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2. In what preventive services do we observe the comparative advantage of having a regular doctor over having a regular site?CONCEPTUAL FRAMEWORKIntuitively, individuals, especially those who have one or more chronic conditions, would prefer having a usual source of care in order to receive continuous monitoring and medical attention. Also, having a usual source of care can improve the timeliness and comprehensiveness of the receipt of preventive care for health conscientious or risk-averse individuals. Because both groups of individuals are concerned about their health, they may seek out services more aggressively (Ettner 1999). Thus, when a usual source of care is present in the service utilization process of these two groups of individuals, more observed service use does not necessarily imply that the usual source of care is the cause of the increased utilization of prevention. The endogeneity of having a usual source of care was also examined by Kuder and Levitz (1985), in which they conceptualized the relationship between having a usual source of care and physician visits under the behavioral model specification (Aday and Andersen 1984; Andersen and Aday 1978; Andersen and Newman 1973; Andersen 1995). In a traditional behavioral model, individuals'' predisposing, enabling, and need factors are used in predicting service use. Having a usual source of care, one of the enabling factors, is treated as predetermined (i.e., independent of predisposing, need, and other enabling factors) in explaining service use. However, numerous empirical studies rejected such an independence assumption (Hayward et al. 1991; Hayward et al. 1988; Merzel 2000; Rask et al. 1994; Schur, Albers, and Berk 1995). In these studies, the probability of having a usual source of care was modeled by using a subset of predisposing, enabling, and need factors, such as insurance status, as explanatory variables. Thus, the traditional behavioral model did not capture the intermediacy of having a usual source of care in linking predisposing, enabling, and need factors to service use. More importantly, many previous studies ignored the fact that the choice of a usual source of care was correlated with the error term in a regression of service use, controlling for observable consumer characteristics. Figure 1 illustrates a modified structure of the behavioral model.
Driven by the unobservable preferences, individuals who are likely to use more preventive services may choose to have a regular doctor or site. With the presence of the unobservable preferences, a single-equation estimation not incorporating the correlation between the error terms in the equations for having a usual source of care and service use may provide misleading information to health care policymakers, causing them to over- or under-promote the benefits of having a usual source of care. Ettner (1996) showed that when the endogeneity of having a usual source of care was controlled for, the impact magnitude of having a usual source of care was smaller than in an estimation where the endogeneity was not controlled. This type of bias was also found by Kuder and Levitz (1985).
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