Breaking Down Healthcare
Impacts of Hospital Data Breach on Healthcare Quality
Dapeng Chen, Shin-Yi Chou & Xiaosong (David) Peng
Health Services Research, forthcoming
Data Source: Hospital-level data breach reports from the U.S. Department of Health and Human Services and patient-level hospitalization records from Florida State Inpatient Database during 2013–2017.
Study Design: We employ a propensity score matching difference-in-difference model to estimate changes in a patient's emergency department (ED) door-to-hospital admission hours, days to undergo principal procedure after admission, length of stay days, and in-hospital mortality rates following data breaches. We compare the health information technology (HIT) functionalities of breached and non-breached hospitals during both pre and post periods.
Data Collection/Extraction Methods: Our primary analysis covers 1,295,537 records of inpatients admitted through the EDs of 12 hospitals.
Principal Findings: Data breaches are associated with long-term improvements in healthcare quality, particularly in the timeliness of patient care and acute myocardial infarction (AMI) mortality. Over time, patients experience a reduction of 0.56 h in ED door-to-hospital admission time (95% confidence interval [CI]: −1.04 to −0.06 h) and a decrease of 0.18 days in time to undergo the principal procedure after hospital admission (95% CI: −0.23 to −0.13 days). Additionally, AMI patients experience a one percentage point reduction in in-hospital mortality (95% CI: −2 to −0.06 percentage points), while mortality rates for other patient groups remain unchanged. Hospitals affected by data breaches show long-term advancements in their HIT functionalities.
The Politics of Rural Hospital Closures
Michael Shepherd
Political Behavior, forthcoming
Abstract:
Who do citizens hold responsible for outcomes and experiences? Hundreds of rural hospitals have closed or significantly reduced their capacity since just 2010, leaving much of the rural U.S. without access to emergency health care. I use data on rural hospital closures from 2008 to 2020 to explore where and why hospital closures occurred as well as who–if anyone–rural voters held responsible for local closures. Despite closures being over twice as likely to occur in the Republican-controlled states that did not expand Medicaid, closures were associated with reduced support for federal Democrats and the Affordable Care Act following local closures. I show that rural voters who lost hospitals were roughly 5–10 percentage points more likely to vote Republican in subsequent presidential elections. If anything state Republicans seemed to benefit in rural areas from rejecting Medicaid and resulting rural health woes following the passage of the ACA. These results have important implications for population health and political accountability in the U.S.
Nursing Home Payroll Subsidies and the Trade-Off between Staffing and Access to Care for Medicaid Enrollees
Thomas Hegland
HHS Working Paper, November 2024
Abstract:
Payroll subsidies are a promising tool for increasing nursing home staffing levels. However, promoting increased staffing may come at the expense of access to care for Medicaid enrollees if it enables nursing homes to attract more lucrative, non-Medicaid residents. In this study, I examine a set of payroll subsidies offered by state Medicaid programs, using nursing home-level variation in subsidy generosity to identify subsidy effects. I find that each additional dollar of subsidies offered per resident-day increased staffing by just over 10 minutes per resident-day, but decreased the Medicaid share of new nursing home admissions by about 1.8 percentage points. The subsidies also increased resident turnover and decreased the average care needs of newly admitted residents. Overall, these results highlight that while nursing home payroll subsidies are effective tools for increasing staffing levels, the subsidies can lead to changes in nursing home admissions and the characteristics of admitted residents.
Intensive care supply and admission decisions
Seth Freedman, Lauren Hoehn-Velasco & Diana Jolles
Journal of Health Economics, March 2025
Abstract:
Over 2005–2019, the number of neonatal intensive care units (NICUs) grew by 10%, and the number of NICU beds increased by 30%. This expansion in intensive care has raised concerns over unwarranted intensive care admissions. In this study, we examine whether the greater supply of NICUs causally raises admission rates. Our event-study results show that an additional NICU opening in a county raises the share of newborns admitted to the NICU by 8%. The majority of new NICU admissions come from healthier newborns (2,500 grams and over) rather than very premature newborns (<1,500 grams). Admission for the smallest newborns (those under 1,500 grams) only increases in counties with limited NICU access. In these areas, greater NICU supply also reduces mortality, but only for very small newborns (<1,500 grams). Together, our findings suggest a tradeoff, where higher NICU supply reduces neonatal mortality for the most vulnerable infants while also raising admission for healthier newborns.
Health Professional Shortage Area Bonus Payments and Access to Care Under Medicare
Christopher Brunt
Health Economics, forthcoming
Abstract:
For over 3 decades, the Centers for Medicare & Medicaid Services (CMS) has provided a bonus payment for outpatient physician services provided to beneficiaries under Medicare Part B in areas designated as Primary Care Health Professional Shortage Areas (HPSAs) during the previous calendar year. Despite the longstanding existence of the program, no studies have explicitly evaluated how previously established physicians practicing in areas subject to an HPSA designation respond to the bonus payments. Using 2012–2019 physician-level data with stacked event study models that control for several characteristics, including the underlying criteria used to construct HPSA scores, I find little to no statistically significant changes in access to care (as measured through total annual beneficiaries treated or services delivered to Medicare beneficiaries) in the years leading up to HPSA designation. However, once physicians become eligible for a 10% bonus payment, their annual number of beneficiaries treated and volume of services decline, consistent with recent empirical work and CMS's actuarial assumptions about how physicians respond to changes in reimbursement.
The impact of surprise billing laws on hospital-based physician prices and network participation
Christopher Garmon et al.
Health Economics, Policy and Law, forthcoming
Abstract:
Prior to the No Surprises Act (NSA), numerous states passed laws protecting patients from surprise medical bills from out-of-network (OON) hospital-based physicians supporting elective treatment in in-network hospitals. Even in non-emergency situations, patients have little ability to choose physicians such as anaesthesiologists, pathologists or radiologists. Using a comprehensive, multi-payer claims database, we estimated the effect of these laws on hospital-based physician reimbursement, charges, network participation and potential surprise billing episodes. Overall, the state laws were associated with a reduction in anaesthesiology prices and charges, but an increase in pathology and radiology prices. The price effects for each state exhibit substantial heterogeneity. California and New Jersey experienced increases in network participation by anaesthesiologists and pathologists and reductions in potential surprise billing episodes, but, overall, we find little evidence of changes in network participation across all of the states implementing surprise billing laws. Our results suggest that the effects of the NSA may vary across states.
Changes in Patient Care Experience After Private Equity Acquisition of US Hospitals
Anjali Bhatla et al.
Journal of the American Medical Association, forthcoming
Design, Settings, and Participants: This cohort study identified 73 US hospitals newly acquired by private equity firms and 293 matched control (nonacquired) US hospitals from 2008 through 2019. An event study, difference-in-differences design was used to evaluate changes in patient experiences measures from 3 years before to 3 years after private equity acquisition.
Results: There were 73 private equity–acquired hospitals and 293 matched control hospitals. The percentage of patients rating hospitals as a 9 or 10, on a scale of 0 to 10, decreased at private equity–acquired hospitals (65.0% before acquisition and 65.2% after acquisition) when compared with control hospitals (66.2% to 69.2%) during the postacquisition period relative to the preacquisition period with a difference-in-differences estimate of −2.4 percentage points (95% CI, −3.9 to −0.9). In addition, the percentage of patients who would definitely recommend the hospital also decreased at private equity–acquired hospitals (66.9% before acquisition and 65.5% after acquisition) compared with control hospitals (68.2% to 69.3%) with a difference-in-difference estimate of −2.1 percentage points (95% CI, −3.6 to −0.7). For both of these global measures of patient experience, the difference between private equity–acquired and control hospitals increased over time and was largest in year 3 after acquisition (−5.2 percentage points [95% CI, −8.8 to −1.5] and −4.4 percentage points [95% CI, −8.0 to −0.70] for each measure, respectively). For secondary measures of patient care experience, there was a decrease in patient-reported responsiveness of hospital staff at private equity–acquired hospitals compared with control hospitals (−1.3 percentage points [95% CI, −2.4 to −0.2]), but no differential change across other measures of clinical process, communication, and environment.
Increases In Physician Professional Fees In Private Equity–Owned Gastroenterology Practices
Yashaswini Singh et al.
Health Affairs, February 2025, Pages 215-223
Abstract:
Consolidation of physician practices, largely driven by health systems, has motivated policy efforts to move care toward lower-price, non–health system settings. At the same time, however, private equity (PE) firms are increasingly acquiring those non–health system practices, potentially negating the prior price advantages of those practices. We used novel ownership data on gastroenterology practices linked to commercial claims for the period 2015–20 to study how PE acquisitions affect the prices and volume of care relative to both health system–affiliated practices and independent practices. We examined both professional fees and facility fees. After PE acquisition, prices increased by $92 per claim, or 28.4 percent, driven by a 78.1 percent increase in professional fees. Facility fees did not exhibit a statistically significant change. Meanwhile, utilization also increased. These findings suggest that PE firms have multiple avenues for raising prices -- in this case, primarily via professional fees. For policy makers, although moving care out of higher-price health system settings remains a key strategy to lower spending, unchecked growth in professional fees in PE-acquired outpatient settings may nullify some of the intended effects.
The Role of Physician Altruism in the Physician-Industry Relationship: Evidence from Linking Experimental and Observational Data
Shan Huang, Jing Li & Anirban Basu
NBER Working Paper, January 2025
Abstract:
Altruism is a key component of medical professionalism that underlies the physician's role as a representative agent for patients. However, physician behavior can be influenced when private gains enter the objective function. We study the relationship between altruism and physicians' receipt of financial benefits from pharmaceutical manufacturers, as well as the extent to which altruism mitigates physicians' responsiveness to these industry payments. We link data on altruistic preferences for 280 physicians, identified using a revealed preference economic experiment, with administrative information on their receipt of financial transfers from pharmaceutical firms along with drug prescription claims data. Non-altruistic physicians receive industry transfers that are on average 2,184 USD or 254% higher than altruistic physicians. While industry transfers lead to higher drug spending and prescribing on paid drugs, these relationships are entirely driven by non-altruistic physicians. Our results indicate that altruism is an important determinant of physicians’ relationships with and responses to industry benefits.
Medicaid-Ing Coverage Volatility for Displaced Workers: Evidence from the 2019 Virginia Medicaid Expansion
Bradley Heim et al.
Indiana University Working Paper, January 2025
Abstract:
Using novel administrative tax data, we study the effect of the ACA’s Medicaid expansion on health insurance coverage dynamics for over 1.6 million displaced workers. Leveraging Virginia’s Medicaid expansion, we estimate a 190% increase in Medicaid as first coverage source following job loss. We also find that the expansion immediately and persistently increased the likelihood of coverage and reduced the duration of uninsurance for displaced workers. Additionally, our findings suggest that the expansion influenced labor search dynamics, enhancing job match quality, particularly among those that came from the lower half of earnings.