Ellis R, (1998)

‘Creaming, Skimping and Dumping: Provider Competition on the Intensive and Extensive Margins’

Journal of Health Economics 17, pp. 537-555

Theoretical paper modelling the effect of competition and differing payment systems on healthcare providers.
Examines 3 different strategies a provider might adopt in response to different incentives:
1. Creaming: over-provision of services to low cost patients.
2. Skimping: under-provision of services to high cost patients.
3. Dumping: explicit avoidance of high cost patients.
The model involves two healthcare providers competing to attract patients.
In this model cash-based reimbursement results in overprovision of services (creaming) to all types of patients.
Prospectively paid providers cream low severity patients and skimp on high severity ones. If there is dumping of high severity patients, then there will also be skimping.