Caring for money
How the American Medical Association's Rent-Seeking Strategy Compensated for Its Loss of Members
Miriam Laugesen
Journal of Health Politics, Policy and Law, February 2019, Pages 67-85
Abstract:
Membership in the American Medical Association (AMA) has suffered a precipitous decline since the 1970s and, with it, a loss in revenue. The expansion of subsidized student memberships has bolstered its official membership number; only 12.6% of physicians who have completed their training now belong. The AMA strengthened its alliances with specialty societies and even tried to restructure the organization around organizational (rather than individual) membership: two hundred specialty societies are incentivized to encourage their members to join the AMA. Earlier federal policies supported by the AMA that gave it a central role in recommending Medicare reimbursement policies have established a membership pipeline for the AMA partly because specialty societies need to influence reimbursement policies. Commercial products have also helped subsidize AMA lobbying efforts that reinforce its historical position, despite a loss of members.
Incoming Medical Students' Political Orientation Affects Outcomes Related to Care of Marginalized Groups: Results from the Medical Student CHANGES Study
Diana Burgess et al.
Journal of Health Politics, Policy and Law, February 2019, Pages 113-146
Abstract:
This article characterizes the political ideology of first-year medical students and describes the extent to which their political ideology was associated with attitudes and beliefs related to the care of marginalized patients assessed during their fourth year. Analyses use data from online questionnaires administered to 3,756 medical students from a stratified random sample of forty-nine medical schools in their first and fourth years of study. The primary measure of political ideology was a five-point scale anchored by “very conservative” and “very liberal.” Mixed-effects linear regression was used to test the predictive power of political ideology at year 1 on year 4 outcomes. Among incoming medical students, 47.7% identified as liberal, 33.3% as moderate, and 19.0% as conservative. More conservative ideology was associated at year 4 with greater implicit bias against black and gay individuals, more negative explicit attitudes toward stigmatized groups, lower internal motivation to control racial prejudice, lower levels of trait empathy and empathy toward patients, and lower levels of patient-centered attitudes. Future research is needed to inform and develop interventions to improve care of patients from marginalized groups that are effective for medical students and health care providers across the political spectrum.
Employer‐Sponsored Health Insurance and the Gender Wage Gap: Evidence from the Employer Mandate
Conor Lennon
Southern Economic Journal, January 2019, Pages 742-765
Abstract:
In the United States, female workers tend to have higher medical expenditures than male workers. Due to experience rated premiums, the cost of providing employer‐sponsored health insurance (ESI) therefore differs by gender. This article examines if that cost difference contributes to the gender wage gap. Identification comes from the exogenous variation provided by the Affordable Care Act's employer mandate. Estimation uses a difference‐in‐difference framework with data from the Medical Expenditure Panel Survey. Findings suggest the portion of the gender wage gap attributable to ESI is smaller than existing estimates in the literature and is statistically no different to zero once individual medical expenses are included as a control. In addition, the article's empirical approach highlights that existing work on the role of ESI in the gender wage gap does not separately identify the effect of ESI from plausible alternatives.
Antipoverty Impact Of Medicaid Growing With State Expansions Over Time
Naomi Zewde & Christopher Wimer
Health Affairs, January 2019, Pages 132-138
Abstract:
Out-of-pocket spending on health care pushed over 10.5 million Americans into poverty in 2016. Medicaid helps offset this risk by providing medical coverage to millions of poor and near-poor children and adults and thereby constraining out-of-pocket medical spending. This article examines whether recent state-level expansions to the Medicaid program resulted in reductions in poverty and whether future changes to the program are likely to have similar impacts on poverty. Using a difference-in-differences research design, we found that the recent Medicaid expansion caused a significant reduction in the poverty rate. Moreover, by simulating a counterfactual poverty rate for a hypothetical world without Medicaid coverage, we found that the program’s antipoverty impact grew over the past decade independent of expansion, by shielding beneficiaries from growing out-of-pocket spending. Future expansions or retractions of Medicaid are likely to produce associated effects on poverty.
Effects of the 2010 Affordable Care Act Dependent Care Provision on Military Participation Among Young Adults
Pinka Chatterji, Xiangshi Liu & Barış Yörük
Eastern Economic Journal, January 2019, Pages 87–111
Abstract:
The ACA dependent care provision mandated that private health insurance plans that offer dependent coverage must allow young adults to stay on parents’ insurance until age 26. In addition to the health and labor market-related outcomes that have been studied, the ACA dependent care provision also may have affected young adults’ decisions about whether or not to serve in the military and the type of military service chosen. In this paper, we use data from the 2008–2016 American Community Survey to test whether the ACA dependent care provision is associated with participating in the military, being on active duty, participating in the National Reserves, and having military health insurance. Findings indicate that the provision is associated with reductions in the probability that young adults (mainly men) are serving on active duty and are sponsors on TRICARE health insurance plans. The results also show a corresponding increase in participation in the National Guard/Reserves.
The Effect of the Affordable Care Act on Entrepreneurship among Older Adults
James Bailey & Dhaval Dave
Eastern Economic Journal, January 2019, Pages 141–159
Abstract:
One goal of the Affordable Care Act (ACA) was to enable entrepreneurship by increasing access to non-employer-based health insurance. We evaluate the extent to which the ACA was successful at this, providing some of the first estimates of the effect of the main provisions of the ACA on entrepreneurship. We are the first to focus specifically on older adults, whose higher average health costs and health insurance premiums make health insurance more salient to their labor market decisions. We do so using data from the American Community Survey and a difference-in-difference strategy, taking advantage of Medicare-eligibles as a control group less affected by the ACA. We find that the ACA led to a 3–4% increase in self-employment. We find similar increases in the likelihood of being self-employed in an incorporated business and of generating at least $5000 in business income, as well as a 9% increase in the likelihood of being self-employed full time. By lowering the cost of non-employer health insurance policies to older adults, the ACA appears to have eased their transition from employment to self-employment.
Who Is an Efficient and Effective Physician? Evidence From Emergency Medicine
Soroush Saghafian, Raha Imanirad & Stephen Traub
Harvard Working Paper, October 2018
Abstract:
Improving the performance of the healthcare sector requires an understanding of the efficiency and effectiveness of care delivered by providers. Although this topic is of great interest to policymakers, researchers, and hospital managers, fair and scientific methods of measuring efficiency and effectiveness of care delivery have proven elusive. Through Data Envelopment Analysis (DEA), we make use of evidence from care delivered by emergency physicians, and shed light on scientific metrics that can gauge performance in terms of efficiency and effectiveness. We use these metrics along with Machine Learning techniques and Tobit analyses to identify the distinguishing behaviors of physicians who perform highly on these metrics. Our findings indicate a statistically significant positive relationship between a physician’s effectiveness and efficiency scores suggesting that, contrary to conventional wisdom, high levels of effectiveness are not necessarily associated with low efficiency levels. In addition, we find that a physician’s effectiveness is positively associated with his/her average contact-to-disposition time and negatively associated with his/her years of experience. We also find a statistically significant negative relationship between a physician’s efficiency and his/her average MRI orders per patient visit. Furthermore, we find evidence of a peer effect of one physician upon another, which suggests an opportunity to improve system performance by taking physician characteristics into account when determining the set of physicians that should be scheduled during same shifts.
The Effect of Shared Decisionmaking on Patients’ Likelihood of Filing a Complaint or Lawsuit: A Simulation Study
Elizabeth Schoenfeld et al.
Annals of Emergency Medicine, forthcoming
Methods: This was a randomized controlled simulation experiment conducted by survey, using clinical vignettes featuring no shared decisionmaking, brief shared decisionmaking, or thorough shared decisionmaking. Participants were adult US citizens recruited through an online crowd-sourcing platform. Participants were randomized to vignettes portraying 1 of 3 levels of shared decisionmaking. All other information given was identical, including the final clinical decision and the adverse outcome. The primary outcome was reported likelihood of pursuing legal action. Secondary outcomes included perceptions of fault, quality of care, and trust in physician.
Results: We recruited 804 participants. Participants exposed to shared decisionmaking (brief and thorough) were 80% less likely to report a plan to contact a lawyer than those not exposed to shared decisionmaking (12% and 11% versus 41%; odds ratio 0.2; 95% confidence interval 0.12 to 0.31). Participants exposed to either level of shared decisionmaking reported higher trust, rated their physicians more highly, and were less likely to fault their physicians for the adverse outcome compared with those exposed to the no shared decisionmaking vignette.
The Effects of Competition on Prescription Payments in Retail Pharmacy Markets
Jihui Chen
Southern Economic Journal, January 2019, Pages 865-898
Abstract:
Using pharmacy claims from New Hampshire between 2009 and 2011, I study the extent to which pharmacy competition affects prescription payments. I measure pharmacy competition by the distance to nearby rivals, as well as a fixed‐travel‐time Herfindahl–Hirschman index (HHI) (Dunn and Shapiro 2014). After controlling for various factors, including insurer, pharmacy, drug, and area characteristics, I find higher average drug prices in more concentrated seller (pharmacy) markets, but lower prices in more concentrated buyer (insurer) markets. Ceteris paribus, pharmacies with high market power (concentration in the 90th percentile) charge 2.78% more than those with low market power (concentration in the 10th percentile). The distance effect is more pronounced if a nearby pharmacy belongs to the same national chain. In addition, I show heterogeneous distance effects across different drug types and areas. My analysis contributes to the empirical literature on competition measures by adding new evidence from the retail pharmaceutical market.
The Contribution Of New Product Entry Versus Existing Product Inflation In The Rising Costs Of Drugs
Inmaculada Hernandez et al.
Health Affairs, January 2019, Pages 76-83
Abstract:
It is unknown to what extent rising drug costs are due to inflation in the prices of existing drugs versus the entry of new products. We used pricing data from First Databank and pharmacy claims from UPMC Health Plan to quantify the contribution of new versus existing drugs to the changes in costs of oral and injectable drugs used in the outpatient setting in 2008–16. The costs of oral and injectable brand-name drugs increased annually by 9.2 percent and 15.1 percent, respectively, largely driven by existing drugs. For oral and injectable specialty drugs, costs increased 20.6 percent and 12.5 percent, respectively, with 71.1 percent and 52.4 percent of these increases attributable to new drugs. Costs of oral and injectable generics increased by 4.4 percent and 7.3 percent, respectively, driven by new drug entry. The rising costs of generic and specialty drugs were mostly driven by new product entry, whereas the rising costs of brand-name drugs were due to existing drug price inflation.