Caring about them

Kevin Lewis

March 11, 2019

Healing the Poor: The Influence of Patient Socioeconomic Status on Physician Supply Responses
Alice Chen & Darius Lakdawalla
Journal of Health Economics, March 2019, Pages 43-54


A longstanding literature explores how altruism affects the way physicians respond to incentives and provide care. We analyze how patient socioeconomic status mediates these responses. We show theoretically that patient socioeconomic status systematically influences the way physicians respond to reimbursement changes, and we identify the channels through which these effects operate. We use two Medicare reimbursement changes to investigate these insights empirically. We confirm that a given physician facing an increase in reimbursement boosts utilization by more when treating richer patients. We show that average supply price elasticities vary from 0.02 to 0.18 for a given physician, depending on the patient’s socioeconomic status. Finally, we show that the Medicare reforms we study led to overall reimbursement increases that raised healthcare utilization by 10% more for high-income patients compared to their low-income peers.

Knowledge Persists, Opinions Drift: Learning and Opinion Change in a Three-Wave Panel Experiment
Conor Dowling, Michael Henderson & Michael Miller
American Politics Research, forthcoming


Considerable evidence exists that Americans possess not only low levels of political knowledge but also relatively uninformed — and sometimes misinformed — opinions on policy matters. Many recent studies focus on whether informational treatments have immediate effects on citizens’ factual beliefs and opinions about policy, but less is known about whether such treatments have enduring effects. Using a three-wave panel experiment, we assess the immediate and enduring effects of factual information provision on factual beliefs and opinion of the Affordable Care Act. We find a relatively persistent effect of information provision on accuracy of factual beliefs, but only an ephemeral shift in opinion, which typically drifts back to its pretreatment state within a few weeks. Our findings have implications for the understanding of citizen learning and opinion change, as well as ongoing scholarly debates about how long-lasting the effects of (experimental) interventions are.

Association of Primary Care Physician Supply With Population Mortality in the United States, 2005-2015
Sanjay Basu et al.
JAMA Internal Medicine, forthcoming

Design, Setting, and Participants: This epidemiological study evaluated US population data and individual-level claims data linked to mortality from 2005 to 2015 against changes in primary care and specialist physician supply from 2005 to 2015. Data from 3142 US counties, 7144 primary care service areas, and 306 hospital referral regions were used to investigate the association of primary care physician supply with changes in life expectancy and cause-specific mortality after adjustment for health care, demographic, socioeconomic, and behavioral covariates. Analysis was performed from March to July 2018.

Results: Primary care physician supply increased from 196 014 physicians in 2005 to 204 419 in 2015. Owing to disproportionate losses of primary care physicians in some counties and population increases, the mean (SD) density of primary care physicians relative to population size decreased from 46.6 per 100 000 population (95% CI, 0.0-114.6 per 100 000 population) to 41.4 per 100 000 population (95% CI, 0.0-108.6 per 100 000 population), with greater losses in rural areas. In adjusted mixed-effects regressions, every 10 additional primary care physicians per 100 000 population was associated with a 51.5-day increase in life expectancy (95% CI, 29.5-73.5 days; 0.2% increase), whereas an increase in 10 specialist physicians per 100 000 population corresponded to a 19.2-day increase (95% CI, 7.0-31.3 days). A total of 10 additional primary care physicians per 100 000 population was associated with reduced cardiovascular, cancer, and respiratory mortality by 0.9% to 1.4%. Analyses at different geographic levels, using instrumental variable regressions, or at the individual level found similar benefits associated with primary care supply.

Vulnerable And Less Vulnerable Women In High-Deductible Health Plans Experienced Delayed Breast Cancer Care
Frank Wharam et al.
Health Affairs, March 2019, Pages 408-415


The effects of high-deductible health plans (HDHPs) on breast cancer diagnosis and treatment among vulnerable populations are unknown. We examined time to first breast cancer diagnostic testing, diagnosis, and chemotherapy among a group of women whose employers switched their insurance coverage from health plans with low deductibles ($500 or less) to plans with high deductibles ($1,000 or more) between 2004 and 2014. Primary subgroups of interest comprised 54,403 low-income and 76,776 high-income women continuously enrolled in low-deductible plans for a year and then up to four years in HDHPs. Matched controls had contemporaneous low-deductible enrollment. Low-income women in HDHPs experienced relative delays of 1.6 months to first breast imaging, 2.7 months to first biopsy, 6.6 months to incident early-stage breast cancer diagnosis, and 8.7 months to first chemotherapy. High-income HDHP members had shorter delays that did not differ significantly from those of their low-income counterparts. HDHP members living in metropolitan, nonmetropolitan, predominantly white, and predominantly nonwhite areas also experienced delayed breast cancer care. Policies may be needed to reduce out-of-pocket spending obligations for breast cancer care.

Expressions of Gratitude and Medical Team Performance
Arieh Riskin et al.
Pediatrics, forthcoming

Methods: Forty-three NICU teams (comprising 2 physicians and 2 nurses) participated in training workshops of acute care simulations. Teams were randomly assigned to 1 of 4 conditions: (1) maternal gratitude (in which the mother of a preterm infant expressed gratitude to NICU teams, such as the one that treated her child), (2) expert gratitude (in which a physician expert expressed gratitude to teams for participating in the training), (3) combined maternal and expert gratitude, or (4) control (same agents communicated neutral statements). The simulations were evaluated (5-point Likert scale: 1 = failed and 5 = excellent) by independent judges (blind to team exposure) using structured questionnaires.

Results: Maternal gratitude positively affected teams’ performances (3.9 ± 0.9 vs 3.6 ± 1.0; P = .04), with most of this effect explained by the positive impact of gratitude on team information sharing (4.3 ± 0.8 vs 4.0 ± 0.8; P = .03). Forty percent of the variance in team information sharing was explained by maternal gratitude. Information sharing predicted team performance outcomes, explaining 33% of the variance in diagnostic performance and 41% of the variance in therapeutic performance.

How Does Supplemental Medicare Coverage Affect the Disabled Under-65 Population?: An Exploratory Analysis of the Health Effects of States' Medigap Policies for SSDI Beneficiaries
Philip Armour & Claire O’Hanlon
NBER Working Paper, February 2019


A substantial portion of the costs associated with, and the value to beneficiaries of, Social Security Disability Insurance is Medicare eligibility. However, the benefits of this eligibility can vary due to differences in state policies on supplemental Medicare coverage, also known as Medigap. Although Medigap policies are federally regulated to be issued to 65-and-over Medicare beneficiaries with specific restrictions over underwriting, these policies are left to states to regulate with regard to the under-65 SSDI population, generating substantial cross-state and temporal variation. This paper documents the variation in availability and generosity of under-65 Medigap eligibility for the SSDI population. Furthermore, it exploits this variation to provide initial estimates of how this eligibility affects the health status of non-Medicaid-eligible SSDI recipients. Our main finding is that requiring Medigap plans be offered for under-65 SSDI recipients substantially improves self-reported health of this population, with suggestive evidence that this improvement is stronger as underwriting restrictions increase and among SSDI beneficiaries with mental health conditions. The estimated effect is highly robust to alternative scaling or categorizations of self-reported health, choice of data set, inclusion of fixed effects, controls for local Medicare Advantage penetration, and falsification tests. This effect is nearly three times the size of the estimated increase in self-reported health in the Oregon Medicaid expansion.

Attitudes About Consumer Strategies Among Americans in High-deductible Health Plans
Betsy Cliff et al.
Medical Care, March 2019, Pages 187–193

Research Design: We conducted a nationally representative web survey of 1637 HDHP enrollees that included 2 hypothetical scenarios amenable to consumer strategies. For each scenario, we asked participants whether they would compare price or quality information, discuss cost with a provider, or try to negotiate a service price. We measured participants’ ratings of the difficulty of each strategy, its effectiveness at reducing cost or increasing the likelihood of getting care, and how likely participants would be to actually engage in each strategy.

Results: Fewer than half of HDHP enrollees intended to engage in any of the surveyed strategies. Enrollees who viewed a consumer strategy as helpful were more likely to engage in that strategy; no associations were found with perceived difficulty of a strategy and intent to engage in it.

How Much Does Medication Nonadherence Cost the Medicare Fee-for-Service Program?
Jennifer Lloyd et al.
Medical Care, March 2019, Pages 218–224

Research Design: Medicare fee-for-service (FFS) claims data were used to calculate the prevalence of medication nonadherence among individuals with diabetes, heart failure, hypertension, and hyperlipidemia. Per person estimates of avoidable health care utilization and spending associated with medication adherence, adjusted for healthy adherer effects, from prior literature were applied to the number of nonadherent Medicare beneficiaries.

Subjects: A 20% random sample of community-dwelling, continuously enrolled Medicare FFS beneficiaries aged 65 years or older with Part D (N=14,657,735) in 2013.

Results: Medication nonadherence for diabetes, heart failure, hyperlipidemia, and hypertension resulted in billions of Medicare FFS expenditures, millions in hospital days, and thousands of emergency department visits that could have been avoided. If the 25% of beneficiaries with hypertension who were nonadherent became adherent, Medicare could save $13.7 billion annually, with over 100,000 emergency department visits and 7 million inpatient hospital days that could be averted.

The Effect of Health Insurance on Mortality: Power Analysis and What We Can Learn from the Affordable Care Act Coverage Expansions
Bernard Black et al.
NBER Working Paper, February 2019


A large literature examines the effect of health insurance on mortality. We contribute by emphasizing two challenges in using the Affordable Care Act (ACA)’s quasi-experimental variation to study mortality. The first is non-parallel pretreatment trends. Rising mortality in Medicaid non-expansion relative to expansion states prior to Medicaid expansion makes it difficult to estimate the effect of insurance using difference-in-differences (DD). We use various DD, triple difference, age-discontinuity and synthetic control approaches, but are unable to satisfactorily address this concern. Our estimates are not statistically significant, but are imprecise enough to be consistent with both no effect and a large effect of insurance on amenable mortality over the first three post-ACA years. Thus, our results should not be interpreted as evidence that health insurance has no effect on mortality for this age group, especially in light of the literature documenting greater health care use as a result of the ACA. Second, we provide a simulation-based power analysis, showing that even the nationwide natural experiment provided by the ACA is underpowered to detect plausibly sized mortality effects in available datasets, and discuss data needs for the literature to advance. Our simulated pseudo-shocks power analysis approach is broadly applicable to other natural-experiment studies.

Spillover Effects From A Consumer-Based Intervention To Increase High-Value Preventive Care
Betsy Cliff, Richard Hirth & Mark Fendrick
Health Affairs, March 2019, Pages 448-455


Increasing the use of high-value medical services and reducing the use of services with little or no clinical value are key goals for efficient health systems. Yet encouraging the use of high-value services may unintentionally affect the use of low-value services. We examined the likelihood of high- and low-value service use in the first two years after an insurance benefit change in 2011 for one state’s employees that promoted use of high-value preventive services. In the intervention group, compared to a control sample with stable benefit plans, in year 1 the likelihood of high-value service use increased 11.0 percentage points, and the likelihood of low-value service use increased 7.9 percentage points. For that year we associated 74 percent of the increase in high-value services and 57 percent of the increase in low-value services with greater use of preventive visits. Our results imply that interventions aimed at increasing receipt of high-value preventive services can cause spillovers to low-value services and should include deterrents to low-value care as implemented in later years of this program.

The Effect of Predictive Analytics-Driven Interventions on Healthcare Utilization
Guy David, Aaron Smith-McLallen & Benjamin Ukert
Journal of Health Economics, March 2019, Pages 68-79


This paper studies a commercial insurer-driven intervention to improve resource allocation. The insurer developed a claims-based algorithm to derive a member-level healthcare utilization risk score. Members with the highest scores were contacted by a care management team tasked with closing gaps in care. The number of members outreached was dictated by resource availability and not by severity, creating a set of arbitrary cutoff points, separating treated and untreated members with very similar predicted risk scores. Using a regression discontinuity approach, we find evidence that predictive analytics-driven interventions directed at high-risk individuals reduced emergency room and specialist visits, yet not hospitalizations.

More intelligent designs: Comparing the effectiveness of choice architectures in US health insurance marketplaces
Andrew Barnes et al.
Organizational Behavior and Human Decision Processes, forthcoming


We examine the effectiveness of alternate choice architectures for health plan choice in US marketplaces under the Affordable Care Act (ACA) using three experiments based on the Health Reform Monitoring Survey: two experiments tested how choice architectures used in presenting information on health plans influenced plan choices and how existing designs could be improved; the third experiment checked the robustness of the choice architecture effects to more naturalistic choice scenarios in which consumers select plans when future medical spending is uncertain. More vulnerable consumers (e.g., worse health, lower literacy) experienced the largest relative improvements when ACA marketplace plans were displayed and sorted by total expected costs for the year rather than premiums (Experiment 1). The benefits of sorting plans by total expected costs was not improved further by making the importance of total expected costs more salient or by providing just-in-time education about such costs (Experiment 2). However, just-in-time education increased the likelihood consumers did not choose a plan, suggesting they may be in the process of updating their plan selection strategy given the new information. Broadly, these results were consistent across alternative scenarios where total expected costs were subject to uncertainty and consistent with expected patterns of consumer behavior under risk aversion (Experiment 3). Thus, a policy-feasible mechanism — sorting health plan options by and highlighting total expected costs — may improve health plan choices, saving money for consumers and the government.

Political Issues, Evidence, and Citizen Engagement: The Case of Unequal Access to Affordable Health Care
Yanna Krupnikov & Adam Seth Levine
Journal of Politics, forthcoming


Some social and economic problems do not gain broad awareness. Yet others become prominent (and perhaps are alleviated) in part because they successfully engage the wider citizenry. In this paper, we investigate how the evidence used to describe problems affects public engagement. Using disparities in access to affordable health care — a focal aspect of economic inequality in the United States — as our main issue, we conduct a series of field and survey experiments showing how some forms of evidence reduce attitudinal and behavioral engagement while other forms increase them. Our results challenge common arguments about political communication and behavior, while also shedding new light on a central question in the study of politics: What determines when citizens become concerned about a social problem?


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