Health shocks, health and labor market dynamics, and the socioeconomic-health gradient in older Singaporeans.

Health disparities by socioeconomic status (SES) are potentially shaped by how an individual's health status and work capacity are affected by the incidence of illness, and how these effects vary across SES groups. We examine the impact of illness on the dynamics of health status, work activity and income in older Singaporeans to gain new insights on how ill health shapes the socioeconomic health gradient. Our data comprise of 60 monthly waves (2015-2019) of panel survey data containing 445,464 person-observations from 11,827 unique respondents from Singapore. We apply a matched event-study difference-in-differences research design to track how older adults' health and work changes following the diagnosis of heart disease and cancer. Our focus is how the dynamics of health and work differ for different SES groups, which we measure by post-secondary education attainment. We find that the dynamics of how self-assessed health recovers following the diagnosis of a new heart disease or cancer do not vary significantly across SES groups. Work activity however varies significantly, with less well-educated males and females being significantly less likely to be in active employment and have income from work, and are marginally more likely to be in retirement following the onset of ill health. By contrast, more well-educated males work more, and earn more a year after the health shock than they did before they fell ill. Occupational differences likely played a role in how work activity of less well-educated men decline more after an acute health event compared with more well-educated men. Understanding the drivers of the socioeconomic health gradient necessitates a focus on individual-level factors, as well as system-level influences, that affect health and work.

The relationship between hospital ownership, in-hospital mortality, and medical expenses: an analysis of three common conditions in China.

BACKGROUND: Private hospitals expanded rapidly in China since 2009 following its national health reform encouraging private investment in the hospital sector. Despite long-standing debates over the performance of different types of hospitals, empirical evidence under the context of developing countries remains scant. We investigated the disparities in health care quality and medical expenses among public, private not-for-profit, and private for-profit hospitals. METHODS: A total of 64,171 inpatients (51,933 for pneumonia (PNA), 9,022 for heart failure (HF) and 3,216 for acute myocardial infarction (AMI)) who were admitted to 528 secondary hospitals in Sichuan province, China, during the fourth quarters of 2016, 2017, and 2018 were selected for this study. Multilevel logistic regressions and multilevel linear regressions were utilized to assess the relationship between hospital ownership types and in-hospital mortality, as well as medical expenses for PNA, HF, and AMI, after adjusting for relevant hospital and patient characteristics, respectively. RESULTS: The private not-for-profit (adjusted OR, 1.69; 95% CI, 1.08, 2.64) and for-profit (adjusted OR, 1.67; 95% CI, 1.06, 2.62) hospitals showed higher in-hospital mortality than the public ones for PNA, but not for AMI and HF. No significant differences were found in medical expenses across hospital ownership types for AMI, but the private not-for-profit was associated with 9% higher medical expenses for treating HF, while private not-for-profit and for-profit hospitals were associated with 10% and 11% higher medical expenses for treating PNA than the public hospitals. No differences were found between the private not-for-profit and private for-profit hospitals both in in-hospital mortality and medical expenses across the three conditions. CONCLUSION: The public hospitals had at least equal or even higher healthcare quality and lower medical expenses than the private ones in China, while private not-for-profit and for-profit hospitals had similar performances in these aspects. Our results added evidences on hospitals' performances among different ownership types under China's context, which has great potential to inform the optimization of healthcare systems implemented among developing countries confronted with similar challenges.

The effect of income-based mandates on the demand for private hospital insurance and its dynamics.

We examine the effect of an income-based mandate on the demand for private hospital insurance and its dynamics in Australia. The mandate, known as the Medicare Levy Surcharge (MLS), is a levy on taxable income that applies to high-income individuals who choose not to buy private hospital insurance. Our identification strategy exploits changes in MLS liability arising from both year-to-year income fluctuations, and a reform where income thresholds were increased significantly. Using data from the Household, Income and Labour Dynamics in Australia longitudinal survey, we estimate dynamic panel data models that account for persistence in the decision to purchase insurance stemming from unobserved heterogeneity and state dependence. Our results indicate that being subject to the MLS penalty in a given year increases the probability of purchasing private hospital insurance by between 2 to 3 percent in that year. If subject to the penalty permanently, this probability grows further over the following years, reaching 13 percent after a decade. We also find evidence of a marked asymmetric effect of the MLS, where the effect of the penalty is about twice as large for individuals becoming liable compared with those going from being liable to not being liable. Our results further show that the mandate has a larger effect on individuals who are younger.

How do gender differences in family responsibilities affect doctors' labour supply? Evidence from Australian panel data.

We use nine annual waves of a unique longitudinal dataset of Australian doctors to examine how children and family responsibilities influence the number of hours worked by female and male medical doctors. We exploit the longitudinal feature of the data to investigate how hours worked change in response to within-doctor changes in family circumstances over time. We find strong evidence of a 'carer effect' of having children for female doctors, whose working hours are significantly reduced by the presence of children, the number of children, and young children. The working hours by female doctors are also strongly influenced by the employment status of their spouses. In contrast, for male doctors, having children leads to a slight increase in hours worked. The effect of children in dual medical career households is highly asymmetric: female doctors reduce their hours worked by a very large margin, whereas male doctors report not changing their working hours. Finally we also find evidence of heterogeneous effects of how family circumstances affect hours worked across different quantiles of hours worked.

Monthly spending dynamics of the elderly following a health shock: Evidence from Singapore.

We use novel longitudinal data from 19 monthly waves of the Singapore Life Panel to examine the short-term dynamics of the effects health shocks have on household health and nonhealth spending and income by the elderly. The health shocks we study are the occurrence of new major conditions such as cancer, heart problems, and minor conditions (e.g., diabetes and hypertension). Our empirical strategy is based on an event study approach that exploits unanticipated changes in health status through the diagnosis of new health conditions. We find that major shocks have large and persistent effects whereas minor shocks have small and mainly contemporaneous effects. We find that household income reduces following a major shock for males but not females. Major health shocks lead to a decrease in households' nonhealth expenditures that is particularly pronounced for cancer and stroke sufferers, driven largely by reductions in leisure spending. The financial impact of major shocks on medical saving account balances occurs to those without private health insurance, whereas the impact is on cash balances for privately insured individuals.

DO YOU HAVE TO WIN IT TO FIX IT? A Longitudinal Study of Lottery Winners and Their Health-Care Demand.

We exploit lottery wins to investigate the effects of exogenous changes to individuals' income on the utilization of health care services, and the choice between private and public health care in the United Kingdom. Our empirical strategy focuses on lottery winners in an individual fixed effects framework and hence the variation of winnings arises from within-individual differences in small versus large winnings. The results indicate that lottery winners with larger wins are more likely to choose private health services than public health services from the National Health Service. The positive effect of wins on the choice of private care is driven largely by winners with medium to large winnings (win category > £500 (or US$750); mean = £1922.5 (US$2,893.5), median = £1058.2 (US$1592.7)). There is some evidence that the effect of winnings vary by whether individuals have private health insurance. We also find weak evidence that large winners are more likely to take up private medical insurance. Large winners are also more likely to drop private insurance coverage between approximately 9 and 10 months earlier than smaller winners, possibly after their winnings have been exhausted. Our estimates for the lottery income elasticities for public health care (relative to no care) are very small and are not statistically distinguishable from zero; those of private health care range from 0 - 0.26 for most of the health services considered, and 0.82 for cervical smear.

LONGITUDINAL EVIDENCE FOR A MIDLIFE NADIR IN HUMAN WELL-BEING: RESULTS FROM FOUR DATA SETS.

There is a large amount of cross-sectional evidence for a midlife low in the life cycle of human happiness and well-being (a 'U shape'). Yet no genuinely longitudinal inquiry has uncovered evidence for a U-shaped pattern. Thus, some researchers believe the U is a statistical artefact. We re-examine this fundamental cross-disciplinary question. We suggest a new test. Drawing on four data sets, and only within-person changes in well-being, we document powerful support for a U shape in longitudinal data (without the need for formal regression equations). The article's methodological contribution is to use the first-derivative properties of a well-being equation.

Attrition Bias in Panel Data: A Sheep in Wolf's Clothing? A Case Study Based on the Mabel Survey.

This paper investigates the nature and consequences of sample attrition in a unique longitudinal survey of medical doctors. We describe the patterns of non-response and examine if attrition affects the econometric analysis of medical labour market outcomes using the estimation of physician earnings equations as a case study. We compare the econometric gestimates obtained from a number of different modelling strategies, which are as follows: balanced versus unbalanced samples; an attrition model for panel data based on the classic sample selection model; and a recently developed copula-based selection model. Descriptive evidence shows that doctors who work longer hours, have lower years of experience, are overseas trained and have changed their work location are more likely to drop out. Our analysis suggests that the impact of attrition on inference about the earnings of general practitioners is small. For specialists, there appears to be some evidence for an economically significant bias. Finally, we discuss how the top-up samples in the Medicine in Australia: Balancing Employment and Life survey can be used to address the problem of panel attrition.

Changes in Doctors' Working Hours: A Longitudinal Analysis.

The study examined changes in doctors' working hours and satisfaction with working hours over five time points and explored the influence of personal characteristics on these outcomes. Latent growth curve modeling was applied to Medicine in Australia: Balancing Employment and Life data, collected from 2008 to 2012. Findings showed that working hours significantly declined over time, with a greater decrease among males, older doctors, and doctors with fewer children. Satisfaction increased faster over time among specialists, doctors with poorer health, those whose partners did not work full-time, and those with older children. The more hours the doctors worked initially, the lower satisfaction reported, and the greater the increase in satisfaction. Findings are consistent with a culture change in the medical profession, whereby long working hours are no longer seen as synonymous with professionalism. This is important to take into account in projecting future workforce supply.

Cream skimming and hospital transfers in a mixed public-private system.

The increasing prominence of the private sector in health care provision has generated considerable interest in understanding its implications on quality and cost. This paper investigates the phenomenon of cream skimming in a mixed public-private hospital setting using the novel approach of analysing hospital transfers. We analyse hospital administrative data of patients with ischemic heart disease from the state of Victoria, Australia. The data set contains approximately 1.77 million admission episodes in 309 hospitals, of which 132 are public hospitals, and 177 private hospitals. We ask if patients transferred between public and private hospitals differ systematically in the severity and complexity of their medical conditions; and if so, whether utilisation also differs. We find that patients with higher disease severity are more likely to be transferred from private to public hospitals whereas the opposite is true for patients transferred to private hospitals. We also find that patients transferred from private to public hospitals stayed longer and cost more than private-to-private transfer patients, after controlling for patients' observed health conditions and personal characteristics. Overall, the evidence is suggestive of the presence of cream skimming in the Victorian hospital system, although we cannot conclusively rule out other mechanisms that might influence hospital transfers.

An empirical analysis of public and private medical practice in Australia.

The combination of public and private medical practice is widespread in many health systems and has important consequences for health care cost and quality. However, its forms and prevalence vary widely and are poorly understood. This paper examines factors associated with public and private sector work by medical specialists using a nationally representative sample of Australian doctors. We find considerable variations in the practice patterns, remuneration contracts and professional arrangements across doctors in different work sectors. Both specialists in mixed practice and private practice differ from public sector specialists with regard to their annual earnings, sources of income, maternity and other leave taken and number of practice locations. Public sector specialists are likely to be younger, to be international medical graduates, devote a higher percentage of time to education and research, and are more likely to do after hours and on-call work compared with private sector specialists. Gender and total hours worked do not differ between doctors across the different practice types.