Inside Care
“It Takes More Than a Pill to Kill”: Bounded Accountability in Disciplining Professional Misconduct Despite Heightened Transparency
Ece Kaynak & Hatim Rahman
Organization Science, forthcoming
Abstract:
Existing theory suggests that professionals are ineffective at regulating the work of their peers, especially when it comes to disciplining misconduct, because of professional norms of collegiality. In response, transparency measures have been put in place over the years to increase accountability toward key external audiences, such as the public, and to ensure that professionals hold guilty peers accountable for misconduct. Few studies, however, have sufficiently investigated how professionals discipline peer misconduct in the face of transparency measures. We gained access to a state medical board’s internal deliberations about how to discipline physicians guilty of overprescribing opioids, endangering public health. We found that even in the most egregious cases, the board predominantly refrained from implementing stringent disciplinary action despite extensive transparency measures. Our data allow us to theorize what we call bounded accountability, which refers to individuals charged with holding guilty actors accountable for their misconduct instituting only limited discipline. We found four mechanisms that constrained the exercise of accountability: information asymmetries between regulatory bodies, bureaucratic inefficiencies of the disciplinary apparatus, shared professional beliefs among decision makers, and interpersonal emotions between decision makers and the guilty professionals who are put in charge of disciplining. We found that these mechanisms operated at the field, occupational, organizational, and interpersonal levels, respectively. Utilizing a highly consequential study context, our findings suggest that when professional misconduct is disciplined by members of the same occupation, bounded accountability is the most likely outcome, even with extensive transparency measures in place.
Access to Psychiatric Appointments for Medicaid Enrollees in 4 Large US Cities
Diksha Brahmbhatt & William Schpero
Journal of the American Medical Association, 27 August 2024, Pages 668-669
Methods: We selected at random 80 psychiatric prescribing clinicians (psychiatrists, nurse practitioners, and physician assistants) listed as accepting new patients from the provider directories for the Medicaid managed care plans with the highest enrollment in New York City, Los Angeles, Chicago, and Phoenix, the 4 largest cities in states that have expanded Medicaid eligibility under the Patient Protection and Affordable Care Act. Using a standardized protocol and calling script, 5 researchers called sampled clinicians during normal business hours between May 12, 2023, and July 6, 2023, as Medicaid enrollees seeking the soonest available appointment. When an appointment could not be provided with the sampled clinician, callers requested consultation with an alternate clinician at the same practice. We examined appointment availability, wait times, and reasons an appointment could not be made with the sampled clinician. We made comparisons between cities for appointment availability with the χ2 test with Bonferroni correction. We compared wait times with a 1-way analysis of variance test. Analyses were performed with Stata version 16 (StataCorp). We defined significance as 2-sided P < .05. The study was approved by the institutional review board at the Biomedical Research Alliance of New York, which provided a waiver of informed consent because the research involved minimal risk and could not be carried out without a waiver, and a waiver would not adversely affect individuals being studied.
Results: Across the 320 clinician offices called, 87 (27.2%) had appointments available, including 57 (17.8%) with the sampled clinician and 30 (9.4%) with an alternate clinician at the same practice. The proportion of calls resulting in an appointment with any clinician was 36.3% in New York City, 30.0% in Phoenix, 27.5% in Chicago, and 15.0% in Los Angeles. The 2 cities with significantly different appointment availabilities were New York and Los Angeles (P = .002). Median wait times were 11 days (IQR, 6-20 days) in Phoenix, 23 days (IQR, 9-35 days) in Chicago, 28 days (IQR, 11-84 days) in New York, and 64 days (IQR, 24-126 days) in Los Angeles. The cities with significantly different wait times were Phoenix and Los Angeles (P = .001), Phoenix and New York City (P = .03), and Chicago and Los Angeles (P = .049). Among the 263 sampled clinicians with whom appointments could not be made, 15.2% had a listed number that was incorrect or out of service and 35.0% did not answer the phone on either of 2 attempts.
Moral Hazard on the ACA Exchanges: Evidence from a Cost-Sharing Subsidy Discontinuity
Cameron Ellis, Meghan Esson & Eli Liebman
University of Iowa Working Paper, July 2024
Abstract:
This paper examines the moral hazard effects of cost-sharing subsidies in the Affordable Care Act's Health Insurance Exchanges. Exploiting a sharp discontinuity in subsidy generosity at 150% of the federal poverty level, we compare healthcare spending for individuals just above and below this threshold using a regression discontinuity design and data from the Medical Expenditure Panel Survey. We find that individuals just below 150% FPL who receive the most generous subsidies spend approximately $1,700 more annually on healthcare compared to those just above the threshold receiving less generous subsidies, implying an elasticity of -0.48. Several analyses suggest this discontinuity reflects moral hazard rather than adverse selection or health differences across the income threshold. The results highlight the significant impact of moral hazard induced by generous cost-sharing subsidies, with important implications for the design of means-tested health insurance subsidies.
Trauma Activation Fees Vary Widely Across US Trauma Centers
Kirstin Woody Scott et al.
Health Affairs, August 2024, Pages 1180-1189
Abstract:
Trauma activation fees are intended to help trauma centers cover the costs of providing lifesaving care at all times, but they have fallen under greater scrutiny because of a lack of regulation and wide variability in charges. We leveraged the federal Hospital Price Transparency rule to systematically describe trauma activation fees as captured in the Turquoise Health database for all Level I–III trauma centers nationally and across payer types. As of April 18, 2023, a total of 38 percent of US trauma centers published trauma activation fees. These fees varied widely by payer type. The minimum fee charged was $40 (for a Medicaid contract); the maximum fees charged were $28,356 (self-pay) and $28,893 (commercial payers). Trauma centers that were larger, metropolitan, located in the West, and associated with proprietary (investor-owned, for-profit) hospitals had higher trauma activation fees. Proprietary hospitals posted fees that were 60 percent higher than those published by public, nonfederal hospitals. Unmerited variation in trauma activation fees may suggest that the current funding strategy is equitable neither for trauma centers nor for the severely injured patients who rely on them for lifesaving care.
Financial Effects of Remote Product Delivery: Evidence from Hospitals
Kimberly Cornaggia, Xuelin Li & Zihan Ye
Review of Financial Studies, September 2024, Pages 2817–2854
Abstract:
We study financial effects of remote product delivery in the healthcare industry. Exploiting staggered law adoption for identification, we find that telehealth provision redistributes hospital operations and access to capital away from rural communities. As urban telehealth providers acquire rural patients, rural hospitals experience decreased revenue and profit, credit rating downgrades, increased cost of capital, and ultimately risk of closure. Although telehealth reduces travel costs, some communities lose access to acute care. Overall, we conclude that remote healthcare services have financial consequences as well as real effects, and their benefits are unequally distributed.
Consumer Out-Of-Pocket Drug Prices Grew Faster Than Prices Faced By Insurers After Accounting For Rebates, 2007–20
Justine Mallatt, Abe Dunn & Lasanthi Fernando
Health Affairs, September 2024, Pages 1284-1289
Abstract:
The rising price of branded drugs has garnered considerable attention from the public and policy makers. This article investigates the complexities of pharmaceutical pricing, with an emphasis on the overlooked aspects of manufacturer rebates and out-of-pocket prices. Rebates granted by pharmaceutical manufacturers to insurers reduce the actual prices paid by insurers, causing the true prices of prescriptions to diverge from official statistics. We combined claims data on branded retail prescription drugs with estimates on rebates to provide new price index measures based on pharmacy prices, negotiated prices (after rebates), and out-of-pocket prices for the commercially insured population during the period 2007–20. We found that although retail pharmacy prices increased 9.1 percent annually, negotiated prices grew by a mere 4.3 percent, highlighting the importance of rebates in price measurement. Surprisingly, consumer out-of-pocket prices diverged from negotiated prices after 2016, growing 5.8 percent annually while negotiated prices remained flat. The concern over drug price inflation is more reflective of the rapid increase in consumer out-of-pocket expenses than the stagnated inflation of negotiated prices paid by insurers after 2016.
Monetizing Kindness: The Impact of CSR on Hospital Financial Performance
Yuchen Zhang
University of Utah Working Paper, August 2024
Abstract:
This paper examines the monetary benefits hospitals receive for fulfilling their social responsibility. Hospitals that provide more charity care, a form of financial aid to low-income patients, experience higher patient revenue and profitability in subsequent periods. This is because offering charity care helps hospitals establish a philanthropic reputation and increases patient demand for their medical services. Using ICU visits as an instrumental variable, I find that increased charity care leads to better financial performance. These results provide an economic rationale for corporations to engage in more corporate social responsibility (CSR) initiatives.
Fitting in? Physician practice style after forced relocation
Alice Chen, Michael Richards & Rachel Shriver
Health Services Research, August 2024
Data Sources: All hospital-based births in Florida from 2003 through 2017.
Study Design: Difference-in-differences approach is adopted that leverages obstetric unit closures as the source of identifying variation to exogenously shift obstetricians to a new, nearby hospital with different propensities to approach newborn deliveries less intensively.
Principal Findings: All of the physicians meeting our inclusion criteria shifted their births to a new hospital less than 20 miles from the hospital shuttering its obstetric unit. The new hospitals approached newborn births more conservatively, and treatment group physicians sharply became less aggressive in their newborn birth clinical management (e.g., use of C-section). The immediate 11-percentage point (33%) increase in delivering newborns without any procedure behavior change is statistically significant (p value <0.01) and persistent after the closure event; however, the physicians' payer and patient mix are unchanged.
Can AI Distort Human Capital?
Xuelin Li & Meizi Zhou
Columbia University Working Paper, May 2024
Abstract:
We document that interactions with manipulated AI can distort the development of human capital in opioid prescription contexts. Physicians in our sample adopted electronic health record software from a list of federally certified companies in 2011. Between 2016 and spring 2019, one company secretly embedded a biased AI reminder system to promote extended-release opioid sales. Affected physicians not only increased opioid claims relative to the control group during the treatment window but also maintained a higher propensity for prescriptions even after the removal of the biased function. This long-term distortion of human capital relies on the unconsciousness of AI biases and does not occur following other explicit promotions, such as pharmaceutical detailing payments. Using machine-learning algorithms, we quantify that human capital distortion explains 54% of the treatment effects in a physician decision model with dynamic learning. Experience with opioids, along with caution regarding elder patients, mitigates the distortion.
Drivers of Racial Differences in C-Sections
Adriana Corredor-Waldron, Janet Currie & Molly Schnell
NBER Working Paper, August 2024
Abstract:
Black mothers with unscheduled deliveries are 25 percent more likely to deliver by C-section than non-Hispanic white mothers. The gap is highest for mothers with the lowest risk and is reduced by only four percentage points when controlling for observed medical risk factors, sociodemographic characteristics, hospital, and doctor or medical practice group. Remarkably, the gap disappears when the costs of ordering an unscheduled C-section are higher due to the unscheduled delivery occurring at the same time as a scheduled C-section. This finding is consistent with provider discretion -- rather than differences in unobserved medical risk -- accounting for persistent racial disparities in delivery method. The additional C-sections that take place for low-risk women when hospitals are unconstrained negatively impact maternal and infant health.
Health insurance access and the career choices of college graduates with majors in the arts: Evidence from the Affordable Care Act’s dependent coverage expansion
Richard Paulsen & Rajendra Dulal
Journal of Cultural Economics, September 2024, Pages 367–385
Abstract:
In this study, we test for the impact of the Affordable Care Act’s dependent coverage expansion on the career choices of young college graduates with majors in the arts in the United States. Since working as an artist often involves employment arrangements like self-employment and project-based work that lack health insurance coverage, policies that expand access to health insurance have the potential to make employment in the arts more attractive for arts graduates. Using American Community Survey data, we use a difference-in-differences regression approach comparing the likelihood of working in the arts for college graduates with majors in the arts who are just under- and just over-26, pre- and post-implementation of the ACA’s dependent coverage expansion. We find that the ACA increased the likelihood that arts graduates under 26 years of age were working in the arts by over 2% points, effects that are statistically significant and large as less than 20% of arts graduates in our sample work in the arts. Such changes are not observed for other graduates, suggesting that this response is unique to arts graduates, who are often found to behave differently than other workers.