Pierre Thomas Léger

Treatment and referral decisions under different physician payment mechanisms

This paper analyzes and compares the incentive properties of some common payment mechanisms for GPs, namely fee for service (FFS), capitation and fundholding. It focuses on gatekeeping GPs and it specifically recognizes GPs heterogeneity in both ability and altruism. It also allows inappropriate care by GPs to lead to more serious illnesses. The results are as follows. Capitation is the payment mechanism that induces the most referrals to expensive specialty care. Fundholding may induce almost as much referrals as capitation when the expected costs of GPs care are high relative to those of specialty care. Although driven by financial incentives of different nature, the strategic behaviors associated with fundholding and FFS are very much alike. Finally, whether a regulator should use one or another payment mechanism for GPs will depend on (i) his priorities (either cost-containment or quality enhancement) which, in turn, depend on the expected cost difference between GPs care and specialty care, and (ii) the distribution of profiles (diagnostic ability and altruism levels) among GPs.

Self-Selection in Migration and Returns to Unobservable Skills

Several papers have tested the empirical validity of the migration models proposed by Borjas (1987) and Borjas, Bronars, and Trejo (1992). However, to our knowledge, none has been able to disentangle the separate impact of observable and unobservable individual characteristics, and their respective returns across different locations, on an individuals decision to migrate. We build a model in which individuals sort, in part, on potential earnings - where earnings across different locations are a function of both observable and unobservable characteristics. We focus on the inter-provincial migration patterns of Canadian physicians. We choose this particular group for several reasons including the fact that they are paid on a fee-for-service basis. Since wage rates are exogenous, earning differentials are driven by differences in productivity. We then estimate a mixed conditional-logit model to determine the effects of individual and destination-specific characteristics (particularly earnings differentials) on physician location decisions. We find, among other things, that high-productivity physicians (based on unobservables) are more likely to migrate to provinces where the productivity premium is greater, while low-productivity physicians are more likely to migrate to areas where the productivity premium is lower. These results are consistent with a modified Borjas model of self-selection in migration based on both unobservables and observables.

The Living Arrangement Dynamics of Sick, Elderly Individuals

We model the dynamics associated with living-arrangement decisions of sick elderly individuals. Using the Panel Study of Income Dynamics’ Parental Health Supplement, we construct the complete living-arrangement histories of elderly individuals in need of care. We use a simultaneous random-effects competing-risks model to analyze the impact of demographic characteristics, health, and wealth on the living-arrangement decisions of sick elderly individuals while taking into account state and duration dependence as well as unobserved heterogeneity. We find that the sick elderly individual’s current living arrangement as well as the time spent in that living arrangement serve as important predictors of future living-arrangements.

Quality control mechanisms under capitation payment for medical services

As a result of rising health care costs, many countries, including the United States, have turned to managed care organizations and the use of capitation payment systems. Although this type of system is an effective mechanism for reducing excessive utilization of health care, it may lead to the underprovision of medical services. In this paper propensity to underprovide medical services in a prepayment system as well as the effects of auditing/monitoring on physician behaviour and patient well-being are examined. Conditions are found under which managed care yields more efficient outcomes than traditional fee-for-service care.

Estimating differences between male and female physician service provision using panel data

Using panel data, we estimate the impact of an increasing share of female physicians on the total output of Canadian physicians. A micro-econometric model is developed specifically for the Canadian context and estimated using administrative data on all Canadian physicians paid on a fee-for-service basis from 1989 to 1998. Our results suggest that female physicians systematically provide fewer services than their male counterparts for almost all specialties and provinces studied. Given that females account for an increasing share of the physician population and that female physicians provide, on average, fewer services, potentially important future reductions in total health-care service provision are likely.

Payment mechanism and GP self-selection: capitation versus fee for service.

This paper analyzes the consequences of allowing gatekeeping general practitioners (GPs) to select their payment mechanism. We model GPs’ behavior under the most common payment schemes (capitation and fee for service) and when GPs can select one among them. Our analysis considers GP heterogeneity in terms of both ability and concern for their patients’ health. We show that when the costs of wasteful referrals to costly specialized care are relatively high, fee for service payments are optimal to maximize the expected patients’ health net of treatment costs. Conversely, when the losses associated with failed referrals of severely ill patients are relatively high, we show that either GPs’ self-selection of a payment form or capitation is optimal. Last, we extend our analysis to endogenous effort and to competition among GPs. In both cases, we show that self-selection is never optimal.

Firm-Sponsored Classroom Training: is it Worth it for Older Workers ?

We use longitudinal linked employer-employee data and find that the probability of participating in firm-sponsored classroom training diminishes rapidly for workers aged 45 years and older. Although the standard human capital investment model predicts such a decline, we also consider the possibility that returns to training decline with age. Taking into account endogenous training decisions, we find that the training wage premium diminishes only slightly with age. However, estimates of the impact of training on productivity decrease dramatically with age, suggesting that incentives for firms to invest in classroom training are much lower for older workers.

Firm-Sponsored Classroom Training: Is It Worth It for Older Workers?

We use longitudinal linked employer-employee data and find that the probability of participating in firm-sponsored classroom training diminishes with age. Although the standard human capital investment model predicts such a decline, we also consider the possibility that the wage and productivity impacts of training decline with age. Taking into account endogenous training decisions, we find that the training wage premium diminishes only slightly with age. However, estimates of the impact of training on productivity decrease dramatically with age, suggesting that incentives for firms to invest in classroom training are much lower for older workers.