Malpractice
After 50 Years, Health Professional Shortage Areas Had No Significant Impact On Mortality Or Physician Density
Justin Markowski, Jacob Wallace & Chima Ndumele
Health Affairs, November 2023, Pages 1507-1516
Abstract:
Since 1965, the US federal government has incentivized physicians to practice in high-need areas of the country through the designation of Health Professional Shortage Areas (HPSAs). Despite its being in place for more than half a century and directing more than a billion dollars annually, there is limited evidence of the HPSA program’s effectiveness at reducing geographic disparities in access to care and health outcomes. Using a generalized difference-in-differences design with matching, we found no statistically significant changes in mortality or physician density from 1970 to 2018 after a county-level HPSA designation. As a result, we found that 73 percent of counties designated as HPSAs remained physician shortage areas for at least ten years after their inclusion in the program. Fundamental improvements to the program’s design and incentive structure may be necessary for it to achieve its intended results.
Geographic Variation in Cesarean Sections in the United States: Trends, Correlates, and Other Interesting Facts
Sarah Robinson, Heather Royer & David Silver
NBER Working Paper, November 2023
Abstract:
Analyzing data spanning three decades covering the near universe of births, we study county-level differences in Cesarean section (C-section) rates among first-time mothers of singleton births. Our research reveals persistent geographic variation in C- section rates for both low- and high-risk groups. Counties with elevated C-section rates consistently perform more C-sections across mothers at all levels of appropriateness for the procedure. These elevated rates of C-section in high C-section counties are associated with reduced maternal and infant morbidity. We also find that C-section decisions are less responsive to underlying risks for Black mothers relative to white mothers, suggesting potential welfare-reducing disparities.
FDA Global Drug Inspections: Surveillance Of Manufacturing Establishments Remains Well Below Pre-COVID-19 Levels
Emily Cuddy, Yun Peng Lu & David Ridley
Health Affairs, December 2023, Pages 1758-1766
Abstract:
During the initial phase of the COVID-19 pandemic, the Food and Drug Administration (FDA) halted inspections of most overseas drug manufacturing establishments. Looking at data from the period 2012–22, we observed steep declines in both foreign and domestic inspections in 2020. By 2022, numbers of inspections remained well below prepandemic levels, with a 79 percent decrease in foreign inspections and a 35 percent decline in domestic inspections compared with 2019. There was no corresponding reduction in drug manufacturing or imports. Also, the resources allocated per inspection surged, although the FDA’s overall budget and staffing remained steady. Finally, citations rose dramatically, despite all establishments being given advance notice of inspections. The findings of our study underscore the pressing need to explore alternative methods for ensuring drug safety.
Are Hospital Quality Indicators Causal?
Amitabh Chandra, Maurice Dalton & Douglas Staiger
NBER Working Paper, October 2023
Abstract:
Hospitals play a key role in patient outcomes and spending, but efforts to improve their quality are hindered because we do not know whether hospital quality indicators are causal or biased. We evaluate the validity of commonly used quality indicators, such as mortality, readmissions, inpatient costs, and length-of-stay, using a quasi-experimental design where hospital closures reallocate large numbers of patients to hospitals of different quality. This setting allows us to measure whether patient outcomes improve as much as quality indicators predict when a relatively low-quality hospital closes, or decline as predicted when a relatively high-quality hospital closes. Using more than 20 years of Medicare claims for over 30 million patients admitted with five common diagnoses, we find that hospital quality indicators overstate differences in the causal impact of hospitals on mortality and readmission rates by 7 percent or less, but overstate differences in the causal impact of hospitals on inpatient cost and length-of-stay measures by closer to 40 percent. On average, hospital closures reduce patient mortality by shifting patients to higher quality hospitals, but the effect varies widely depending on the relative quality of the closing hospital.
Merging Rural And Urban ACA Rating Areas Improved Choice, Premiums In Rural Texas
Simon Haeder et al.
Health Affairs, November 2023, Pages 1527-1531
Abstract:
Rural consumers often face a limited choice of carriers and plans and high premiums. To mitigate this issue, Texas recently adjusted its Affordable Care Act Marketplace rating areas to integrate rural areas into nearby urban markets for rating purposes. We found that rural consumers subsequently saw increases in carrier and plan choices, as well as decreases in overall plan premiums.
The Academic and Behavioral Impacts of an Autism Health Insurance Mandate: Evidence from Massachusetts
Stephanie Coffey
Education Finance and Policy, forthcoming
Abstract:
Today, all 50 states have enacted mandates requiring some level of insurance coverage for the treatment of Autism Spectrum Disorders (ASD). In this paper, I examine the impact of Massachusetts' mandate, ARICA (An Act Relative to Insurance Coverage for Autism) on the academic and behavioral outcomes of students with ASD in the state. Using administrative data on Massachusetts public school students, I employ a triple difference strategy to estimate impacts on special education setting, attendance, suspensions and achievement. I find that ARICA increased inclusion for students with ASD; they were 4 percentage points more likely to be fully included after the reform. Further, days suspended decreased by about 26%, and the likelihood of receiving a suspension decreased by about 2 percentage points. I find that improvements in student outcomes were larger for students in grades 6-8 (versus elementary students). While I find no statistically significant improvement in test scores for students with ASD overall, math (ELA) achievement increased by .09 (.13) sd. for students in middle grades.
First, do no harm, second, say sorry? Investigating the impact of a new tort reform
Philip DeCicca & Natalie Malak
Journal of Law, Economics, and Organization, forthcoming
Abstract:
We investigate the effect of so-called “apology laws” on physician procedure choice and birth outcomes. Advocates believe they may reduce litigation since a harmed person who receives an apology or explanation may be less likely to sue, all else equal. In the medical context, this could translate into a reduction in defensive medicine practiced. To investigate this possibility, we examine the impact of these laws on the use of C-sections, a common measure for gauging the practice of defensive medicine by OB/GYN physicians. We find consistent evidence that “partial” versions actually increase the use of C-sections, contrary to the intention of these laws. More specifically, we find it is older, presumably more established physicians who respond the most. Moreover, we also find some evidence that these particular laws also reduced the rate of preventable pregnancy complications, which suggests that the extra C-sections induced may not just represent defensive medicine.
Medicare Care Choices Model Improved End-Of-Life Care, Lowered Medicare Expenditures, And Increased Hospice Use
Keith Kranker et al.
Health Affairs, November 2023, Pages 1488-1497
Abstract:
The Medicare Care Choices Model (MCCM) tested a new option for eligible Medicare beneficiaries to receive conventional treatment for terminal conditions along with supportive and palliative care from participating hospice providers. Using claims data, we estimated differences in average outcomes from enrollment to death between deceased MCCM enrollees and matched comparison beneficiaries who received usual services covered by original Medicare. Enrollees were 15 percentage points less likely to receive an aggressive life-prolonging treatment at the end of life and spent more than five more days at home. MCCM also reduced net Medicare expenditures by 13 percent, decreased inpatient admissions by 26 percent, reduced outpatient emergency department visits by 12 percent, and increased hospice use by 18 percentage points. Although the Centers for Medicare and Medicaid Services did not expand the model, given concerns about generalizability, these results provide evidence that MCCM is a promising approach to transforming care delivery at the end of life.
Hospital ownership and admission rates from the emergency department, evidence from Florida
David Howard & Guy David
Health Services Research, forthcoming
Data Sources: We used statewide visit-level inpatient and emergency department records from Florida's Agency for Healthcare Administration for 2007–2019.
Study Design: We calculated differences in admission rates between for-profit and other hospitals, adjusting for patient and hospital characteristics. We also estimated instrumental variables models using differential distance to a for-profit hospital as an instrument.
Principal Findings: Adjusted admission rates among patients ages 65 and older were 7.1 percentage points (95% CI: 5.1–9.1) higher at for-profit hospitals in 2019 (or 18.8% of the sample mean of 37.8%). Differences in admission rates have remained constant since 2009.
Paid medical malpractice claims: How strongly does the past predict the future?
Kowsar Yousefi, Bernard Black & David Hyman
Journal of Empirical Legal Studies, December 2023, Pages 818-851
Abstract:
When does the past predict the future? In financial markets, warnings that “past results are no guarantee of future performance” are ubiquitous. But in multiple fields (including professional sports, insurance, and criminal law), it is widely believed that the past is a useful guide to the future. Does that insight apply to medical malpractice (“med mal”)? Using a novel dataset (which includes detailed data on all licensed physicians and all paid claims in Illinois over a 25-year period), we study whether past paid med mal claims, physician characteristics, and specialty predict future paid med mal claims. After controlling for other factors, physicians with a single prior paid claim have a fourfold higher risk of future claims than physicians with zero prior paid claims. The more prior paid claims a physician has, the higher the likelihood of a future paid claim. Multiple factors (male gender, having an MD, attending a non-U.S. medical school, practicing in a high-claim-risk specialty, and mid-career status [6–15 prior years of experience]) predict a higher likelihood of having one or more paid med mal claims.
Home Health Agencies With High Quality of Patient Care Star Ratings Reduced Short-Term Hospitalization Rates and Increased Days Independently at Home
Jun Li
Medical Care, January 2024, Pages 11-20
Objective: The aim of this study was to determine whether using the highest-rated home health agency available in a ZIP code improves outcomes.
Research Design: A retrospective study of 1,870,080 Medicare fee-for-service beneficiaries using home health care from July 2015 through July 2016 in the United States. An instrumental variables approach is used to address the endogeneity of agency choice, where the instrument is the differential proximity of the patient to the closest highest-rated and closest lower-rated agency.
Results: Treatment by the highest-rated agencies available decreased risks (in percentage points) of hospitalization (−3.2; 95% CI, −4.1 to −2.3), emergency department use (−2.2; 95% CI, −3.2 to −1.1), and institutionalization (−0.9; 95% CI, −1.3 to −0.5) during the initial episode, and increased days independently at home by 2.6% or 3.75 (95% CI, 2.20–5.29) days in the 180 days after the end of the initial episode. Treatment effects were more pronounced for agencies that were above-average (6.51 d; 95% CI, 4.15–8.87), had ≥1 more star than the next-best agency (7.80 d; 95% CI, 4.13–11.47), and nonrural residents (4.57 d; 95% CI, 2.75–6.40). Effects were positive for both postacute (3.40; 95% CI, 1.80–5.00) and community-entry (5.60; 95% CI, 2.30–8.89) patients.