Hospital Reimbursement in the Presence of Cherry Picking and Upcoding

Published Online:https://doi.org/10.1287/mnsc.2023.4752

References

  • Adida E, Bravo F (2019) Contracts for healthcare referral services: Coordination via outcome-based penalty contracts. Management Sci. 65(3):1322–1341.LinkGoogle Scholar
  • Adida E, Mamani H, Nassiri S (2017) Bundled payment vs. fee-for-service: Impact of payment scheme on performance. Management Sci. 63(5):1606–1624.LinkGoogle Scholar
  • Alexander D (2020) How do doctors respond to incentives? Unintended consequences of paying doctors to reduce costs. J. Political Econom. 128(11):4046–4096.CrossrefGoogle Scholar
  • Arifoğlu K, Ren H, Tezcan T (2020) Hospital readmissions reduction program does not provide the right incentives: Issues and remedies. Management Sci. 67(4):2191–2210.Google Scholar
  • Aswani A, Shen Z-JM, Siddiq A (2019) Data-driven incentive design in the medicare shared savings program. Oper. Res. 67(4):1002–1026.AbstractGoogle Scholar
  • Busse R, Geissler A, Aaviksoo A, Cots F, Häkkinen U, Kobel C, Mateus C, et al. (2013) Diagnosis related groups in Europe: Moving toward transparency, efficiency, and quality in hospitals? BMJ. 346:f3197.CrossrefGoogle Scholar
  • Chen C, Savva N (2018) Unintended consequences of hospital regulation: The case of the hospital readmissions reduction program. Preprint, submitted September 3, https://dx.doi.org/10.2139/ssrn.3236983.Google Scholar
  • CMS.gov (2021a) Acute inpatient PPS. Accessed April 5, 2023, https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS.Google Scholar
  • CMS.gov (2021b) HRRP readmission measures. Accessed April 5, 2023, https://qualitynet.cms.gov/inpatient/measures/readmission/methodology.Google Scholar
  • Dafny LS (2005) How do hospitals respond to price changes? Amer. Econom. Rev. 95(5):1525–1547.CrossrefGoogle Scholar
  • Darby MR, Karni E (1973) Free competition and the optimal amount of fraud. J. Law Econom. 16(1):67–88.CrossrefGoogle Scholar
  • Debo LG, Toktay LB, Van Wassenhove LN (2008) Queuing for expert services. Management Sci. 54(8):1497–1512.LinkGoogle Scholar
  • Delana K, Savva N, Tezcan T (2021) Proactive customer service: Operational benefits and economic frictions. Manufacturing Service Oper. Management 23(1):70–87.LinkGoogle Scholar
  • Dranove D (1987) Rate-setting by diagnosis related groups and hospital specialization. RAND J. Econom. 18(3):417–427.CrossrefGoogle Scholar
  • Dulleck U, Kerschbamer R (2006) On doctors, mechanics, and computer specialists: The economics of credence goods. J. Econom. Literature 44(1):5–42.CrossrefGoogle Scholar
  • Ellis RP (1998) Creaming, skimping and dumping: Provider competition on the intensive and extensive margins. J. Health Econom. 17(5):537–555.CrossrefGoogle Scholar
  • Ellis RP, McGuire TG (1986) Provider behavior under prospective reimbursement: Cost sharing and supply. J. Health Econom. 5(2):129–151.CrossrefGoogle Scholar
  • Fetter RB (1991) Diagnosis related groups: Understanding hospital performance. Interfaces 21(1):6–26.LinkGoogle Scholar
  • Freeman M, Savva N, Scholtes S (2020) Economies of scale and scope in hospitals: An empirical study of volume spillovers. Management Sci. 67(2):3147–3167.Google Scholar
  • Gottschalk F, Mimra W, Waibel C (2020) Health services as credence goods: A field experiment. Econom. J. (London) 130(629):1346–1383.Google Scholar
  • Greenwald L, Cromwell J, Adamache W, Bernard S, Drozd E, Root E, Devers K (2006) Specialty vs. community hospitals: Referrals, quality, and community benefits. Health Affairs 25(1):106–118.CrossrefGoogle Scholar
  • Guo P, Tang CS, Wang Y, Zhao M (2019) The impact of reimbursement policy on social welfare, revisit rate, and waiting time in a public healthcare system: Fee-for-service vs. bundled payment. Manufacturing Service Oper. Management 21(1):154–170.LinkGoogle Scholar
  • Gupta D, Mehrotra M (2015) Bundled payments for healthcare services: Proposer selection and information sharing. Oper. Res. 63(4):772–788.LinkGoogle Scholar
  • Heskett JL (2003) Shouldice Hospital Limited. HBS Case 9-683-068 (Harvard Business School, Boston).Google Scholar
  • Holmstrom B (1982) Moral hazard in teams. Bell J. Econom. 13(2):324–340.CrossrefGoogle Scholar
  • Jiang H, Pang Z, Savin S (2012) Performance-based contracts for outpatient medical services. Manuf. Serv. Oper. Manag. 14(4):654–669.LinkGoogle Scholar
  • Jiang H, Pang Z, Savin S (2020) Performance incentives and competition in healthcare markets. Production Oper. Management 29(5):1145–1164.CrossrefGoogle Scholar
  • Jürges H, Köberlein J (2015) What explains DRG upcoding in neonatology? The roles of financial incentives and infant health. J. Health Econom. 43:13–26.Google Scholar
  • KC D, Terwiesch C (2011) The effects of focus on performance: Evidence from California hospitals. Management Sci. 57(11):1897–1912.LinkGoogle Scholar
  • Laffont JJ, Tirole J (1993) A Theory of Incentives in Procurement and Regulation (MIT Press, Cambridge, MA).Google Scholar
  • Latta VB, Helbing C (1991) Medicare short-stay hospital services by diagnosis-related groups. Health Care Financial Rev. 12(4):105.Google Scholar
  • Lee DKK, Zenios SA (2012) An evidence-based incentive system for Medicare’s End-Stage Renal Disease program. Management Sci. 58(6):1092–1105.LinkGoogle Scholar
  • Lefouili Y (2015) Does competition spur innovation? The case of yardstick competition. Econom. Lett. 137:135–139.CrossrefGoogle Scholar
  • Ma CA (1994) Healthcare payment systems: Cost and quality incentives. J. Econom. Management trategy. 3(1):93–112.CrossrefGoogle Scholar
  • Mayes R (2007) The origins, development, and passage of Medicare’s revolutionary prospective payment system. J. History Medicine Allied Sci. 62(1):21–55.CrossrefGoogle Scholar
  • Nalebuff BJ, Stiglitz JE (1983) Information, competition, and markets. Amer. Econom. Rev. 73(2):278–283.Google Scholar
  • Naor P (1969) The regulation of queue size by levying tolls. Econometrica 37(1):15–24.CrossrefGoogle Scholar
  • Nassiri S, Adida E, Mamani H (2021) Reference pricing for healthcare services. Manufacturing Service Oper. Management 24(2):921–937.Google Scholar
  • Newhouse JP (1989) Do unprofitable patients face access problems? Health Care Financial Rev. 11(2):33.Google Scholar
  • Newhouse JP (1996) Reimbursing health plans and health providers: Efficiency in production vs. selection. J. Econom. Literature 34(3):1236–1263.Google Scholar
  • NHS Digital (2021) Patient level information and costing system (plics) data collections. Accessed April 5, 2023, https://digital.nhs.uk/data-and-information/data-tools-and-services/data-services/patient-level-information-and-costing-system-plics-data-collections.Google Scholar
  • Pope GC (1989) Hospital nonprice competition and Medicare reimbursement policy. J. Health Econom. 8(2):147–172.CrossrefGoogle Scholar
  • Psaty BM, Boineau R, Kuller LH, Luepker RV (1999) The potential costs of upcoding for heart failure in the United States. Amer. J. Cardiology 84(1):108–109.CrossrefGoogle Scholar
  • Savva N, Tezcan T, Yildiz Ö (2019) Can yardstick competition reduce waiting times? Management Sci. 65(7):3196–3215.LinkGoogle Scholar
  • Shactman D (2005) Specialty hospitals, ambulatory surgery centers, and general hospitals: Charting a wise public policy course. Health Affairs 24(3):868–873.CrossrefGoogle Scholar
  • Shleifer A (1985) A theory of yardstick competition. RAND J. Econom. 16(3):319–327.CrossrefGoogle Scholar
  • Silverman E, Skinner J (2004) Medicare upcoding and hospital ownership. J. Health Econom. 23(2):369–389.CrossrefGoogle Scholar
  • So KC, Tang CS (2000) Modeling the impact of an outcome-oriented reimbursement policy on clinic, patients, and pharmaceutical firms. Management Sci. 46(7):875–892.LinkGoogle Scholar
  • Sobel J (1999) A reexamination of yardstick competition. J. Econom. Management Strategy 8(1):33–60.CrossrefGoogle Scholar
  • Tangerås TP (2009) Yardstick competition and quality. J. Econom. Management Strategy 18(2):589–613.CrossrefGoogle Scholar
  • Victoor A, Delnoij D, Friele R, Rademakers J (2016) Why patients may not exercise their choice when referred for hospital care. An exploratory study based on interviews with patients. Health Expectations 19(3):667–678.CrossrefGoogle Scholar
  • Zhang DJ, Gurvich I, Van Mieghem JA, Park E, Young RS, Williams MV (2016) Hospital readmissions reduction program: An economic and operational analysis. Management Sci. 62(11):3351–3371.LinkGoogle Scholar
  • Zorc S, Chick SE, Hasija S (2017) Outcomes-based reimbursement policies for chronic care pathways Working paper, INSEAD, Fontainebleau, France.Google Scholar
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