Health Care Cost Shifting: Show Me the Studies

In response to my two posts on cost shifting (or lack thereof) in health care, I’ve heard many arguments why I am wrong (see comments at The Health Care Blog and Ezra Klein’s blog). In brief: my claim is that there is little or no cost shifting from public to private payers in health care. I cited recent studies (which in turn cited peer-reviewed papers) to support my claim.

But nobody has yet pointed to credible studies that counter what I wrote. Here’s the challenge: find a qualified (see below) publication that supports your health care cost shifting claim. Send it to me (pdf or URL to paper please). I will read it, and I will blog about it.

“Qualified” means:

  • Appears in a peer-reviewed journal (send me a link to the journal’s editorial policy that confirms this if it is not obvious) or is based in large part on peer-reviewed articles.
  • Has been published in the last decade.
  • Is by authors that are not obviously conflicted (not employed, recently employed, or funded by the insurance or hospital industries).
  • Has not already been covered in my posts or the references I cite (see below).

References already covered (don’t bother to send me these):

  • MedPAC report, March 2009.
  • CBO report, December 2009.
  • GAO report, August 2005.
  • Milliman report, December 2008 (doesn’t actually qualify since there are conflicts of interest, but I reviewed it anyway because it is what the insurance and hospital industries cite).
  • Richard Frank, Health Affairs, March/April 2001.
  • Dranove, D., and W. White. 1998. Medicaid-dependent hospitals and their patients: How have they fared? Health Services Research 33, no. 2: 165–185. “We find no evidence that [CA] Medicaid-dependent hospitals raised prices to private patients in response to Medicaid (or Medicare) cutbacks; if anything, they lowered them…. We find no evidence of cost shifting.”
  • Zwanziger, J., and A. Bamezai. 2006. Evidence of cost shifting in California hospitals. Health Affairs 25, no. 1: 197–203. “We found that a 1 percent relative decrease in the average Medicare price is associated with a 0.17 percent increase in the corresponding price paid by privately insured patients; similarly, a 1 percent relative reduction in the average Medicaid price is associated with a 0.04 percent increase.”
  • Zwanziger, Glenn A. Melnick, and Anil Bamezai, Can Cost Shifting Continue in a Price Competitive Environment Health Economics, vol. 9, no. 3 (April 2000).
  • Michael A. Morrisey, Cost Shifting in Health Care: Separating Evidence from Rhetoric (Washington, D.C.: AEI Press, 1994)
  • Jack Hadley, Stephen Zuckerman, and Lisa I. Iezzoni, “Financial Pressure and Competition: Changes in Hospital Efficiency and Cost-Shifting Behavior,” Medical Care, vol. 34, no. 3 (1996), pp. 205–219.
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