Enough Care
Why Your Doctor Didn’t Go to Class: Student Culture, High-Stakes Testing, and Novel Coupling Configurations in an Allopathic Medical School
Judson Everitt, James Johnson & William Burr
Journal of Health and Social Behavior, forthcoming
Abstract:
A clear pattern has emerged in allopathic medical schools across the United States: Most medical students have stopped going to class. While this trend among students is well known in medical education, few studies to date have examined the underlying sociological mechanisms driving this collective behavior or how these dynamics are related to institutional change in medical education. Drawing on 33 in-depth interviews with medical students in an allopathic medical school, we examine medical student culture and its role in shaping how medical students make sense of the institutionalized licensing requirement of the United States Medical Licensing Exam. We find that medical students learn to rely on digital recordings of their course content and third-party digital resources for Step 1 prep and stop attending their academic courses in person altogether. We argue that medical students create novel coupling configurations between local interaction and institutionalized licensure rules via their student cultures.
The effect of Medicaid on recidivism: Evidence from Medicaid suspension and termination policies
Gultekin Gollu & Mariyana Zapryanova
Southern Economic Journal, forthcoming
Abstract:
Although people who go through the prison and jail system in the United States have significant health care needs, many leave it with no health insurance and, as a result, they experience gaps in access to care. Exploiting variation in Medicaid eligibility policies for incarcerated individuals across states and using administrative prison release data, we find that suspending rather than terminating Medicaid upon incarceration decreases the probability of returning to prison within 1 and 3 years of release by 2.91 and 4.58 percentage points, respectively. These effects are observed among different types of prisoners, but are greater for Black and repeat offenders. Our results suggest that faster and easier reinstatement of Medicaid benefits upon prison release decreases recidivism rate and are directly relevant to ongoing policy debates on the health care coverage of vulnerable populations.
Office-based mental healthcare and juvenile arrests
Monica Deza, Thanh Lu & Johanna Catherine Maclean
Health Economics, forthcoming
Abstract:
We estimate the effect of local access to office-based mental healthcare on juvenile arrest outcomes. We leverage variation in the number of offices of physicians and non-physicians specializing in mental healthcare in a county over the period 1999–2016 in a two-way fixed-effects regression. Office-based treatment is the most common modality of mental healthcare received by juveniles. We find that 10 additional offices of physicians and non-physicians specializing in mental healthcare in a county leads a decrease of 2.3%–2.6% in the per capita costs to society of juvenile arrest. Findings are similar for arrest rates although often less precise, which suggests that accounting for social costs is empirically important. Crime imposes substantial costs on society and individuals, and interventions during early life can have more pronounced effects than those received at later stages, therefore our results imply increased juvenile access to mental healthcare may have an unintended benefit for the current and future generations.
State Mental Health Insurance Parity Laws and College Educational Outcomes
Keisha Solomon & Kabir Dasgupta
Journal of Health Economics, forthcoming
Abstract:
We examine the effect of the state-level full parity mental illness law implementation on mental illness among college-aged individuals and human capital accumulation in college. We utilize administrative data on completed suicides and grade point average and survey data on reported mental illness days and decisions to disenroll from college between 1998 and 2008 in a difference-in-differences (DD) analysis to uncover the causal effects of state-level parity laws. We find that state-level parity law reduces youth suicide rate and propensity to report any poor mental health day, increases college GPA, and does not change the propensity to disenroll from college.
Capacity Strain and Racial Disparities in Hospital Mortality
Manasvini Singh & Atheendar Venkataramani
NBER Working Paper, August 2022
Abstract:
A growing literature has documented racial disparities in health care. We argue that racial disparities may be magnified when hospitals operate at capacity, when behavioral and structural conditions associated with poor patient outcomes – e.g., limited provider cognitive bandwidth or reliance on biased care algorithms – are aggravated. Using detailed, time-stamped electronic health record data from two large hospitals, we document that in-hospital mortality increased more for Black patients than for White patients when hospitals approached capacity. We estimate that 8.5% of Black patient deaths were capacity-driven and thus avoidable. We then investigate the extent to which differential care inputs explain our findings. While strain exacerbated wait times similarly for Black and White patients, Black patients both waited the longest at high strain and faced greater mortality consequences from prolonged wait times. Finally, the largest racial disparities in mortality were among women and uninsured patients, highlighting biases in provider behavior and hospital processes as key mechanisms driving our results.
Provider Charges And State Surprise Billing Laws: Evidence From New York And California
Aliza Gordon et al.
Health Affairs, September 2022, Pages 1316-1323
Abstract:
Surprise billing laws that allow dispute arbitration relying on provider charges may incentivize out-of-network providers to increase their charges to increase upcoming or future out-of-network payments. Although the federal No Surprises Act forbids arbitrators from considering charges during payment disputes over surprise bills covered by the act, states with existing laws can continue to use the specified state laws, which may allow the consideration of charges. This analysis examined provider charges in two such states, using claims data to compare trends in billed charges for out-of-network care during surprise bill scenarios involving nonemergency inpatient hospitalizations. The analysis considered New York, where state law uses arbitration tied to charges; California, where state law uses a payment standard rather than charges; and a comparison group of states without a law regarding surprise billing. We estimated that provider out-of-network charges for the nonemergency out-of-network bills we studied increased by $1,157 (24 percent) in New York after the passage of New York’s surprise billing law and decreased by $752 (25 percent) in California compared to states without surprise billing laws. Assistant surgeons and surgical assistants had a large increase in charges in New York from before to after the law’s passage, which may have driven the overall increase in charges.
Enrollment Brokers Did Not Increase Medicaid Enrollment, 2008–18
Becky Staiger et al.
Health Affairs, September 2022, Pages 1333-1341
Abstract:
Between 2008 and 2018, six states and Washington, D.C., began contracting with enrollment brokers to facilitate enrollment into Medicaid, joining the eighteen states that already had such contracts in place as of 2008. Using newly collected data covering all contracts between state Medicaid agencies and independent enrollment brokers during this period, we compared changes in Medicaid participation following the initiation of contracts with enrollment brokers with contemporaneous changes in Medicaid participation in states that never contracted with brokers. We found that contract initiation had no statistically significant effects on state-level Medicaid participation. We further found no evidence of other enrollment-related benefits, such as improved application processing times.
Giving A Buck Or Making A Buck? Donations By Pharmaceutical Manufacturers To Independent Patient Assistance Charities
Leemore Dafny, Christopher Ody & Teresa Rokos
Health Affairs, September 2022, Pages 1263-1272
Abstract:
The federal Anti-Kickback Statute prohibits biopharmaceutical manufacturers from directly covering Medicare enrollees’ out-of-pocket spending for the drugs they manufacture, but manufacturers may donate to independent patient assistance charities and earmark donations for a condition treated by their drugs. To assess whether this law and its associated regulations prevent manufacturers from profiting from their donations, we analyzed drug spending of more than three million Medicare Advantage enrollees in 2010 and 2017, together with data on conditions and drugs covered by these charities. We found that donations by the leading manufacturer of drugs for each condition were often likely to be profitable, even if relatively few patients were induced to use the manufacturer’s drugs as a result. This was particularly true among the ten costliest conditions, where the leading manufacturer accounted for 67 percent of sales in 2010 and 89 percent in 2017, on average, indicating that manufacturers could effectively assist in the purchase of their own medications by contributing to condition-specific charities. We conclude that the current regulations or enforcement permit donations that violate the spirit of Medicare’s Anti-Kickback Statute.
Does consumer demand pull scientifically novel drug innovation?
David Dranove, Craig Garthwaite & Manuel Hermosilla
RAND Journal of Economics, Fall 2022, Pages 590-638
Abstract:
Prior literature shows that stronger consumer demand leads to increased pharmaceutical R&D. However, how strong these “demand-pull” effects are for more scientifically novel drug innovation remains unknown. We address this question using comprehensive clinical trial data that include precise characterizations of the scientific approaches used in tested molecules. We characterize scientific novelty as the number of times each approach has been used in the past. Exploiting exogenous demand variation introduced by the introduction of Medicare Part D, we find strong evidence that demand-pull effects are markedly skewed in favor of non-novel or “follow-on” drug R&D.
The Private Provision of Public Services: Evidence from Random Assignment in Medicaid
Danil Agafiev Macambira et al.
NBER Working Paper, August 2022
Abstract:
Nearly all prior work on government outsourcing has focused on the contracting firm's incentives. This paper shows how strong incentive contracts may be insufficient to generate spending reductions (or other desired outcomes) in the presence of a binding technological or managerial constraint. We study this outsourcing problem in the context of Medicaid. In healthcare, plans may have special capacity to interdict care provision at the pharmacy, where real-time adjudication enables insurers to deny services before they are rendered. Exploiting a large natural experiment in which Medicaid beneficiaries were randomly assigned between a state-administered FFS system and private managed care, we document how Medicaid outsourcing impacted spending, utilization, and consumer satisfaction. We find that spending was 5%-10% lower for enrollees assigned to managed care. These effects were concentrated in prescription drugs, where spending declined by about one quarter. Using administrative records that include information on real-time denials, we show that utilization management by plans caused efficiently-targeted reductions and substitutions at the pharmacy. Our results indicate that private managed care plans may have sharp tools for managing pharmacy benefits but blunter tools for managing medical benefits, where real-time claims adjudication is less feasible.
Competition and health-care spending: Theory and application to Certificate of Need laws
James Bailey & Tom Hamami
Contemporary Economic Policy, forthcoming
Abstract:
Hospitals and other health-care providers in 34 states must obtain a Certificate of Need (CON) from a state board before opening or expanding, leading to reduced competition. We develop a theoretical model of how market concentration affects health-care spending. Our theoretical model shows that increases in concentration, such as those brought about by CON, can either increase or decrease spending. Our model predicts that CON is more likely to increase spending in markets in which costs are low and patients are sicker. We test our model using spending data from the Household Component of the Medical Expenditure Panel Survey (MEPS).
Price Spillovers and Specialization in Health Care: The Case of Children's Hospitals
Ian McCarthy & Mehul Raval
NBER Working Paper, September 2022
Abstract:
Specialty hospitals tend to negotiate higher commercial insurance payments, even for relatively routine procedures with comparable clinical quality across hospital types. How specialty hospitals can maintain such a price premium remains an open question. In this paper, we examine a potential (horizontal) differentiation effect in which patients perceive specialty hospitals as sufficiently distinct from other hospitals, so that specialty hospitals effectively compete in a separate market from general acute care hospitals. We estimate this effect in the context of routine pediatric procedures offered by both specialty children’s hospitals as well as general acute care hospitals, and we find strong empirical evidence of a differentiation effect in which specialty children’s hospitals appear largely immune to competitive forces from non-children’s hospitals.