capital structure ownership and capital payment policy the case of hospitals this study examines effects of pertinent features of hospital capital payment policies on hospital capital structure decisions in a one period stochastic value maximization model separate models are developed for for profit and not for profit hospitals hospital debt to assets ratios are analyzed empirically using a cross section of data from the american hospital association although the effect on capital structure of hospital reliance on cost based reimbursement cannot be signed theoretically in both for profit and not for profit cases a higher cost based share leads to higher leverage factors associated with high bankruptcy risk e g earnings volatility cause hospitals to take on less debt the hospital industry exhibits two prominent characteristics that have unique implications for its capital structure first the majority of hospitals are organized as private not for profit nfp institutions since there is no applicable corporate income tax any risk of bankruptcy might imply that the nfp hospital would select an all equity hospital structure yet it is a stylized fact that almost all nfp hospitals have debt obligations at the same time there exists a sizeable minority of hospitals operated by government or as for profit organizations forprofit hospitals are subject to all tax privileges and obligations applicable to forprofit enterprises in other sectors thus the industry provides a laboratory for analysis of the effect of ownership on organizations capital structures a second unique feature of the industry is that almost all hospital revenue is derived from public and private insurers waldo et al 21 at least until very recently insurers in this industry paid hospitals on either a retrospective cost or

the growing supply of physicians has the market become more competitive the stock of u s physicians at any point in time is modeled as a weighted average of the supply that a perfect cartel would produce and that would prevail under perfect competition estimation of a system of stock and income equations over the post world war ii period shows that after holding constant demand and marginal cost conditions and accounting for gradual adjustment to changes in equilibrium the weighting parameter has moved toward the competitive extreme since 1965 this rise in the degree of competition is estimated to have increased physician stock by 6 20 and concomitantly decreased medical incomes by 19 45

the design of the university system abstract this paper compares the organisation of the university sector under unregulated private provision with the structure which would be chosen by a welfare maximising government it studies a general equilibrium model where students attend university to earn higher incomes in the labour market and universities teach them and carry out research each university chooses its tuition fee to maximise the amount of resources it can devote to research research bestows an externality on society government intervention needs to balance labour market efficiency considerations which would tend to equalise the number of students attending each university with considerations of efficiency on the production side which suggest that the most productive universities should teach more students and carry out more research we find that government concentrates research more that the private market would but less than it would like to do if it had perfect information about the productivity of universities it also allows fewer universities than would operate in a private system

outside options in a bargaining model with decay in the size of the cake abstract a simple bargaining model in which the cake decays over time at a positive rate is analysed in the limit the unique perfect equilibrium payoffs take the split the difference form these results generalise to three party bargaining

the supply of charity services by nonprofit hospitals motives and market structure this article studies provision of charity care by private nonprofit hospitals we demonstrate that in the absence of large positive income effects on charity care supply convex preferences for the nonprofit hospital imply crowding out by other private or government hospitals extending our model to include impure altruism rivalry provides a possible explanation for the previously reported empirical result that both crowding out and income effects on indigent care supply are often weak or insignificant empirical analysis of data for hospitals in maryland provides evidence of rivalry on the supply of charity care

hospital costs and competition for services a multiproduct analysis the authors estimate the effects of market structure on hospital costs using a translog multiproduct cost function recognizing the multiplicity of services provided by hospitals the results show that costs are substantially determined by service configuration and that there are distinct economies of size and sco pe the model also distinguishes market concentration measures by servic e type including obstetrics radiation therapy diagnostic imaging a nd surgery estimates show that after controlling for the other determinants of cost the degree of competition has only modest cost increasing effects copyright 1992 by mit press

migratory labor and agriculture farm workers are shown to respond strongly to economic incentives to seasonally migrate for work the economic model is specified with separate earnings structures for migratory and nonmigratory work and a reservation wage for migration is specified to reflect the choice between migratory and nonmigratory work the empirical model adjusts for self selectivity in the sample and demonstrates that domestic farm workers sort themselves into migratory and nonmigratory workers in a manner consistent with the theory of comparative advantage implications for immigration and government employment and training programs are considered

the returns from schooling in a diversified rural economy controlling for the endogeneity of activity choice and considering both household head and family schooling we findevid ence of high returns from schooling in both crop andnoncrop activities as schooling levels increase the returns from schooling shift away from crop production failure to control for activity selection andfamily schooling is likely to result in biasedestimates of the returns from schooling in individual activities copyright 2000 oxford university press

profit sharing credit market imperfections and equilibrium unemployment we investigate the interaction between labour and credit market imperfections for equilibrium unemployment in the presence of profit sharing in a partial equilibrium with exogenous outside options increased bargaining power of banks has adverse employment effects in a general equilibrium with endogenous outside options this relationship is frequently reversed reduced credit market imperfections increase equilibrium unemployment if the labour market imperfections measured by the bargaining power of trade unions are sufficiently strong and the benefit replacement ratio is sufficiently high finally we show that higher bankruptcy risks increase equilibrium unemployment under similar conditions

a declining farm workforce analysis of panel data from rural mexico analysis of nationally representative individual level panel data from 1980 to 2010 reveals a significant negative trend in the agricultural labor supply from rural mexico which is the primary source of hired workers for u s farms these findings offer an explanation for the rise over time in u s farm wages concomitants of the agricultural transformation including growth in the non farm economy falling birth rates and an increase in rural education accelerate the transition of rural mexicans out of farm work higher u s farm wages and increased border enforcement slow the transition but the combined impact of these offsetting variables is relatively small a diminishing farm labor supply has far reaching implications for farmers farm labor organizers rural communities and agricultural workers

enter at your own risk hmo participation and enrollment in the medicare risk market we examine hmo participation and enrollment in the medicare risk market for the years 1990 to 1995 we develop a profit maximization model of hmo behavior which explicitly considers potential linkages between an hmo s production decision in the commercial enrollee market and its participation and production decisions in the medicare risk market our results suggest that the payment rate is a primary determinant of hmo participation while the price of a supplemental medicare insurance policy positively affects hmo medicare enrollment we also find empirical support for the existence of complementarities in the joint production of an hmo s commercial and medicare products

the effects of for profit status and system membership on the financial performance of hospitals this research examines whether for profit status or system membership is significantly related to the financial performance of hospitals panel data containing 573 observations of florida hospitals for 1984 through 1987 are used in a fixed effects regression model the results indicate that it is system membership rather than forprofit status that is significantly related to better financial performance for profit status is unrelated to overall financial performance system hospitals have higher revenues per admission but not higher expenditures per admission than independent hospitals the findings are consistent with the hypothesis that expanding hospital systems target locations and services that are potentially profitable

nonprofit hospital mergers and the exercise of market power government challenges to mergers within the hospital industry have become more frequent many of those mergers involve nonprofit organizations rather than the for profit firms that are the norm in most other industries this difference in ownership has made no apparent difference in the antitrust agencies approach to proposed hospital mergers in this article i test the proposition that nonprofit and for profit hospitals price differently in response to the structure of the markets in which they compete based on a cross sectional analysis of california hospitals i find that estimated merger effects on hospital prices do vary by type of ownership in response to either higher market share or to the joint combination of higher share and higher market concentration private nonprofit hospital prices are statistically significantly lower than for profit hospital prices and on balance in this sample there is no evidence of any systematic price increasing effect on private nonprofit hospitals

is there a competitive market for hospital services this paper focuses on the price elasticity of hospital specific demand curves each hospital is assumed to practice price discrimination with respect to medicare medicaid and other patients among the third group patients covered by blue cross are analyzed separately from those who pay their own bills or are covered by commercial insurance or a health maintenance organization hmo we use two different methods to estimate the price elasticity of demand first a pricing rule is developed from which hospital specific price elasticities may be inferred second the distribution of each payer s admissions at specific hospitals is examined to determine if low priced hospitals attract more patients data for the analysis are taken from 31 hospitals in the minneapolis st paul metropolitan area in 1981 results of the first analytic method indicate that hospitals had monopoly power in their markets for blue cross and self pay commercial insurance hmo patients these results are confirmed and extended to medicare patients by the hospital demand analysis

measuring hospital efficiency with frontier cost functions this paper uses a stochastic frontier multiproduct cost function to derive hospital specific measures of inefficiency the cost function includes direct measures of illness severity output quality and patient outcomes to reduce the likelihood that the inefficiency estimates are capturing unmeasured differences in hospital outputs models are estimated using data from the aha annual survey medicare hospital cost reports and medpar we explicitly test the assumption of output endogeneity and reject it in this application we conclude that inefficiency accounts for 13 6 percent of total hospital costs this estimate is robust with respect to model specification and approaches to pooling data across distinct groups of hospitals

the determinants of nonfarm activities and incomes of rural households in mexico with emphasis on education abstract this paper presents the main results of a study of the effects of education as well as other household assets on the choice of activities and incomes of rural mexican households our study examines the various income sources as well as the education of the household s head and its members implications are drawn for rural education and development policies to promote rural nonfarm incomes and employment

sunk investment bargaining and choice of capital structure this paper shows how a firm might optimally choose debt to affect the outcome of bilateral bargaining with workers or other input suppliers it is shown that debt may alleviate the well known underinvestment problem associated with the inability to write precommitment contracts also in such circumstances debt could be pareto improving over complete equity financing the relationship between the optimal level of debt and asset specificity of investment and bargaining power of the firm vis a vis the workers is explored the williamson conjecture that higher asset specificity will lead to less debt is shown not to be valid in general

targeting the poor in mexico an evaluation of the selection of households into progresa abstract in this paper we conduct an evaluation of the targeting method used by health education and nutrition program progresa of mexico to identify beneficiary households we address two key questions a how well does progresa s targeting perform and b how does the program perform in terms of its impact on poverty alleviation relative to other feasible methods and transfer schemes the first question is accomplished by comparing progresa s method to an alternative selection method based on household consumption which is our preferred measure of welfare we employ the concepts of undercoverage and leakage and find that progresa selection method is more effective in identifying the extremely poor localities or households but less so when it comes to distinguishing among localities or households in the middle of the scale to address the second question we compare the potential impact of progresa on poverty alleviation against uniform transfers that involve no targeting at all targeting based on consumption and geographic targeting i e targeting at the locality level rather than at the household level we find that progresa s method of targeting households outperforms uniform coverage and targeting at the locality level in terms of reducing the poverty gap and severity of poverty indices even after taking into account the economic costs of targeting but the closeness of progresa s performance to what could be achieved by geographic targeting alone raises some serious questions about the costs and benefits associated with the practice of household targeting within poor localities

pricing behavior of non profit agencies the case of blood products abstract in this study we examine the pricing behavior of a non profit agency the american national red cross blood service units two alternative hypotheses are presented one in which the agency maximizes profits and one in which output is maximized subject to a breakeven constraint following a general approach developed by eckstein and fromm pricing equations for separate blood products are applied to cross sectional data from red cross blood centers to determine the impact of demand cost competition and subsidy variables the impact of these variables in particular the impact of the fixed subsidy on price is shown to be consistent with the output maximizing model

a nested logit migration model with selectivity in this paper we specify a multiple choice migration model with selectivity we estimate this model using observations on individuals drawn from the 1971 census of venezuela there are two main innovations in this paper we apply a correction for the presence of selectivity in wage equations in the context of a multiple choice migration model and we apply a less restrictive technique for modelling multiple discrete choices than in previous studies we study the choices of individuals among 23 states of venezuela each individual is observed to have chosen one state so one wage is observable per person our hypothesis is that individuals choose where to locate on the basis of an evaluation of costs and benefits associated with choosing each state we measure the benefits associated with choosing a given state by means of the wage a person could earn in this state since we observe only one wage for each person we have to impute the unobserved wages for the states this person did not choose in order to study the role of wages in migration however it is possible that unobserved factors which affect both an individual s choice of location and his wages may result in sample selection bias if we try to estimate state specific wage equations by ols on the basis of the self selected samples we apply an estimator proposed by lee 1983 to estimate state specific wage equations free from sample selection bias the wage equations permit us to investigate whether individuals who choose particular states earn different wages from observationally identical individuals drawn from the population at random in the context of a developing country where internal migration flows are large evidence on the selectivity of migration will enhance our understanding of an important labor market adjustment mechanism evidence that people who choose particular locations earn more in those locations than would observationally identical individuals drawn at random from the population positive selection will suggest that migration decisions are made according to the principle of comparative advantage in modelling the choice of location we test whether subsets of states are more highly similar to each other than to other states unobserved similarities between states may arise because of similar amenities or economic conditions which are not otherwise explicitly controlled for in the model we implement the

reimbursing health plans and health providers efficiency in production versus selection the tradeoff between an insurer s or medical provider s incentives to select good risks and to produce efficiently is governed by the supply price analog to the demand price tradeoff between moral hazard and risk aversion under a variety of models the optimum supply price is a mixture of capitation and fee for service payments empirical literature shows that pure capitation payment leaves strong incentives for selection that are acted upon the presence of contracting costs in a rothschild stiglitz model means a limited pooling equilibrium can exist and that poor risks will not be at their preferred outcome

the changing effects of competition on non profit and for profit hospital pricing behavior abstract has the nature of hospital competition changed from a medical arms race in which hospitals compete for patients by offering their doctors high quality services to a price war for the patients of payors this paper uses time series cross sectional methods on california hospital discharge data from 1986 1994 to show the association of hospital prices with measures of market concentration changed steadily over this period with prices now higher in less competitive areas even for non profit hospitals regression results are used to simulate the price impact of hypothetical hospital mergers

debt and wage negotiations a bankruptcy based approach the role of debt in wage negotiations is considered in a framework where both the entrepreneur and the workforce are indispensable in production when workers and the entrepreneur fail to reach an agreement the firm eventually defaults bankruptcy is represented as a three party bargaining game among the entrepreneur workers and lenders we show that debt financing by reducing workers bargaining power increases the firm s share of surplus and improves the incentives to invest further our model allows for overborrowing the firm borrows more than required by its productive activity as well as underinvestment due to wealth constraints i introduction as asserted by grout 1984 the inability of labour unions to make wage commitments creates an underinvestment problem when wages can be negotiated after investment has been sunk the entrepreneur chooses an inefficiently low investment level in this paper we reconsider grout s underinvestment problem by concentrating on the role of debt in wage bargaining when long term labour contracts cannot be written as we show through an explicit analysis of the threat of bankruptcy the extent of underinvestment depends on whether leverage can influence the distribution of surplus between wages and profits we analyse the relation between debt and wages in a strategic bargaining framework assuming that delays in agreement will reduce the surplus

migration of seasonal agricultural workers nearly half of all seasonal farm workers migrate at least 75 miles in a given year an expected earnings differential from migration weakly induces migration a 10 earnings differential raises the probability of migrating by slightly more than 1 this result indicates that there are substantial costs to migrating and that employers must offer large earnings premia to induce a substantial number of workers to move to their jobs some demographic groups earn substantially higher earnings by migrating these higher earnings from migration are primarily due to higher wages rather than more hours of work

school subsidies for the poor evaluating the mexican progresa poverty program abstract this paper evaluates how the progresa program which provides poor mothers in rural mexico with education grants has affected enrollment poor children who reside in communities randomly selected to participate in the initial phase of the progresa are compared to those who reside in other control communities pre program comparisons check the randomized design and double difference estimators of the program s effect on the treated are calculated by grade and sex probit models are also estimated for the probability that a child is enrolled controlling for additional characteristics of the child their parents local schools and community and for sample attrition to evaluate the sensitivity of the program estimates these estimates of program short run effects on enrollment are extrapolated to the lifetime schooling and the earnings of adults to approximate the internal rate of return on the public schooling subsidies as they increase expected private wages

quality and outside capacity in the provision of health services abstract this paper studies the effects of non contractibility of investment on the choices made by a health authority and a hospital which supplies a specific service non contractibility determines inefficiencies compared with any pareto efficient outcome the quality of the service chosen by the hospital is too low and the health authority relies too much on outside providers

insider forces and wage determination this paper investigates the relative importance of firm specific factors i e insider forces in wage determination using firm level data on 219 u k companies over 1974 82 it finds that a 1 percent rise in a firm s prices or productivity relative to the aggregate economy leads to a rise in relative wages of 0 1 0 2 percent as a corollary to this outside factors like the aggregate wage and the unemployment rate also play an important role there is evidence for insider based hysteresis effects but these are inversely related to the extent to which firms take national agreements into account copyright 1990 by royal economic society

income strategies among rural households in mexico the role of off farm activities abstract off farm activities generate on average more than half of farm households incomes in the mexican ejido sector participation in these activities helps reduce poverty and contributes to greater equality in the distribution of income this paper analyzes the determinants of access to off farm sources of income across households we find that education plays a major role in accessing better remunerated nonagricultural employment adults of indigenous ethnic origin suffer from an educational lag and have less access to off farm nonagricultural employment than non indigenous adults at identical educational levels the regional availability of off farm employment strongly affects participation in addition women are differentially limited by distance to urban centers in their ability to gain off farm employment

behavioural differences among hospitals it is ownership or location by about 1988 the consensus among leading health economists was that no meaningful differences existed among hospitals of differences owernership form and this position was embraced by the antitrust division of the us department of justice but behavioural differences among hospitals of different among hospitals of different owernership has continued to be a matter of both academic and judicial interest recent empirical studies have concluded that real differences do exist while many earlier studies reached the opposite conclusion this contradiction in finding over time as competition intensified is exactly opposite to what expense preference theory would predict we examine this apparent paradox using a very general test of behavioural differences by hospital ownership we find that the omission of location specific variables can lead to biased estimates of ownership effects and that no significant behavioural differences exist among private california hospitals in 1986 90 when this source of o

nonprofit organizations revised theory and new evidence it is apparent that comprehensive analysis requires at least some application of elementary axioms from the economics of politics or public choice one of these implies that because of asymmetric costs of political participation some suppliers of goods and services usually do better for themselves out of lobbying and organization than do others moreover for the same reason dispersed consumers would appear to do worst of all legislation and policy on nonprofit organization seems to be one of many examples of this phenomenon in this case however the supply side lobbyists are aided by an ancient and deep seated popular prejudice against profit making the man in the street has apparently not yet fully grasped the point that so long as competition is possible the profit inducement acts as a continued incentive to minimize costs constantly and indiscriminately to condone pejorative language against profits is to create a climate that results in legislation giving unprecedented new profit opportunities via not for profit organizations and such increased rewards can result in social harm rather than social gain granted there may be cases that justify nonprofits in some circumstances preston 1988 the fact remains that the costs of separating and monitoring these cases at least at federal level would appear to be overwhelming the nonprofit system that is usually advocated calls for a federal general tax exemption yet the value of this advantage is the same to all nonprofit firms whereas we need to know the extent of the particular social benefits generated in each particular case so as to give tailor made government assistance and since in very many instances the social benefits are negative the government s shotgun approach appears highly questionable

profit variability in for profit and not for profit hospitals this paper proposes two tests of the hypothesis that not for profit hospitals nfps behave differently than for profit hospitals the profit variability test states that the profits of an nfp will be less variable over time than profits of a for profit hospital if the nfp maximizes utility subject to a profit constraint the second test examines whether nfp profits respond less to change in exogenous factors such as medicare reimbursement rates than profits of for profit hospitals both tests performed on panel data from 1983 to 1988 support the hypothesis that nfps behave differently than for profit hospitals

an international comparison of hospital efficiency does institutional environment matter the consensus among many health economists is that no meaningful performance differences exist among for profit and non profit hospitals in the us but this topic has continued to be a matter of academic judicial and public policy interest a similar debate has ensued internationally regarding the potential efficiency gains from privatization of public enterprises in this paper we examine empirical evidence from the public highly regulated norwegian hospital sector and the private highly competitive and unregulated california hospital sector to ascertain whether institutional environment and level of market competition significantly affect the degree of productive efficiency in hospitals we compare and discuss the productive efficiency of four similar sets of hospitals operating in different institutional and competitive environments the four samples are carefully matched in the dimensions of sample size hospital size and average lengths of stay heterogeneity in output definition is used to co

the specification of a hospital cost function a comment on the recent literature in the empirical estimation of hospital cost functions two radically different types of specifications have been chosen to date ad hoc forms and flexible functional forms based on neoclassical production theory this paper discusses the respective strengths and weaknesses of both approaches and emphasizes the apparently unreconcilable conflict between the goals of maintaining functional flexibility and keeping the number of variables manageable if at the same time patient heterogeneity is to be adequately reflected in the case mix variables a new specification is proposed which strikes a compromise between these goals and the underlying assumptions are discussed critically

hospital profits the effects of reimbursement policies this paper provides a theoretical and empirical analysis of the effect of cost based reimbursement cbr on hospital costs and charges it takes issue with previous analyses which have treated cbr as paying economic costs plus a mark up and have concluded that the mark up is too small to significantly distort hospital decision making the basic thesis here is that if reimbursement is based on costs accounting costs become a price to cost paying patients and will be optimized to maximize revenue a hospital serving both cost and charge paying private patients can set two price schedules accounting profits ratio of charges to costs are not a measure of economic profit but of relative prices to these two groups of patients in the absence of constraints from regulation or patient co payment the optimum level of accounting costs would be infinite in practice the medicare reimbursement formula links allowable costs to charges received from charge paying patients this formula creates incentives for the hospital to raise charges above the single price profit maximizing monopoly level this inflationary effect of the medicare formula does not presuppose that medicare pays less than full cost the empirical analysis of hospital laboratory costs and charges generally supports the predictions for other departments the conclusions are consistent but more tentative because of data limitations overall evidence suggests minimal cross subsidy between cost and charge paying patients comparisons of cost and charge levels in for profit voluntary non profit and government hospitals are presented but it is emphasized that inferences about relative efficiency and profitability cannot be drawn from accounting data given the incentives created by cbr

undocumented mexico u s migration and the returns to households in rural mexico this paper presents estimates of net income gains to a sample of households in rural mexico from sending migrants illegally to the united states correcting for sample selectivity bias and it examines the role of expected income gains in driving illegal mexico u s migration there is no evidence that people who migrate illegally to the united states are above average contributors to household income either as workers in mexico or as mexico u s migrants however other things being equal villagers who are in the best position to contribute to household income as workers in mexico are positively selected not to migrate to the united states

market share and the illusion of power can blue cross force hospitals to discount researchers in health care financing have claimed that large private insurers like blue cross frequently exercise monopsony power to obtain discounts from normal hospital charges they claim that the monopsony power derives from a large blue cross share of a given hospital cost shifting whereby hospitals offset the discount by raising charges to less powerful customers this paper re examines both theoretically and empirically the conditions necessary for a private insurer to extract discounts from a hospital we demonstrate that the theoretical conditions necessary for blue cross to force a discount do not exist in the indiana market using revenue data from 110 indiana hospitals we reject the traditional claim that blue cross pays less than other insurers as a function of market share

voluntary and proprietary hospital behavioural response to socio economic stimuli this paper contributes to the literature on the economic aspects of hospital behaviour in the united states in these substantive ways 1 a theoretical basis for incorporating socio economic variables in the form of indices into our analysis of hospital behaviour is presented 2 it is found that hospitals of the same ownership type exhibit different economic behaviour when located in different socio economic environments in fact our results indicate that the prevailing assumption of structural homogeneity among differing ownership types is incorrect 3 findings further suggest that the relative affluence of an urban area is a better determinant of the impact of factor price variation among hospitals than the extent of urbanization alone finally the cost function specified here has broad implications for future empirical studies of hospital behaviour it is found that the flexible form quadratic approximation estimated generally gives theoretically consistent results