models of optimum currency areas. But it is safe to say that none of these has “taken off” in the sense of becoming the workhorse framework on which subsequent scholarship builds. The theoretical literature remains heavily qualitative and narrative compared to other areas of economic theory. While Mundell, McKinnon, Kenen, and the other founding fathers of optimum-currency-area theory provided powerful intuition, attempts to further formalize that intuition evidently contributed less to advances in economic understanding than has been the case for other theoretical literatures.
Second, recent contributions to the literature on optimum currency areas are motivated to an unusual extent by a particular case, namely Europe’s monetary union. This was true already in the 1990s, when the EU’s unprecedented decision to proceed with the creation of the euro highlighted the question of whether Europe was an optimum currency area and, if not, how it might become one. That tendency was reinforced when Europe then descended into crisis starting in 2009. With only slight exaggeration it can be said that the literature on optimum currency areas became almost entirely a literature on Europe and on that continent’s failure to satisfy the relevant criteria.
Third, the literature on optimum currency areas remains the product of its age. When the founders wrote, in the 1960s, banks were more strictly regulated, and financial markets were less internationalized than subsequently. Consequently, the connections between monetary integration and financial integration—whether monetary union requires banking union, as the point is now put—were neglected in the earlier literature. The role of cross-border financial flows as a destabilizing mechanism within a currency area did not receive the attention it deserved. Because much of that earlier literature was framed in a North American context—the question was whether the United States or Canada was an optimum currency area—and because it was asked by a trio of scholars, two of whom hailed from Canada and one of whom hailed from the United States, the challenges of reconciling monetary integration with political nationalism and the question of whether monetary requires political union were similarly underplayed. Given the euro area’s descent into crisis, a number of analysts have asked why economists didn’t sound louder warnings in advance. The answer is that their outlooks were shaped by a literature that developed in an earlier era when the risks and context were different.
This is an advance summary of a forthcoming article in the Oxford Research Encyclopedia of Economics and Finance. Please check back later for the full article.
Detection of outliers is an important explorative step in empirical analysis. Once detected, the investigator will have to decide how to model the outliers depending on the context. Indeed, the outliers may represent noisy observations that are best left out of the analysis or they may be very informative observations that would have a particularly important role in the analysis. For regression analysis in time series a number of outlier algorithms are available, including impulse indicator saturation and methods from robust statistics. The algorithms are complex and their statistical properties are not fully understood. Extensive simulation studies have been made, but the formal theory is lacking. Some progress has been made toward an asymptotic theory of the algorithms. A number of asymptotic results are already available building on empirical process theory.
Jun Li and Edward C. Norton
Pay-for-performance programs have become a prominent supply-side intervention to improve quality and decrease spending in health care, touching upon long-term care, acute care, and outpatient care. Pay-for-performance directly targets long-term care, with programs in nursing homes and home health. Indirectly, pay-for-performance programs targeting acute care settings affect clinical practice for long-term care providers through incentives for collaboration across settings.
As a whole, pay-for-performance programs entail the identification of problems it seeks to solve, measurement of the dimensions it seeks to incentivize, methods to combine and translate performance to incentives, and application of the incentives to reward performance. For the long-term care population, pay-for-performance programs must also heed the unique challenges specific to the sector, such as patients with complex health needs and distinct health trajectories, and be structured to recognize the challenges of incentivizing performance improvement when there are multiple providers and payers involved in the care delivery.
Although empirical results indicate modest effectiveness of pay-for-performance in long-term care on improving targeted measures, some research has provided more clarity on the role of pay-for-performance design on the output of the programs, highlighting room for future research. Further, because health care is interconnected, the indirect effects of pay-for-performance programs on long-term care is an underexplored topic. As the scope of pay-for-performance in long-term care expands, both within the United States and internationally, pay-for-performance offers ample opportunities for future research.
Mark F. Grady
Tort law is part of the common law that originated in England after the Norman Conquest and spread throughout the world, including to the United States. It is judge-made law that allows people who have been injured by others to sue those who harmed them and collect damages in proper cases. Since its early origins, tort law has evolved considerably and has become a full-fledged “grown order,” like the economy, and can best be understood by positive theory, also like the economy. Economic theories of tort have developed since the early 1970s, and they too have evolved over time. Their objective is to generate fresh insight about the purposes and the workings of the tort system.
The basic thesis of the economic theory is that tort law creates incentives for people to minimize social cost, which is comprised of the harm produced by torts and the cost of the precautions necessary to prevent torts. This thesis, intentionally simple, generates many fresh insights about the workings and effects of the tort system and even about the actual legal rules that judges have developed. In an evolved grown order, legal rules are far less concrete than most people would expect though often very clear in application. Beginning also in the 1970s, legal philosophers have objected to the economic theory of tort and have devised philosophical theories that compete. The competition, moreover, has been productive because it has spurred both sides to revise and improve their theories and to seek better to understand the law. Tort law is diverse, applicable to many different activities and situations, so developing a positive theory about it is both challenging and rewarding.
James P. Ziliak
The interaction between poverty and social policy is an issue of longstanding interest in academic and policy circles. There are active debates on how to measure poverty, including where to draw the threshold determining whether a family is deemed to be living in poverty and how to measure resources available. These decisions have profound impacts on our understanding of the anti-poverty effectiveness of social welfare programs. In the context of the United States, focusing solely on cash income transfers shows little progress against poverty over the past 50 years, but substantive gains are obtained if the resource concept is expanded to include in-kind transfers and refundable tax credits. Beyond poverty, the research literature has examined the effects of social welfare policy on a host of outcomes such as labor supply, consumption, health, wealth, fertility, and marriage. Most of this work finds the disincentive effects of welfare programs on work, saving, and family structure to be small, but the income and consumption smoothing benefits to be sizable, and some recent work has found positive long-term effects of transfer programs on the health and education of children. More research is needed, however, on how to measure poverty, especially in the face of deteriorating quality of household surveys, on the long-term consequences of transfer programs, and on alternative designs of the welfare state.
Jesús Gonzalo and Jean-Yves Pitarakis
This is an advance summary of a forthcoming article in the Oxford Research Encyclopedia of Economics and Finance. Please check back later for the full article.
Predictive regressions refer to models whose aim is to assess the predictability of a typically noisy time series, such as stock returns or currency returns with past values of a highly persistent predictor such as valuation ratios, interest rates, or volatilities, among other variables. Obtaining reliable inferences through conventional methods can be challenging in such environments mainly due to the joint interactions of predictor persistence, potential endogeneity, and other econometric complications. Numerous methods have been developed in the literature ranging from adjustments to test statistics used in significance testing to alternative instrumental variable based estimation methods specifically designed to neutralize inferences to the stochastic properties of the predictor(s).
Early developments in this area were mainly confined to linear and single predictor settings, but recent developments have raised the issue of adaptability of existing estimation and inference methods to more general environments so as to extend the use of predictive regressions to a wider range of potential applications.
An important extension involves allowing predictability to enter nonlinearly so as to capture time variation in the role of particular predictors. Economically interesting nonlinearities include, for instance, the use of threshold effects that allow predictability to vanish or strengthen during particular episodes, creating pockets of predictability. Such effects may kick in in the conditional means but also in the variances or both and may help uncover important phenomena such as the countercyclical nature of stock return predictability recently documented in the literature.
Due to the frequent need to consider multiple as opposed to single predictors it also becomes important to evaluate the validity and feasibility of inferences about linear and nonlinear predictability when multiple predictors of potentially different degrees of persistence are allowed to coexist in such settings.
Payment systems based on fixed prices have become the dominant model to finance hospitals across OECD countries. In the early 1980s, Medicare in the United States introduced the Diagnosis Related Groups (DRG) system. The idea was that hospitals should be paid a fixed price for treating a patient within a given diagnosis or treatment. The system then spread to other European countries (e.g., France, Germany, Italy, Norway, Spain, the United Kingdom) and high-income countries (e.g., Canada, Australia). The change in payment system was motivated by concerns over rapid health expenditure growth, and replaced financing arrangements based on reimbursing costs (e.g., in the United States) or fixed annual budgets (e.g., in the United Kingdom).
A more recent policy development is the introduction of pay for performance (P4P) schemes, which, in most cases, pay directly for higher quality. This is also a form of regulated price payment but the unit of payment is a (process or outcome) measure of quality, as opposed to activity, that is admitting a patient with a given diagnosis or a treatment.
Fixed price payment systems, either of the DRG type or the P4P type, affect hospital incentives to provide quality, contain costs, and treat the right patients (allocative efficiency). Quality and efficiency are ubiquitous policy goals across a range of countries.
Fixed price regulation induces providers to contain costs and, under certain conditions (e.g., excess demand), offer some incentives to sustain quality. But payment systems in the health sector are complex. Since its inception, DRG systems have been continuously refined. From their initial (around) 500 tariffs, many DRG codes have been split in two or more finer ones to reflect heterogeneity in costs within each subgroup. In turn, this may give incentives to provide excessive intensive treatments or to code patients in more remunerative tariffs, a practice known as upcoding. Fixed prices also make it financially unprofitable to treat high cost patients. This is particularly problematic when patients with the highest costs have the largest benefits from treatment. Hospitals also differ systematically in costs and other dimensions, and some of these external differences are beyond their control (e.g., higher cost of living, land, or capital). Price regulation can be put in place to address such differences.
The development of information technology has allowed constructing a plethora of quality indicators, mostly process measures of quality and in some cases health outcomes. These have been used both for public reporting, to help patients choose providers, but also for incentive schemes that directly pay for quality. P4P schemes are attractive but raise new issues, such as they might divert provider attention and unincentivized dimensions of quality might suffer as a result.
Pharmaceutical expenditure accounts for approximately 20% of healthcare expenditure across the Organisation for Economic Cooperation and Development (OECD) countries. Pharmaceutical products are regulated in all major global markets primarily to ensure product quality but also to regulate the reimbursed prices of insurance companies and central purchasing authorities that dominate this sector. Price regulation is justified as patent protection, which acts as an incentive to invest in R&D given the difficulties in appropriating the returns to such activity, creates monopoly rights to suppliers. Price regulation does itself reduce the ability of producers’ to recapture the substantial R&D investment costs incurred. Traditional price regulation through Ramsey pricing and yardstick competition is not efficient given the distortionary impact of insurance holdings, which are extensive in this sector and the inherent uncertainties that characterize Research and Development (R&D) activity. A range of other pricing regulations aimed at establishing pharmaceutical reimbursement that covers both dynamic efficiency (tied to R&D incentives) and static efficiency (tied to reducing monopoly rents) have been suggested. These range from cost-plus pricing, to internal and external reference pricing, rate-of-return pricing and, most recently value-based (essential health benefit maximization) pricing. Reimbursed prices reflecting value based pricing are, in some countries, associated with clinical treatment guidelines and cost-effectiveness analysis. Some countries are also requiring or allowing post-launch price regulation thorough a range of patient access agreements based on predefined population health targets and/or financial incentives. There is no simple, single solution to the determination of dynamic and static efficiency in this sector given the uncertainty associated with innovation, the large monopoly interests in the area, the distortionary impact of health insurance and the informational asymmetries that exist across providers and purchasers.
The concept of soft budget constraint, describes a situation where a decision-maker finds it impossible to keep an agent to a fixed budget. In healthcare it may refer to a (nonprofit) hospital that overspends, or to a lower government level that does not balance its accounts. The existence of a soft budget constraint may represent an optimal policy from the regulator point of view only in specific settings. In general, its presence may allow for strategic behavior that changes considerably its nature and its desirability. In this article, soft budget constraint will be analyzed along two lines: from a market perspective and from a fiscal federalism perspective.
The creation of an internal market for healthcare has made hospitals with different objectives and constraints compete together. The literature does not agree on the effects of competition on healthcare or on which type of organizations should compete. Public hospitals are often seen as less efficient providers, but they are also intrinsically motivated and/or altruistic. Competition for quality in a market where costs are sunk and competitors have asymmetric objectives may produce regulatory failures; for this reason, it might be optimal to implement soft budget constraint rules to public hospitals even at the risk of perverse effects. Several authors have attempted to estimate the presence of soft budget constraint, showing that they derive from different strategic behaviors and lead to quite different outcomes.
The reforms that have reshaped public healthcare systems across Europe have often been accompanied by a process of devolution; in some countries it has often been accompanied by widespread soft budget constraint policies. Medicaid expenditure in the United States is becoming a serious concern for the Federal Government and the evidence from other states is not reassuring. Several explanations have been proposed: (a) local governments may use spillovers to induce neighbors to pay for their local public goods; (b) size matters: if the local authority is sufficiently big, the center will bail it out; equalization grants and fiscal competition may be responsible for the rise of soft budget constraint policies. Soft budget policies may also derive from strategic agreements among lower tiers, or as a consequence of fiscal imbalances. In this context the optimal use of soft budget constraint as a policy instrument may not be desirable.
Joanna Coast and Manuela De Allegri
Qualitative methods are being used increasingly by health economists, but most health economists are not trained in these methods and may need to develop expertise in this area. This article discusses important issues of ontology, epistemology, and research design, before addressing the key issues of sampling, data collection, and data analysis in qualitative research. Understanding differences in the purpose of sampling between qualitative and quantitative methods is important for health economists, and the key notion of purposeful sampling is described. The section on data collection covers in-depth and semistructured interviews, focus-group discussions, and observation. Methods for data analysis are then discussed, with a particular focus on the use of inductive methods that are appropriate for economic purposes. Presentation and publication are briefly considered, before three areas that have seen substantial use of qualitative methods are explored: attribute development for discrete choice experiment, priority-setting research, and health financing initiatives.