Someone has to care

Kevin Lewis

June 12, 2019

Still "Saving Babies"? The Impact of Child Medicaid Expansions on High School Completion Rates
Lincoln Groves
Contemporary Economic Policy, forthcoming


The decoupling of child Medicaid from the cash welfare system greatly increased access to public health insurance for low‐income children in the United States. In this paper, I show that the federally mandated public health insurance expansions of the late‐1980s and early‐1990s significantly increased the number of public high school completers in the 2000s. Using the legislated generosity of a state's child Medicaid program as a time‐varying, exogenous source of variation in a quasi‐experimental design, I find substantively large declines in the dropout rate and, importantly, large increases in traditional 4‐year graduation rates. Results for both measures are driven by Hispanic and White students, the two groups experiencing the greatest within‐group increases in eligibility due to the decoupling of child Medicaid from the Aid to Families with Dependent Children program. In addition, I find evidence that increases in the length of childhood years covered (e.g., through age 5 vs. through age 17) leads to greater gains in completion rates. This suggests that public health insurance coverage throughout childhood produces the largest effect.

Resistance to Medical Artificial Intelligence
Chiara Longoni, Andrea Bonezzi & Carey Morewedge
Journal of Consumer Research, forthcoming


Artificial intelligence (AI) is revolutionizing healthcare, but little is known about consumer receptivity toward AI in medicine. Consumers are reluctant to utilize healthcare provided by AI in real and hypothetical choices, separate and joint evaluations. Consumers are less likely to utilize healthcare (study 1), exhibit lower reservation prices for healthcare (study 2), are less sensitive to differences in provider performance (studies 3A-3C), and derive negative utility if a provider is automated rather than human (study 4). Uniqueness neglect, a concern that AI providers are less able than human providers to account for their unique characteristics and circumstances, drives consumer resistance to medical AI. Indeed, resistance to medical AI is stronger for consumers who perceive themselves to be more unique (study 5). Uniqueness neglect mediates resistance to medical AI (study 6), and is eliminated when AI provides care (a) that is framed as personalized (study 7), (b) to consumers other than the self (study 8), or (c) only supports, rather than replaces, a decision made by a human healthcare provider (study 9). These findings make contributions to the psychology of automation and medical decision making, and suggest interventions to increase consumer acceptance of AI in medicine.

The Affordable Care Act's Effects on Patients, Providers and the Economy: What We've Learned So Far
Jonathan Gruber & Benjamin Sommers
NBER Working Paper, June 2019


As we approach the tenth anniversary of the passage of the Affordable Care Act, it is important to reflect on what has been learned about the impacts of this major reform. In this paper we review the literature on the impacts of the ACA on patients, providers and the economy. We find strong evidence that the ACA’s provisions have increased insurance coverage. There is also a clearly positive effect on access to and consumption of health care, with suggestive but more limited evidence on improved health outcomes. There is no evidence of significant reductions in provider access, changes in labor supply, or increased budgetary pressures on state governments, and the law’s total federal cost through 2018 has been less than predicted. We conclude by describing key policy implications and future areas for research.

Information presentation and consumer choice: Evidence from Assisted Reproductive Technology (ART) Success Rate Reports
Bingxiao Wu
Health Economics, forthcoming


How does the presentation of multidimensional quality information in public reporting affect consumer responsiveness? This paper addresses this question exploiting an exogenous change of reporting format in the Assisted Reproductive Technology (ART) reports by the Centers for Disease Control and Prevention. Compared with the first version of the ART report, the second version highlights the “singleton‐birth rate” measure, which is complementary to the “multiple‐birth rate” measure reported in the first version. We find that consumers are more likely to choose clinics with a lower multiple‐birth rate after the format change, indicating more sensitivity to the highlighted measure. This finding implies that information presentation plays an important role in affecting the effectiveness of public reporting.

Explaining the Decline of the U.S. Saving Rate: The Role of Health Expenditure
Yi Chen, Maurizio Mazzocco & Béla Személy
International Economic Review, forthcoming


The U.S. saving rate declined by 8 percent between 1980 and 2009. We document that the decline can be explained by rising health expenditures. Using exogenous variation in medical expenses generated by FDA drug approvals, we document that a 1 percentage point increase in health expenditure generated a decline in saving rate of 0.9 percentage points. We then estimate a model of household decisions to evaluate the mechanisms behind the decline. We find that the rise in health expenses and drop in saving rate are driven by progress in health technology, reduction in co‐payment rates, and improvements in income processes.

Targeting Bad Doctors: Lessons from Indiana, 1975–2015
Jing Liu & David Hyman
Journal of Empirical Legal Studies, June 2019, Pages 248-280


For physicians, quality of care is regulated through the medical malpractice and professional licensing/disciplinary systems. The medical malpractice (med mal) system acts through ex post private litigation; the licensing system acts through ex ante permission to practice (i.e., licensure), coupled with ex post disciplinary action against physicians who engage in “bad” behavior. How often do these separate mechanisms for ensuring quality control take action against the same doctors? With what result? We study these questions using 41 years of data (1975–2015) from Indiana, covering almost 30,000 physicians. Disciplinary sanctions are much less common than med mal claims — whether paid or unpaid. Only a small number of physicians are “tagged” by both systems. Disciplinary risk increases with the number of past med mal claims. Paid claims have a greater impact than unpaid claims, and large payouts (≥100 k, 2015$) have a slightly greater impact than small payouts on disciplinary risk. The risk of a paid claim increases with more severe disciplinary sanctions (i.e., revocation and suspension). Our findings suggest an obvious model for the interaction of these two systems.

Do health insurance and hospital market concentration influence hospital patients’ experience of care?
Caroline Hanson, Bradley Herring & Erin Trish
Health Services Research, forthcoming

Data Sources/Study Setting: Secondary data for 2008‐2015 on patient experience from Hospital Compare's patient survey data, hospital characteristics from the American Hospital Association (AHA) Annual Survey, and insurance market characteristics from HealthLeaders‐InterStudy.

Study Design: Hospital/year‐level regressions predict each hospital's patient experience measure as a function of insurance and hospital market concentration and hospital fixed effects. The model is identified by longitudinal variation in insurance and hospital concentration.

Principal Findings: Changes in patient satisfaction are positively associated with increases in insurance concentration and negatively associated with increases in hospital concentration. Moving from a market with 20th percentile insurance concentration and 80th percentile hospital concentration to a market with 80th percentile insurance concentration and 20th percentile hospital concentration increases the share of patients that rated the hospital highly from 66.9 percent (95% CI: 66.5‐67.2 percent) to 67.9 percent (95% CI: 67.5‐68.3 percent) and the share of patients that definitely recommend the hospital from 69.7 percent (95% CI: 69.4‐70.0 percent) to 70.8 percent (95% CI: 70.5‐71.2 percent). The relationship for insurance concentration is stronger in more concentrated hospital markets, while the relationship for hospital concentration is stronger in less concentrated hospital markets.

Factors Affecting the Labor Supply Decisions of Registered Nurses
Simon Condliffe et al.
Contemporary Economic Policy, forthcoming


We estimate the labor force participation and the full‐time and part‐time work decisions of female registered nurses (RNs) and find higher wages are not a significant factor to (a) increase the likelihood of working nor (b) to encourage full‐time work. Another key factor is age which, given the aging of the RN population, foreshadows dwindling labor supply. This, while demand for RNs is predicted to continue to rise, will exacerbate labor shortages in the market for RNs. The results also offer insight to explain the reduction in labor supply wage elasticities for female workers in general in the United States.

The Effects of Multispecialty Group Practice on Health Care Spending and Use
Laurence Baker, Kate Bundorf & Anne Beeson Royalty
NBER Working Paper, June 2019


U.S. physicians are increasingly joining multispecialty group practices. In this paper, we analyze how a primary care physician’s practice type – single (SSP) versus multispecialty practice (MSP) – affects health care spending and use. Focusing on Medicare beneficiaries who change their primary care physician due to a geographic move, we compare changes in practice patterns before and after the move between patients who switch practice types and those who do not. We use instrumental variables to address potential selection by patients into practice types after the move. We find that changing from a single to a multi-specialty primary care group practice decreases annual Medicare-financed per capita expenditures by about $1,600 - a 28% reduction. The effect is driven primarily by changes in hospital expenditures and is concentrated among patients with two or more chronic conditions, suggesting that MSP improves care delivery by reducing hospitalizations among relatively sick patients. The results imply that, while research has shown the potential for physician consolidation to increase prices in some settings, large multispecialty groups also have the potential to lower costs.

Physician Training Stress and Accelerated Cellular Aging
Kathryn Ridout et al.
Biological Psychiatry, forthcoming

Methods: In a longitudinal cohort study of 250 interns (first-year residents) at 55 U.S hospital systems serving during the 2015-16 academic year, we examined associations between measures of the residency experience and saliva-measured telomere attrition.

Results: Telomere length shortened significantly over the course of internship year, from 6465.1 ± 876.8 base pairs before internship to 6321.5 ± 630.6 base pairs at the end of internship (t(246) = 2.69; P=0.008). Stressful early family environments and neuroticism were significantly associated with shorter pre-internship telomere length. Longer work hours were associated with greater telomere intern telomere loss over the year (p = 0.002). Of note, the mean telomere attrition during internship year was six times greater than the typical annual attrition rate identified in a recent meta-analysis.

Association of Primary Care Clinic Appointment Time With Clinician Ordering and Patient Completion of Breast and Colorectal Cancer Screening
Esther Hsiang et al.
JAMA Network Open, May 2019

Design, Setting, and Participants: Retrospective, quality improvement study of 33 primary care practices in Pennsylvania and New Jersey from September 1, 2014, to August 31, 2016. Participants included adults eligible for breast or colorectal cancer screening. Data analysis was conducted from April 24, 2018, to November 8, 2018.

Main Outcomes and Measures: Primary outcome was clinician ordering of the screening test during the visit. Secondary outcome was patient completion of the tests within 1 year of the visit.

Results: Among the 19 254 patients eligible for breast cancer screening, the mean (SD) age was 60.2 (6.9) years; 19 254 (100%) were female, 11 682 (60.7%) were white, and 5495 (28.5%) were black. Screening test order rates were highest at 8 am at 63.7%, decreased throughout the morning to 48.7% at 11 am, increased to 56.2% at noon, and then decreased to 47.8% at 5 pm (adjusted odds ratio [OR] for overall trend, 0.94; 95% CI, 0.93-0.96; P < .001). Trends in screening test completion rates were similar beginning at 33.2% at 8 am and decreasing to 17.8% at 5 pm (adjusted OR, 0.95; 95% CI, 0.94-0.97; P < .001). Among the 33 468 patients eligible for colorectal cancer screening, the mean (SD) age was 59.6 (7.4) years; 18 672 (55.8%) were female, 22 157 (66.2%) were white, and 7296 (21.8%) were black. Screening test order rates were 36.5% at 8 am, decreased to 31.3% by 11 am, increased at noon to 34.4%, and then decreased to 23.4% at 5 pm (adjusted OR, 0.94; 95% CI, 0.93-0.95; P < .001). Trends in screening test completion rates were similar beginning at 28.0% at 8 am and decreasing to 17.8% at 5 pm (adjusted OR, 0.97; 95% CI, 0.96-0.98; P < .001).

Do Report Cards Predict Future Quality? The Case of Skilled Nursing Facilities
Portia Cornell et al.
Journal of Health Economics, forthcoming


Report cards on provider performance are intended to improve consumer decision-making and address information gaps in the market for quality. However, inadequate risk adjustment of report-card measures often biases comparisons across providers. We test whether going to a skilled nursing facility (SNF) with a higher star rating leads to better quality outcomes for a patient. We exploit variation over time in the distance from a patient’s residential ZIP code to SNFs with different ratings to estimate the causal effect of admission to a higher-rated SNF on health care outcomes, including mortality. We found that patients who go to higher-rated SNFs achieved better outcomes, supporting the validity of the SNF report card ratings.

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