Nice Medicine
Do Physicians Improve More from Positive or Negative Feedback?
Manasvini Singh & Jacob Zureich
Management Science, forthcoming
Abstract:
We use clinical data on more than 240,000 surgeries and quasi-experimental methods to examine how physicians respond to the surprise release of a performance "report card." Such feedback interventions are commonly used to encourage physicians to improve performance yet show limited evidence of success. Our results show that these limited effects mask heterogeneous behavioral responses to feedback valence. In particular, physicians improve more from positive feedback than from negative feedback, with negative feedback even reducing performance for a nontrivial share of patients. Experiments with laypersons replicate these results and show that struggles with negative feedback can be mitigated by giving incentives directly tied to improvement and by adding qualitative information that helps individuals interpret past performance. These results are consistent with behavioral models that suggest cognitive and emotional difficulties limit how well individuals use negative feedback. Thus, feedback interventions in healthcare should be carefully designed to mitigate these counterproductive behavioral responses.
No Free Lunch? Welfare Analysis of Firms Selling through Expert Intermediaries
Matthew Grennan et al.
Review of Economic Studies, forthcoming
Abstract:
We study how firms target and influence expert intermediaries. In our context, pharmaceutical manufacturers provide payments to physicians during promotional interactions. We develop an identification strategy based on plausibly exogenous variation in payments driven by differential exposure to spillovers from academic medical centers' conflict-of-interest policies. Using a case study of an important class of cardiovascular drugs, we estimate heterogeneous effects of payments on prescribing, with firms targeting highly responsive physicians. We also develop a model of supply and demand, which allows us to quantify how oligopoly prices reduce drug prescribing, and how payments move prescribing closer to the optimal level, but at great financial cost. In our estimated model, whether consumers are harmed by payments depends on whether there is substantial under-prescribing due to behavioral or other frictions. In a final exercise, we calibrate such frictions using clinical data and estimate that payments benefit consumers in this case study.
Is There Too Little Antitrust Enforcement in the U.S. Hospital Sector?
Zarek Brot-Goldberg et al.
American Economic Review: Insights, forthcoming
Abstract:
From 2002 to 2020, there were over 1,000 mergers of U.S. hospitals. During this period, the Federal Trade Commission (FTC) took enforcement actions against 13 transactions. However, using the FTC's standard screening tools, we find that 20% of these mergers could have been predicted to meaningfully lessen competition. We then show that, from 2010 to 2015, predictably anticompetitive mergers resulted in price increases over 5%. We estimate that approximately half of predictably anticompetitive mergers had to be reported to the FTC per the Hart-Scott-Rodino Act. We conclude that there appears to be underenforcement of antitrust laws in the hospital sector.
Knowledge Growth and Specialization: Evidence from Oncologists
Maya Lozinski
University of Chicago Working Paper, September 2024
Abstract:
Do expert workers respond to growth in general knowledge by specializing and narrowing their scope? I study this empirically in the context of medical oncology. I document explosive growth in knowledge using changes in historical cancer treatment guidelines. Surprisingly, most oncologists are general oncologists and do not become more specialized over time or in response to knowledge growth. However, exposure to knowledge growth causes a minority of already specialized oncologists to become even more specialized. Specialists also increasingly provide higher quality care: over time, they prescribe more up-to-date cancer drugs and have more experience with the drugs they prescribe than generalists. These results suggest that most oncologists, who are generalists and primarily users of knowledge, may respond to knowledge growth not by specializing but by falling behind the frontier. In addition, specialization increases only in large markets, leading to growing geographic inequality in specialization, and implies growing economies of scale in specialized healthcare and the associated high-skill labor markets.
Medicaid expansion and opioid prescriptions: Evidence from the Medical Expenditure Panel Survey
Chandler McClellan & Asako Moriya
Health Economics, November 2024, Pages 2439-2449
Abstract:
Evidence is mixed on whether increased access to insurance, specifically through the ACA's Medicaid expansion, exacerbated the opioid public health crisis through increased opioid prescribing. Using survey data on retail prescription drug fills from 2008 to 2019, we did not find a significant relationship between Medicaid expansion and opioid prescribing in the newly eligible Medicaid population. It may be that the dangers of opioids were known well enough by the time of the Medicaid expansion that lack of access to care was no longer a binding constraint on opioid prescription receipt.
Paying for Advance Care Planning in Medicare: Impacts on Care and Spending near End of Life
Alice Chen & Jing Li
Journal of Health Economics, December 2024
Abstract:
Spending at end of life (EOL) accounts for a large and growing share of healthcare expenditures in the US, and often reflects aggressive care with questionable value for dying patients. Using a novel instrumental variables approach, we conduct the first study on the causal effect of Medicare reimbursement for advance care planning (ACP) -- the process of discussing and recording patient preferences for goals of care -- on care utilization, spending, and mortality outcomes for critically ill Medicare patients. We find that billed ACP services substantially increase hospice use and hospice spending within a year, accompanied by corresponding increase in one-year mortality. The impacts of ACP services on hospice use and spending are especially prominent among patients with dementia and those of lower socioeconomic status. Among decedents, death is significantly less likely to occur in the hospital, and total and inpatient spending within the last 30 days of life fall significantly. Our findings suggest that paying for ACP services can be effective in improving hospice use for critically ill Medicare patients, with the (possibly intended) consequence of increased one-year mortality.
Scope-of-practice laws and the practice patterns of nurse practitioners and physician assistants
Benjamin McMichael
Contemporary Economic Policy, forthcoming
Abstract:
I evaluate whether nurse practitioners (NPs) and physician assistants (PAs) change how they practice when states relax the scope-of-practice laws governing these professions. I find little evidence that NPs or PAs begin providing specialty services following relaxation. Some evidence suggests that NPs specialize more in rural areas following the relaxation of scope-of-practice laws, but no indication that they do so generally. Overall, the evidence developed here suggests that NPs and PAs do not change how they care for patients following the relaxation of scope-of-practice laws, undermining patient safety arguments along these lines.
The effect of expansion of nurse practitioner scope of practice on early COVID-19 deaths
Bobby Chung & Noah Trudeau
Contemporary Economic Policy, forthcoming
Abstract:
Public safety is often used as an argument against expanding scope of practice (SOP) for nurse practitioners, despite the benefit of filling unmet health care demand. As a response to the COVID-19 Pandemic, some states expanded SOP for nurse practitioners to accommodate the unprecedented healthcare challenge. We analyze the effect of the expansion of SOP on daily COVID-19-related mortality, exploiting the quasi-random state policy changes at the beginning of the COVID-19 pandemic. Checking different model specifications, we do not find evidence that expanding SOP for nurse practitioners during the pandemic causes adverse effects on patients measured by COVID-19 mortality.
The effects of nurse practitioner scope of practice laws on diabetic health care costs
Alexandra Wallace, Moiz Bhai & Danny Hughes
Contemporary Economic Policy, forthcoming
Abstract:
Type 2 Diabetes mellitus patients require regular monitoring and preventive care from healthcare professionals to avoid costly and potentially life-threatening complications. One approach for expanding access to primary care for diabetic patients is to change scope of practice laws for nurse practitioners to allow full practice authority (FPA). We find that state-level implementation of FPA reduces total health care costs for diabetics by approximately 20% in urban areas and reduces rural usage of advanced medical services for diabetics by about 10%. However, we see no effects of FPA on primary care claims, high A1c tests, or diabetic debridements.
Flexible Austerity: Negotiating the Unequal Effects of Resource Shortages in Racialized Organizations
Alexandra Brewer
American Sociological Review, October 2024, Pages 820-848
Abstract:
Resource shortages unfold unequally, often affecting the most socially disadvantaged people and exacerbating preexisting inequalities. Given that most resources are obtained through organizations, what role do organizational processes play in amplifying inequalities during shortages? I argue that workers engage in a practice I term flexible austerity. Flexible austerity describes how resource shortages become opportunities for decision-makers to more readily rationalize unequal resource allocation. I develop this concept by drawing on an ethnography of an urban academic hospital and leveraging data from before and during a nationwide shortage of medical intravenous (IV) opioids. I show that prior to this shortage, clinicians disproportionately assessed Black patients' pain as "undeserving" of IV opioids, but they allocated these resources liberally because they felt constrained by evidence-based clinical best practices guidelines. During the shortage, clinicians constructed resource scarcity as necessitating austerity practices when treating Black patients, yet they exercised flexibility with White patients. This widened care disparities in ways that may have been detrimental to Black patients' health. Based on these findings, I argue that resource shortages amplify inequalities in organizations because they provide new "colorblind" justifications for withholding resources that allow workers to link ideas of deservingness to allocation decisions.