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Econometric treatment of few protest responses in willingness-to-pay studies: An application in health care

Published online by Cambridge University Press:  09 January 2015

Nathalie Havet
GATE Lyon-Saint Etienne, University of Lyon, 93 chemin des Mouilles, 69 130 ECULLY, FRANCE (e-mail:
Magali Morelle
GATE Lyon-Saint Etienne, Léon Bérard Comprehensive Cancer Center, 28 rue Laënnec, 69373 LYON Cedex 08, FRANCE (e-mail:,,
Raphael Remonnay
GATE Lyon-Saint Etienne, Léon Bérard Comprehensive Cancer Center, 28 rue Laënnec, 69373 LYON Cedex 08, FRANCE (e-mail:,,
Marie-Odile Carrere
GATE Lyon-Saint Etienne, Léon Bérard Comprehensive Cancer Center, 28 rue Laënnec, 69373 LYON Cedex 08, FRANCE (e-mail:,,
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In contingent valuation surveys, there is a range of possible explanations for zero bids, from true zero responses consistent with economic decisions to protest responses. According to the empirical literature, which analyzes the determinants of willingness-to-pay (WTP) values from a bidding process, the double-hurdle is the most appropriate econometric approach to account for zero and protest WTP. However, when the number of protest responses is too small to be explicitly modelled, this approach is not applicable. This frequently occurs in critical health care situations, where large samples are not easily available. We discuss the possible econometric strategies for use in such cases. For illustrative purposes, the different models were applied to an empirical situation, which refers to the location preference (i.e. home versus hospital) from French cancer patients for blood transfusion. Our results show that protest responses should not be discarded, even if present in small numbers, and that the type II Tobit and the standard truncated regression model could both be applied. However, since from small finite samples, the most robust estimation is obtained from the bootstrap method with a high number of replications, the truncated regression model, easily applicable, weakly computer time-consuming and not subject to identification problems in this case contrary to the type II Tobit, should be the econometric strategy of choice for various WTP studies in the healthcare field.

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Copyright © Université catholique de Louvain, Institut de recherches économiques et sociales 2012

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Ademokuii, A., Kaznica, S., Deas, S. (2005), “Home blood transfusion: a necessary service development”, Transfusion Medicine, vol. 5, pp. 219222.CrossRefGoogle Scholar
Amemiya, T. (1984), “Tobit models: a survey”, Journal of Econometrics, vol. 24, pp. 361.CrossRefGoogle Scholar
Benson, K. (2006), “Home is where the heart is: Do blood transfusions belong there too?Transfusion Medicine Reviews, vol. 20, pp. 218229.CrossRefGoogle ScholarPubMed
Berwick, D. and Weinstein, M., (1985), “What do patients value? Willingness to pay for ultrasound in normal pregnancy”, Medical Care, vol. 23, pp. 881893.CrossRefGoogle ScholarPubMed
Blumenschein, K., Johannesson, M., Ykoyama, K.K. and Freeman, P.R. (2001), “Hypothetical versus real willingness to pay in the health care sector: results from a field experiment”, Journal of Health Economics, vol. 20, pp. 441457.CrossRefGoogle Scholar
Blundell, R., Ham, J. and Meghir, C. (1987), “Unemployment and female labour supply”, Economic Journal, vol. 97, pp. 4464.CrossRefGoogle Scholar
Brownstone, D. and Valetta, R. (2001), “The Bootstrap and Multiple Imputations: Harnessing Increased Computing Power for Improved Statistical Tests”, Journal of Economic Perspectives, vol.15, n°4, pp. 129141.CrossRefGoogle Scholar
Cella, D.F., Tulsky, D.S., Gray, G. and al. (1993), “The Functional Assessment of Cancer Therapy Scale: development and validation of the general measure”, Journal of Clinical Oncology, vol. 11, pp. 570579.CrossRefGoogle ScholarPubMed
Dalmau-Matarrodona, E. (2001), “Alternative Approaches to obtain optimal bid values in contingent valuation studies and to model protest zeros. Estimating the determinants of individual's willingness to pay for home care services in day case surgery”, Health Economics, vol. 16, pp. 101118.CrossRefGoogle Scholar
Devlin, B., Agnew, A. (2008), “An evaluation of domiciliary blood transfusion service for palliative care patients in Northern Ireland”. Community Practitioner, vol. 81, pp. 3235.Google Scholar
Diener, A., O'Brien, B. and Gafni, A. (1998), “Health care contingent valuation studies: A review and classification of the literature”, Health Economics, vol. 7, pp. 313326.3.0.CO;2-B>CrossRefGoogle ScholarPubMed
Donaldson, C., Jones, A.M., Mapp, T.J., and Olson, J.A. (1998), “Limited dependent variables in willingness to pay studies: applications in health care”, Applied Economics, vol. 30, pp. 667677.CrossRefGoogle Scholar
Donaldson, C. (1999), “Valuing the benefits of publicly-provided health care: does ability to pay preclude the use of willingness to pay?”, Social Science and Medicine, vol. 4, pp. 551563.CrossRefGoogle Scholar
Donaldson, C., Shackley, P., Abdalla, M. and Miedzybrodzka, Z. (1995), “Willingness to pay for antenatal carrier screening for cystic fibrosis”, Health Economics, vol. 4, pp. 439452.CrossRefGoogle Scholar
Donaldson, C., Mason, H. and Shackley, P. (2006), “Contingent Valuation in Health Care”, in Jones, A.M. (éds), The Elgar Companion to Health Economics, Northampton, Edward Elgar, pp. 392404.Google Scholar
Drummond, M.F., Sculpher, M.J., Torrance, G.W., O'Brien, B. and Stoddart, G.L. (2005), Methods for the economic evaluation of health care programmes, Third Edition, Oxford University press, Oxford.Google Scholar
Efron, B. and Tibshirani, R. (1993), An Introduction to the Bootstrap, Boca Raton: Chapman & Hall.CrossRefGoogle Scholar
Flachaire, E. and Hollard, G. (2007), “Starting point bias and respondent's uncertainty”, Ressource and Energy Economics, vol. 29, pp. 183194.CrossRefGoogle Scholar
Flood, L., and Gräsjo, U. (1998), Regression Analysis and Time Use Data: A Comparison of Microeconometric Approaches with Data from the Swedish Time Use Survey (HUS), Working Papers in Economics no. 5. School of Economics and Commercial Law, Göteborg University, Sweden.Google Scholar
Fonta, W., Ichoku, E., and Kabubo-Mariara, J. (2010), “The Effect of Protest Zeros on Estimates of Willingness to Pay in Healthcare Contingent Valuation Analysis”, Applied Health Economics and Health Policy, vol. 8, n°4, pp. 225237.CrossRefGoogle ScholarPubMed
Greene, W. (2005), Econometric Analysis, 5th edition, Prentice-Hall International, Upper Saddle River.Google Scholar
Herriges, J.A. and Shogren, J.F. (1996), “Starting point bias in dichotomous choice valuation with follow-up questioning”, Journal of Environmental Economics and Management, vol. 30, pp. 112131.CrossRefGoogle Scholar
Idri, S., Catoni, M., Ali, H.S., Patte, R. and al. (1996), “La transfusion à domicile ? Une alternative à l'hôpital de jour”, Transfusion Clinique et Biologique, vol. 3, pp. 235239.CrossRefGoogle Scholar
Johannesson, M., Johansson, P.O., Kristrom, B. and Gerdtham, U.G. (1993), “Willingness to pay for antihypertensive therapy - further results”, Journal of Health Economics, vol. 12, pp. 95108.CrossRefGoogle ScholarPubMed
Johannesson, M., Jonsson, B. and Borgquist, L. (1991), “Willingness to pay for antihypertensive therapy - results of a Swedish pilot study”, Journal of Health Economics, vol. 10, pp. 461474.CrossRefGoogle ScholarPubMed
Jones, A.M. (1989), “A double-hurdle model of cigarette consumption”, Journal of Applied Econometrics, vol. 4, pp. 2339.CrossRefGoogle Scholar
Jones, A.M. (1992), “A Note on Computation of the Double Hurdle Model with Dependence with An Application to Tobacco Expenditure”, Bulletin of Economic Research, vol. 44, pp. 6773.CrossRefGoogle Scholar
Jorgensen, B.S., Syme, G.J., Bishop, B.J. and Nancarrow, B.E. (1999), “Protest Responses in Contingent Valuation”, Environmental and Resource Economics, vol. 14, pp. 131150.CrossRefGoogle Scholar
Jorgensen, B.S., Wilson, M.A. and Heberlein, T.A. (2000), “Fairness in the Contingent Valuation of Environmental Integrated knowledge for ecological economics: a database to support ecosystem services evaluation”, Ecological Economics, vol. 36, pp. 133148.CrossRefGoogle Scholar
King, G. and Zeng, L. (2001a), “Explaining Rare Events in International Relations”, International Organization, vol. 55, pp. 693715.CrossRefGoogle Scholar
King, G. and Zeng, L. (2001b), “Logistic Regression in Rare Events Data”, Political Analysis, vol.8, pp. 8398.Google Scholar
Lindsey, G. (1994), “Market models, protest bids, and outliers in contingent valuation”, Journal of Water Resources Planning and Management, vol. 120, pp. 121129.CrossRefGoogle Scholar
Madgwick, K.Y. and Yardumian, A. (1999), “A home blood transfusion programme for beta-thalassaemia patients”, Transfusion Medicine, vol. 9, pp. 135138.CrossRefGoogle Scholar
Manski, C. and Lerman, S. (1977), “The Estimation of Choice Probabilities from Choice Based Samples”, Econometrica, vol. 45, n° 8, pp. 19771988.CrossRefGoogle Scholar
Meyerhoff, J. and Liebe, U. (2006), “Protest Beliefs in Contingent Valuation: Explaining Their Motivation”, Ecological Economics, vol. 57, pp. 583594.CrossRefGoogle Scholar
Miedzybrodzka, Z., Semper, J., Shackley, P., Abdalla, M. and Donaldson, C. (1995), “Stepwise or couple antenatal carrier screening for cystic fibrosis? Women's preferences and willingness to pay”, Journal of Medical Genetics, vol. 32, pp. 282283.CrossRefGoogle Scholar
Mitchell, R. and Carson, R. (1989), Using Surveys to Value Public Goods: The Contingent Valuation Method, John Hopkins University Press, Baltimore.Google Scholar
Narbro, K. and Sjostrom, L. (2000), “Willingness to pay for obesity treatment”, International Journal of Technology Assessment in Health Care, vol. 16, pp. 5059.CrossRefGoogle ScholarPubMed
Moumjid, N., Brémond, A., Mignotte, H., Faure, C., Meunier, A., Carrère, MO. (2007), “Shared decision-making in the physician-patient encounter in France: a general overview”. Zeitschrift für ärztliche Fortbildung und Qualität im Gesundheitswesen, vol. 101, pp 223228.Google ScholarPubMed
National Oceanic and Atmospheric Administration (NOAA). (1994), “Natural resource damage assessments: proposed rules”, Federal Register, vol. 59, pp. 10621191.Google Scholar
O'Brien, B. and Viramontes, JL. (1994), “Willingness to pay: a valid and reliable measure of health state preference?”, Medical Decision Making, vol. 14, pp. 289297.CrossRefGoogle ScholarPubMed
Olsen, J. and Smith, R. (2001), “Theory versus Practice: A review of ‘willingness-to-pay’ in health and health care”, Health Economics, vol. 10, pp. 3952.3.0.CO;2-E>CrossRefGoogle Scholar
Ryan, M., Ratcliffe, J. and Tucker, J. (1997), “Using willingness to pay to value alternative models of antenatal”, Social Science and Medicine, vol. 44, pp. 371380.CrossRefGoogle ScholarPubMed
Sayman, S. and Onculer, A. (2005), “Effects of study design characteristics on the WTA-WTP disparity: A meta analytical framework”, Journal of Economic Psychology, vol. 26, pp. 289312.CrossRefGoogle Scholar
Shepperd, S. and Iliffe, S. (2001), “Hospital at home versus in-patient hospital care (Cochrane Review)”, In: The Cochrane Library Issue 1, Chichester, UK: John Wiley & Sons.Google Scholar
Smith, R., Olsen, JA., Harris, A. (1999), “A review of methodological issues in the conduct of willingness to pay studies in health care III: issues in the analysis and interpretation of WTP data”, Centre for Heath Program Evaluation, Monash University, working paper 86.Google Scholar
Smith, R.D. (2007), “The role of ‘reference goods’ in contingent valuation: should we help respondent to ‘construct’ their willingness to pay?”, Health Economics, vol. 16, pp. 13191332.CrossRefGoogle ScholarPubMed
Smith, R.D. (2003), “Construction of the contingent valuation market in health care: a critical assessment”, Health Economics, vol. 12, pp. 609628.CrossRefGoogle Scholar
Smith, R.D. (2005), “Sensitivity to scale in contingent valuation: The importance of the budget constraint”, Journal of Health Economics, vol. 24, pp. 515529.CrossRefGoogle ScholarPubMed
Smith, R.D. (2006), “It's not just what you do, it's the way that you do it: The effect of different payment card formats and survey administration on willingness to pay for health gain”, Health Economics, vol. 15, pp. 281293.CrossRefGoogle ScholarPubMed
Strazzera, E., Scarpa, R., Calai, P. et al. (2003), “Modelling zero values and protest responses in contingent valuation surveys”, Applied Economics, vol.35, pp. 133138.CrossRefGoogle Scholar
Thompson, M.S. (1986), “Willingness to pay and accept risks to cure chronic disease”, American Journal of Public Health, vol. 76, pp. 392396.CrossRefGoogle ScholarPubMed
Van der Pol, M. and Cairns, J. (1998), “Establishing patient preferences for blood transfusion support: an application of conjoint analysis”, Journal of Health Services Research and Policy, vol. 3, pp. 7076.CrossRefGoogle ScholarPubMed
Whynes, D., Frew, E. and Wolstenholme, J. (2003), “A comparison of two methods for eliciting contingent valuations of colorectal cancer screening”, Journal of Health Economics, vol. 22, pp. 555574.CrossRefGoogle ScholarPubMed
Whynes, D.K., Philipis, Z. and Frew, E. (2005), “Think of a number… any number?”, Health Economics, vol. 14, pp. 11911195.CrossRefGoogle Scholar
Yasunaga, H., Ide, H., Imamura, T. and Ohe, H. (2006), “Willingness to pay for health care services in common cold, retinal detachment and myocardiac information: an internet survey in Japon”, BMC Health Services Research, vol. 6, p. 12.CrossRefGoogle Scholar
Yeung, R.Y.T., Smith, R.D. and McGhee, SM. (2003), “Willingness to pay and size of health benefit: an integrated model to test for ‘sensitivity to scale’Health Economics, vol. 12, pp. 791796.CrossRefGoogle Scholar

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