A. Dale Tussing

THE CESAREAN DECISION IN NEW YORK STATE, 1986 : ECONOMIC AND NONECONOMIC ASPECTS

This study describes a research project involving economic and noneconomic aspects of the cesarean decision. The study was based on a 1986 data set dealing with 68,847 obstetric deliveries in New York State excluding New York City, and had the largest number of variables known to have been assembled to analyze the cesarean decision. The authors estimated a probit multiple regression in which the dependent variable was the method of delivery. The results diverge from widely held beliefs and research findings in some areas, and are of considerable interest in other areas. Contrary to other findings, the authors did not find a relationship between date of graduation from medical school and the probability of a cesarean section. More importantly, the authors failed to find much support for the idea that obstetricians perform cesareans to enrich themselves from the additional fee income. However, our findings are consistent with the idea that obstetricians occasionally perform cesarean sections to manage their time, which does represent a form of economic self-interest. The study developed a proxy measure for fear of malpractice and found a negative relationship between fear of malpractice and cesarean section use. Finally, county cesarean rate and adjusted hospital cesarean section rate strongly and significantly influenced the probability that a given delivery is performed by cesarean section.

Malpractice, defensive medicine, and obstetric behavior.

OBJECTIVES The authors examine 58,441 obstetric deliveries in New York State outside New York City to test for the existence of defensive medicine in obstetrics. METHODS The data consist of merged vital statistics and hospital discharge records from the New York State Department of Health, together with other merged variables. Physician fear of malpractice is proxied by cumulative obstetric malpractice suits by county for 1975 through 1986. A generalized probit analysis is used. RESULTS Malpractice exposure is shown to influence slightly the use of the electronic fetal monitor (EFM), a major diagnostic tool. Use of the EFM is shown to influence the diagnosis of fetal distress; fear of malpractice influences this diagnosis both directly and through the EFM. The diagnosis of fetal distress significantly affects the choice of cesarean section (c-section) as a method of delivery; hence, fear of malpractice influences the choice of a c-section both directly and through the diagnosis of fetal distress. Failure to include indirect effects via diagnostic procedures and diagnosis would result in an underestimate of the effect of fear of malpractice. Of an overall c-section rate of 27.6% in the data set, fear of malpractice accounts for an estimated 6.6 percentage points, of which 4.4 percentage points reflect a direct effect, and the remaining 2.2 percentage points reflect the effect of malpractice exposure on the use of the EFM and, directly and indirectly, the diagnosis of fetal distress. CONCLUSIONS The results appear to confirm the existence of defensive medicine in obstetrics. Whether this is a desirable or undesirable effect remains ambiguous, but it is costly.

Social science in the land of saints and scholars: Policy research in Ireland

Drawing on the authors experiences as an American social scientist working in Ireland on policy-oriented research relating to education and health, the paper discusses differences between such research in Ireland and the USA. In general, differences are due to the small size of the country; its lower level of economic development; the lack of a developed literature in the fields in which the author worked; the lack of published data; and cultural differences affecting scholarship, such as the lower level of competitiveness in human relations. In addition, policy-oriented social science research gets considerable media attention in Ireland. The very considerable attention given the authors work astonished him. The author illustrates the points made with accounts of his own experiences.

Inter-Regional Competition in Retirement Benefit Growth—The Role of the Sub-National Government in Authoritarian China

Abstract After the Chinese central government announced a policy of raising retirement benefits in 2005, there ensued a race to the top in pension benefit growth among its 31 provincial units. This study seeks to explain how this seemingly unusual nationwide social welfare expansion came about in authoritarian China. It helps to open up the black box of mysterious Chinese politics. The study highlights the roles of sub-national governments in decentralized Chinese social welfare policymaking. Instead of treating authoritarian rulers as unitary actors, this study looks into the interplay of center and provinces in a decentralized authoritarian political system. Compared with the center, provinces have traditionally been more reluctant to devote economic resources to social welfare. To motivate provincial governments to implement a policy of increased benefits, the center granted fiscal subsidies to certain provinces. This special subsidy program had three effects: (1) it reduced the provincial costs of the benefit increase; (2) it elevated the center’s annual fiscal transfer base for subsidized provincial governments beyond the current year, into the future; and (3) it increased disposable personal income, a key indicator of local government officials’ political merits in the cadre evaluation system. Inter-provincial competition in raising retirement benefits is explained, first, by provinces’ desires to earn greater fiscal subsidies from the center; and, second, by the efforts of those provinces which did not receive the subsidies to keep their benefit levels up with the levels of those which did. The result of the center’s subsidy program was not only a rise in pension levels, but also an increase in inter-regional social welfare disparities. The central government, perhaps alarmed by the consequences of its policy, acted to bring the rapid expansion of pension levels to an apparent end in 2016.

The agency role of the physician in Ireland, Britain, and the USA

The USA and Britain have medical care delivery and financing systems which are polar opposites. The Irish system incorporates important features of both. Using original household survey data of medical care utilization in Ireland, and published data and studies of the USA and Britain, the effect of the incentive structures in the three systems on physician behavior, especially on the so-called agency role, is examined. We conclude that the incentive structure is of the utmost importance to policy makers concerned with health costs and economic rationality of medical care systems.