Prescribing
Universal Cash Transfers and Prescription Utilization: Evidence from the Alaska Permanent Fund Dividend
Mouhcine Guettabi & Allison Witman
Journal of Health Economics, forthcoming
Abstract:
We investigate the impact of a large cash transfer on prescription utilization. Our identification strategy leverages the Alaksa Permanent Fund Dividend (PFD), which is distributed annually in October and comprises 6% of the average household's annual income. We study the impact of the PFD on the use of prescription medications using a within-Alaska comparison group and difference-in-differences design. Using the IBM MarketScan Commercial Claims and Encounters Prescription Drug Database, we observe prescriptions for 50,866 commercially-insured individuals who filled prescriptions between 2013 and 2019. We find no changes in prescription use overall, by patient characteristic, or by degree of cost sharing after the PFD is distributed. We also conduct a synthetic control analysis using a non-Alaska comparison group and find no effects of the PFD on prescriptions. These findings are useful for understanding liquidity sensitivity for prescription medication and the effects of cash distributions among individuals with employer-based health insurance.
The risk of losing health insurance in the United States is large, and remained so after the Affordable Care Act
Liran Einav & Amy Finkelstein
Proceedings of the National Academy of Sciences, 2 May 2023
Abstract:
Health insurance coverage in the United States is highly uncertain. In the post-Affordable Care Act (ACA), pre-COVID United States, we estimate that while 12.5% of individuals under 65 are uninsured at a point in time, twice as many -- one in four -- are uninsured at some point over a 2-y period. Moreover, the risk of losing insurance remained virtually unchanged with the introduction of the landmark ACA. Risk of insurance loss is particularly high for those with health insurance through Medicaid or private exchanges; they have a 20% chance of losing coverage at some point over a 2-y period, compared to 8.5% for those with employer-provided coverage. Those who lose insurance can experience prolonged periods without coverage; about half are still uninsured 6 mo later, and almost one-quarter are uninsured for the subsequent 2 y. These facts suggest that research and policy attention should focus not only on the “headline number” of the share of the population uninsured at a point in time, but also on the stability and certainty (or lack thereof) of being insured.
What Does a Public Option Do? Evidence from California
Evan Saltzman
Emory University Working Paper, February 2023
Abstract:
Creating a public firm to compete with private firms is an increasingly debated intervention to address inefficiency in concentrated markets. I develop a mixed oligopoly model with alternative firm objectives and estimate it with consumer-level data from the California insurance exchange, where one-third of consumers have access to a public firm. In the best-fitting model, the public firm places more weight on consumer surplus than producer surplus. Adding a public firm decreases premiums, improves welfare in concentrated markets, and increases surplus the most for disadvantaged subpopulations. Enhancing subsidies for private plans, a leading alternative intervention, increases premiums and reduces welfare.
Hospital Boarding Crises: The Impact of Urgent vs. Prevention Responses on Length of Stay
Temidayo Adepoju et al.
Management Science, forthcoming
Abstract:
Healthcare policy makers use wait-time metrics to encourage hospital managers to improve patient experience. In 2002, Massachusetts mandated that hospital managers develop processes to respond to boarding crises, which occur when emergency department (ED) patients experience long waits for inpatient beds. Performance improvement theory suggests that patients would be better served by preventing boarding crises rather than responding urgently after they occur. To empirically test this theory, we use data from a Massachusetts hospital that has two physician-based processes related to boarding and patient flow. First, to comply with the state mandate, the hospital developed processes to identify when the hospital is in a boarding crisis, a code yellow (CY), and subsequently request that physicians prioritize patient discharge (urgent response). Second, physicians can use predischarge orders, optional written communication about discharge barriers, to avoid discharge delays for patients approaching discharge (prevention response). Our data supports the existence of a trade-off between these two responses. Counter to our hypothesis, the state-mandated urgent response does not have any impact on length of stay (LOS). We also find that a CY has no impact on ED hourly occupancy, marginally decreases ED wait times, and increases boarding time. The prevention response is associated with a 26% reduction in LOS. Furthermore, we find that the urgent response reduces the likelihood of physicians’ ability to use the prevention response by 27.3%. We conclude that the state policy has unintended negative consequences that stymie hospital efforts to create longer term improvement.
Added Therapeutic Benefit of Top-Selling Brand-name Drugs in Medicare
Alexander Egilman, Benjamin Rome & Aaron Kesselheim
Journal of the American Medical Association, 18 April 2023, Pages 1283-1289
Objective: To determine the added therapeutic benefit of the 50 top-selling brand-name drugs in Medicare in 2020, as assessed by health technology assessment (HTA) organizations in Canada, France, and Germany.
Results: Forty-nine drugs (98%) received an HTA rating by at least 1 country; 22 of 36 drugs (61%) received a low added benefit rating in Canada, 34 of 47 in France (72%), and 17 of 29 in Germany (59%). Across countries, 27 drugs (55%) had a low added therapeutic rating, accounting for $19.3 billion in annual estimated net spending, or 35% of Medicare net spending on the 50 top-selling single-source drugs and 11% of total Medicare net prescription drug spending in 2020. Compared with those with high added benefit, drugs with a low added therapeutic rating were used by more Medicare beneficiaries (median 387 149 vs 44 869) and had lower net spending per beneficiary (median $992 vs $32 287).
Hospital-Physician Integration Is Associated With Greater Use Of Cardiac Catheterization And Angioplasty
Brady Post et al.
Health Affairs, May 2023, Pages 606-614
Abstract:
In the US in recent years, hospital-physician integration has become a dominant form of consolidation in health care. This transition away from independent practice has raised questions about whether hospital-employed physicians may be more likely than independent physicians to refer patients to high-intensity, hospital-based services. We used Medicare claims data from the period 2013–20 to identify patients who received a new diagnosis of stable angina, a common cardiovascular condition that entails clinical discretion in treatment choice. Using linear probability models and an instrumental variables model, we found that patients whose care was managed by a hospital-integrated cardiologist were no more likely to receive stress tests (an office-based procedure) than those whose care was managed by an independent cardiologist. However, these patients were much more likely to receive high-intensity, hospital-based coronary interventions. These results suggest that hospital-physician integration is an important factor in the intensity of treatment received by patients with stable angina. Policy makers may see these findings as additional impetus for more aggressive antitrust enforcement of integrated arrangements between hospitals and physicians and for other regulatory or payment mechanisms that might deter hospitals from using such arrangements to promote high-intensity treatment unnecessarily.
Optimizing Patient-Specific Medication Regimen Policies Using Wearable Sensors in Parkinson’s Disease
Matt Baucum et al.
Management Science, forthcoming
Abstract:
Effective treatment of Parkinson’s disease (PD) is a continual challenge for healthcare providers, and providers can benefit from leveraging emerging technologies to supplement traditional clinic care. We develop a data-driven reinforcement learning (RL) framework to optimize PD medication regimens through wearable sensors. We leverage a data set of n = 26 PD patients who wore wrist-mounted movement trackers for two separate six-day periods. Using these data, we first build and validate a simulation model of how individual patients’ movement symptoms respond to medication administration. We then pair this simulation model with an on-policy RL algorithm that recommends optimal medication types, timing, and dosages during the day while incorporating human-in-the-loop considerations on medication administration. The results show that the RL-prescribed medication regimens outperform physicians’ medication regimens, despite physicians having access to the same data as the RL agent. To validate our results, we assess our wearable-based RL medication regimens using n = 399 PD patients from the Parkinson’s Progression Markers Initiative data set. We show that the wearable-based RL medication regimens would lead to significant symptom improvement for these patients, even more so than training RL policies directly from this data set. In doing so, we show that RL models from even small data sets of wearable data can offer novel, generalizable clinical insights and medication strategies, which may outperform those derived from larger data sets without wearable data.
The Impact of Eligibility for Medicaid versus Subsidized Private Health Insurance on Medical Spending, Self-Reported Health, and Public Program Participation
Silvia Helena Barcellos, Mireille Jacobson & Helen Levy
American Journal of Health Economics, Spring 2023, Pages 262–295
Abstract:
We use a regression discontinuity design to understand the impact of a sharp change in eligibility for Medicaid versus subsidized marketplace insurance at 138 percent of the federal poverty line on coverage, medical spending, health status, and other public program participation. We find a 5.5 percentage point shift from Medicaid to private insurance, with no net change in coverage. The shift increases individual health spending by $341 or 2 percent of income, with larger increases at higher points in the spending distribution. Two-thirds of the increase is from premiums and one-third from out-of-pocket medical spending. Self-rated health and other public program participation appear unchanged. We find no evidence of bunching below the eligibility threshold, which suggests either that individuals are willing to pay more for private insurance or that optimization frictions are high.
Does subsidized public health insurance for parents improve children's human capital and close achievement gaps?
Anuj Gangopadhyaya & Jeffrey Schiman
Economics of Education Review, April 2023
Abstract:
Between 2009 and 2018, many states dramatically changed income eligibility limits for parental Medicaid. We examine whether increasing parental Medicaid eligibility had spillover benefits on children's development. We study the effects of state-level changes in parental income limits for Medicaid on 3rd through 8th grade mathematics and English-language arts (ELA) achievement using county-level administrative test score data. We find that a 50-percentage point increase in parental Medicaid income limits, roughly equal to the average state increase in eligibility over this period, is associated with a 1.5% reduction in the socioeconomic achievement gap for math and a 3% reduction in the white-black math achievement gap. Math test scores improved significantly following parental Medicaid eligibility expansions among black students residing in poorer counties, with little estimated change in test scores for black students in higher income counties. We find no effect in ELA achievement gaps or white-Hispanic test score gaps. Our findings suggest that means-tested policies that improve parental and family wellbeing have important spillover benefits to children's educational achievement and can help reduce inequities in children's human capital development.
Comparison of survival outcomes among older adults with major trauma after trauma center versus non-trauma center care in the United States
Jessy Nguyen & Prachi Sanghavi
Health Services Research, forthcoming
Data Sources and Study Setting: We used claims of 100% of 2012–2017 Medicare fee-for-service beneficiaries who received hospital care after major trauma.
Study Design: Survival differences were estimated after applying propensity-score-based overlap weights. Subgroup analyses were performed for ambulance-transported patients and by external cause. We assessed the roles of prehospital care, hospital quality, and volume.
Principal Findings: Thirty-day mortality was higher overall at level 1 versus non-trauma centers by 2.2 (95% confidence interval [CI]: 1.8, 2.6) percentage points (pp). Thirty-day mortality was higher at level 1 versus non-trauma centers by 2.3 (95% CI: 1.9, 2.8) pp for falls and 2.3 (95% CI: 0.2, 4.4) pp for motor vehicle crashes. Differences persisted at 1 year. Level 1 and 2 trauma centers had similar outcomes. Hospital quality and volume did not explain these differences. In the ambulance-transported subgroup, after adjusting for prehospital variables, no statistically significant differences remained.