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Factor Substitution and Unobserved Factor Quality in Nursing Homes

  • John Cawley
  • David C. Grabowski
  • Richard A. Hirth

This paper studies factor substitution in one important sector: the nursing home industry. Specifically, we measure the extent to which nursing homes substitute materials for labor when labor becomes relatively more expensive. From a policy perspective, factor substitution in this market is important because materials-intensive methods of care are associated with greater risks of morbidity and mortality among nursing home residents. Studying longitudinal data from 1991-1998 on nearly every nursing home in the United States, we use the method of instrumental variables (IV) to address the potential endogeneity of nursing home wages. The results from the IV models are consistent with the theory of factor substitution: higher nursing home wages are associated with lower staffing, greater use of materials (specifically, physical restraints), and a higher proportion of residents with pressure ulcers. A comparison of OLS and IV results suggests that empirical studies of factor substitution should take into account unobserved heterogeneity in factor quality.

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Paper provided by National Bureau of Economic Research, Inc in its series NBER Working Papers with number 10465.

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Date of creation: May 2004
Date of revision:
Publication status: published as Cawley, John, David Grabowski, and Richard Hirth. "Factor Substitution in Nursing Homes." Journal of Health Economics, March 2006, 25(2): 234-247.
Handle: RePEc:nbr:nberwo:10465
Note: HE
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  1. Grabowski, David C. & Hirth, Richard A., 2003. "Competitive spillovers across non-profit and for-profit nursing homes," Journal of Health Economics, Elsevier, vol. 22(1), pages 1-22, January.
  2. Stephen Machin & Alan Manning & Lupin Rahman, 2002. "Where the minimum wage bites hard: the introduction of the UK national minimum wage to a low wage sector," LSE Research Online Documents on Economics 20070, London School of Economics and Political Science, LSE Library.
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  5. Chou, Shin-Yi, 2002. "Asymmetric information, ownership and quality of care: an empirical analysis of nursing homes," Journal of Health Economics, Elsevier, vol. 21(2), pages 293-311, March.
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  7. Philpot, Gordon, 1970. "Labor Quality, Returns to Scale and the Elasticity of Factor Substitution," The Review of Economics and Statistics, MIT Press, vol. 52(2), pages 194-99, May.
  8. Stephen G. Donald & Kevin Lang, 2007. "Inference with Difference-in-Differences and Other Panel Data," The Review of Economics and Statistics, MIT Press, vol. 89(2), pages 221-233, May.
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  10. Jensen, Gail A & Morrisey, Michael A, 1986. "The Role of Physicians in Hospital Production," The Review of Economics and Statistics, MIT Press, vol. 68(3), pages 432-42, August.
  11. Albert A. Okunade, 1999. "Will the real elasticity of substitution 'in Norwegian dentistry' please stand up?," Health Economics, John Wiley & Sons, Ltd., vol. 8(3), pages 221-232.
  12. Grabowski, David C., 2001. "Medicaid reimbursement and the quality of nursing home care," Journal of Health Economics, Elsevier, vol. 20(4), pages 549-569, July.
  13. Norton, Edward C., 2000. "Long-term care," Handbook of Health Economics, in: A. J. Culyer & J. P. Newhouse (ed.), Handbook of Health Economics, edition 1, volume 1, chapter 17, pages 955-994 Elsevier.
  14. Escarce, Jose J. & Pauly, Mark V., 1998. "Physician opportunity costs in physician practice cost functions," Journal of Health Economics, Elsevier, vol. 17(2), pages 129-151, April.
  15. Okunade, Albert Ade, 1993. "Production Cost Structure of U.S. Hospital Pharmacies: Time-Series, Cross-Sectional Bed Size Evidence," Journal of Applied Econometrics, John Wiley & Sons, Ltd., vol. 8(3), pages 277-94, July-Sept.
  16. Marianne Bertrand & Esther Duflo & Sendhil Mullainathan, 2004. "How Much Should We Trust Differences-in-Differences Estimates?," The Quarterly Journal of Economics, MIT Press, vol. 119(1), pages 249-275, February.
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