Abstract

Government programs are often offered on an optional basis to market participants. We explore the economics of such voluntary regulation in the context of a Medicare payment reform, in which one medical provider receives a single, predetermined payment for a sequence of related healthcare services, instead of separate service-specific payments. This “bundled payment” program was originally implemented as a five-year randomized trial, with mandatory participation by hospitals assigned to the new payment model; however, after two years, participation was made voluntary for half of these hospitals. Using detailed claim-level data, we document that voluntary participation is more likely for hospitals that can increase revenue without changing behavior (“selection on levels”) and for hospitals that had large changes in behavior when participation was mandatory (“selection on slopes”). To assess outcomes under counterfactual regimes, we estimate a stylized model of responsiveness to and selection into the program. We find that the current voluntary regime generates inefficient transfers to hospitals, and that alternative (feasible) designs could reduce these inefficient transfers and raise welfare. Our analysis highlights key design elements to consider under voluntary regulation.

中文翻译：

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自愿监管：来自医疗保险支付改革的证据*

摘要

政府计划通常以可选的方式提供给市场参与者。我们在医疗保险支付改革的背景下探讨了这种自愿监管的经济学，其中一个医疗提供者为一系列相关的医疗保健服务接收单一的、预定的付款，而不是单独的特定服务付款。这种“捆绑支付”计划最初是作为一项为期五年的随机试验实施的，分配给新支付模式的医院强制参与；然而，两年后，这些医院中有一半是自愿参加的。使用详细的索赔级别数据，我们记录了自愿参与更有可能在不改变行为的情况下增加收入的医院（“水平选择”）和在强制参与时行为发生较大变化的医院（“斜坡选择”）更有可能。为了评估反事实制度下的结果，我们估计了对项目的响应和选择的程式化模型。我们发现，目前的自愿制度导致向医院的转移效率低下，而替代（可行的）设计可以减少这些低效率的转移并提高福利。我们的分析强调了在自愿监管下要考虑的关键设计元素。我们发现，目前的自愿制度导致向医院的转移效率低下，而替代（可行的）设计可以减少这些低效率的转移并提高福利。我们的分析强调了在自愿监管下要考虑的关键设计元素。我们发现，目前的自愿制度导致向医院的转移效率低下，而替代（可行的）设计可以减少这些低效率的转移并提高福利。我们的分析强调了在自愿监管下要考虑的关键设计元素。