行为经济学与卫生经济学

NBERWORKINGPAPERSERIESBEHAVIORALECONOMICSANDHEALTHECONOMICSRichardG.FrankWorkingPaper10881öJahnssonFoundation50thAnniversaryConferenceonEconomicInstitutionsandBehavioralEconomics,June22-24,2004(August16,2004).IgratefullyacknowledgefinancialsupportfromtheAHRQ(P0-1HS10803)theAlfredP.SloanFoundation,anNIHExportCenter(P20MD000537)andtheJohnD.andCatherineT.MacArthurFoundation.IthankPeterDiamond,JacobGlazer,SherryGlied,BoKoszegi,TomMcGuire,JoeNewhouse,ArnieEpsteinandPaulClearyforhelpfuldiscussion.Theviewsexpressedhereinarethoseoftheauthor(s)andnotnecessarilythoseoftheNationalBureauofEconomicResearch.©2004byRichardG.Frank.Allrightsreserved.Shortsectionsoftext,nottoexceedtwoparagraphs,maybequotedwithoutexplicitpermissionprovidedthatfullcredit,including©notice,isgiventothesource.BehavioralEconomicsandHealthEconomicsRichardG.FrankNBERWorkingPaperNo.10881October2004JELNo.I1ABSTRACTThehealthsectorisfilledwithinstitutionsanddecision-makingcircumstancesthatcreatefrictioninmarketsandcognitiveerrorsbydecisionmakers.Thispaperexaminesthepotentialcontributionstohealtheconomicsoftheideasofbehavioraleconomics.Thediscussionpresentedherefocusesontheeconomicsofdoctor-patientinteractionsandsomeaspectsofqualityofcare.Italsotouchesonissuesrelatedtoinsuranceandthedemandforhealthcare.Thepaperarguesthatlongstandingresearchimpassesmaybeaidedbyapplyingconceptsfrombehavioraleconomics.RichardG.FrankDepartmentofHealthCarePolicyHarvardMedicalSchool180LongwoodAvenueBoston,[e-mail]dIfoneexaminesthesalienteconomicinstitutionsofthehealthsector,onemightexpectthatsectortobeabreedinggroundforappliedbehavioraleconomics.Considerasetofeconomicactivitieswhereaddictionsfigureprominently;whereconsumershavelimitedinformationthattheymustusetomakechoicesinthecontextoffear,urgencyandtrustinanexpert;andwheretheservicesusedareoftencredencegoods(Emons,1997,Sloan2001)whoseapplicationsarefrequentlygovernedbyprofessionalnormsandhabit.Insuchaneconomicenvironmentthemethodsofbehavioraleconomicsmightbeexpectedtobeprevalentinmodifyingtraditionalmodelstotakeaccountofthesefeaturesthatappeartoconflictwithsimplenotionsofrationalityineconomicbehavior.Yettheapplicationofbehavioraleconomicstoissuesinhealtheconomicshavebeenlargelyconfinedtounderstandingaddictivebehavioraroundcigarettes,drugsandalcohol(seeforexampleBeckerandMurphy,1988;GruberandKoszegi,2001;Lowenstein,2001;O’DonoghueandRabin,1999;andSchoenbaum,1997).A.ResearchTraditionsinHealthEconomicsThelineofresearchonaddictionshasitsoriginsinresearchonhouseholdproductionandthedemandforhealth(Becker,1964andGrossman,1972).Decisionsaboutsubstanceabuseinvolveasetofharmfulhealthchoicesthatappeartorepresentextremetrade-offsbetweentoday’spleasuresandtomorrow’shealthandwell-being.Asubstantialamountofprogresshasbeenmadeinboththeoreticalanalysisandempiricaltestingofmodelsinthisareaandalivelyprogramofresearchthatencompassesbehavioraleconomicconceptsisunderway.InthispaperIwilldrawonadifferentresearchtraditionthatemanatesfromtheseminalpaperbyArrow(1963).Theefficiencyofhealthinsurancemarkets,doctor-patientrelationshipsandtheroleofnon-marketinstitutionsinpromotingefficiency4wereraisedbyArrowandcontinuetobecentralquestionsinthehealtheconomicsresearchprogram.Thissideofhealtheconomicshasreceivedfarlessattentionfromscholarsarmedwiththetoolsofbehavioraleconomics.Iwillfocusondecisionmakingabouttreatmentofillness,rationingofhealthservicesandmarketsforhealthinsurance.Iwillarguethatbehavioraleconomicsmaybeparticularlyimportantformodifyingneo-classicalapproachesbecauseasinmanyareasoftheeconomy,peopleappeartomakechoicesabouthealthcarethataresituationorcontextspecificthatresultincognitiveerrorsandfailurestooptimize.Thehealthsectorisalsocharacterizedbyinstitutionsanddecisionmakingcircumstancesthat,inadditiontomakingcognitiveerrorsmorelikely,createfrictionthatimpedesmarketadjustmentsthatmightleadtocorrectionoferrorsovertime(Glaeser,2003MallainathanandThaler,2001).Theseincludethestressofdecisionmakingaboutone’shealth,professionalism,andalackofinformationaboutmedicalcare.Thepaperisorganizedintofoursections.Inthisintroductorysectionwesettheintellectualcontextforthereview.Thesecondsectionfocusesonphysicianbehavior,whichrepresentsalargeclassofproblemsinthehealthsector,whereIbelievebehavioraleconomicshasmuchtocontribute.Thethirdsectionaddressessomepuzzlesinhealtheconomicsrelatedtodemandbehaviorandthebehaviorofhealthinsurancemarkets.Thefourthandfinalsectionofferssomeconcludingobservationsandcommentsonnormativeissuesinhealtheconomics.B.ArrowandtheHealthCareChallengeforBehavioralEconomicsArrow’s(1963)paperseekstoexplainthehealthsector’sinstitutionsasaresponsetothespecialfeaturesofhealthcareandhealthinsurance.Amongthespecialcharacteristicsareinformationasymmetryandthesignificanceofmedicalcareinhumanaffairs.Theresearchprogramthatdescended