Patients In Isolation
Federalism and Public Opinion on Healthcare: The Design of the Affordable Care Act’s Insurance Exchanges and User Experience with the Exchanges
Scott Liebertz, Jaclyn Bunch & Thomas Shaw
Publius: The Journal of Federalism, Winter 2020, Pages 55–80
Abstract:
Using original survey data and the 2016 American National Election Study (ANES), we examine the effects of healthcare exchange type and user experience on individuals’ support for the Affordable Care Act (ACA). States are divided into three different types of ACA exchange implementation regimes: state-run exchanges, federally operated exchanges, and mixed state-federal exchanges. We hypothesize that individuals in states running their own exchanges will demonstrate greater support for the ACA and individuals with experience using the exchanges will exhibit greater levels of support for the ACA. Results from a survey conducted in 2016 in Alabama (a federal exchange), Kentucky (a state exchange at the time), and Arkansas (a mixed state-federal exchange) support these hypotheses. These findings are also confirmed using national data from the ANES. We therefore provide evidence that local control over healthcare implementation leads to better outcomes in terms of citizen satisfaction and that citizens who have experience with exchanges established by the ACA are more likely to feel positively about the law.
The Effects of Income on Children's Health: Evidence from Supplemental Security Income Eligibility under New York State Medicaid
Hansoo Ko, Renata Howland & Sherry Glied
NBER Working Paper, January 2020
Abstract:
There is a well-established association between income and child health. We examine the Supplemental Security Income (SSI) program, which provides cash assistance to low-income children with disabilities, to assess how this relationship arises. We use a large database of Medicaid administrative records to estimate the causal effects of SSI receipt on children’s health, using a regression discontinuity design that exploits the rule that low-income children born below a birthweight threshold are automatically eligible for SSI. We find that children whose birthweights fall below the threshold are significantly more likely to be awarded SSI. Over the first 8 years of their lives, children with birthweights just below the threshold incur Medicaid expenditures 30% lower than do those born just above the threshold. They are less likely to be admitted to hospital, have shorter hospital stays when admitted, and use fewer specialist services. Eligible children experience reduced rates of diagnosis across a range of conditions, with significantly lower rates of both acute (infection, injury) and chronic (malnutrition, developmental delay) conditions in early life. SSI receipt delays the incidence of new chronic conditions by 1.7 months and reduces the number of new chronic conditions recorded through age 3 by 15%. Past health shocks significantly increase current healthcare utilization, but an interaction term between the SSI eligibility and past health shocks is not statistically significant, a pattern that suggests that increased income derived from SSI reduces the incidence of early health shocks but does not change how families respond to these shocks. Children receiving SSI are more likely to live in higher income neighborhoods mainly because their families are less likely to move out of better neighborhoods. However, we do not find evidence that children’s receipt of SSI affects their mother’s health or fertility. Reductions in Medicaid spending associated with SSI eligibility offset increased cash transfer payments by a ratio of 3.3:1.
Identifying Sources of Inefficiency in Healthcare
Amitabh Chandra & Douglas Staiger
Quarterly Journal of Economics, forthcoming
Abstract:
In medicine, the reasons for variation in treatment rates across hospitals serving similar patients are not well understood. Some interpret this variation as unwarranted, and push standardization of care as a way of reducing allocative inefficiency. An alternative interpretation is that hospitals with greater expertise in a treatment use it more because of their comparative advantage, suggesting that standardization is misguided. A simple economic model provides an empirical framework to separate these explanations. Estimating this model with data for heart attack patients, we find evidence of substantial variation across hospitals in both allocative inefficiency and comparative advantage, with most hospitals overusing treatment in part because of incorrect beliefs about their comparative advantage. A stylized welfare calculation suggests that eliminating allocative inefficiency would increase the total benefits from the treatment that we study by 44%.
Medicaid Expansion Slowed Rates Of Health Decline For Low-Income Adults In Southern States
John Graves et al.
Health Affairs, January 2020, Pages 67-76
Abstract:
Of the fourteen states that have not expanded eligibility for Medicaid, nine are in the southern census region, and two others border that region. Ongoing debate over the merits of Medicaid expansion in these states has focused, in part, on whether the safety net provides sufficient access for uninsured low-income Americans. We analyzed longitudinal survey and vital status data from the twelve-state Southern Community Cohort Study (SCCS) for 15,356 nonelderly adult participants with low incomes, 86 percent of whom were enrolled at community health centers. In difference-in-differences analyses, we compared changes in self-reported health between participants in four expansion and eight nonexpansion states before (2008–13) and after (2015–17) Medicaid expansion. We found that a higher proportion of SCCS participants in expansion states reported increases in Medicaid coverage (a differential change of 7.6 percentage points), a lower proportion experienced a health status decline (−1.8 percentage points), and a higher proportion maintained their baseline health status (1.4 percentage points). The magnitude of estimated reductions in health declines would meaningfully affect a nonexpansion state’s health ranking in our sample if that state elected to expand Medicaid. Our results suggest that for low-income adults in the South, Medicaid expansion yielded health benefits—even for those with established access to safety-net care.
Internal Deadlines, Drug Approvals, and Safety Problems
Lauren Cohen, Umit Gurun & Danielle Li
Harvard Working Paper, July 2019
Abstract:
Absent explicit quotas, incentives, reporting, or fiscal year-end motives, drug approvals around the world surge at the end of each month, and particularly in the last weeks of each year. This pattern is found in a large, global data set consisting of drug approvals from the United States, the European Union, Japan, China, and South Korea, suggesting that this pattern reflects an empirical regularity common across cultures and regulatory regimes. In the United States, the number of December drug approvals is roughly 80% larger than in any other month. Similar approval spikes occur at the end of each calendar month. Additionally, approvals spike before holidays, such as before Thanksgiving in the United States and the Chinese New Year in China (but not vice versa). Drugs approved in December and at month-ends are associated with significantly more adverse effects, including more hospitalizations, life-threatening incidents, and deaths. This pattern is consistent with a model in which regulators rush to meet internal production benchmarks associated with salient calendar periods: this type of "desk-clearing" behavior results in more lax review, which leads both to increased output and increased safety issues.
Does the Marginal Hospitalization Save Lives? The Case of Respiratory Admissions for the Elderly
Janet Currie & David Slusky
NBER Working Paper, January 2020
Abstract:
Some commentators estimate that up to a third of U.S. medical spending may be wasted. This study focuses on the decision to hospitalize elderly Medicare patients who present at the emergency room (ER) with respiratory conditions. Failing to hospitalize sick patients could have dire consequences. However, in addition to generating higher costs, unnecessary hospitalization puts patients at risk of hospital acquired conditions and disrupts their lives. We use variation in the patient’s nearest hospital’s propensity to admit patients with similar observable characteristics as an instrument for the admission decision. While OLS estimates suggest that admitted patients are more likely to die, when we instrument for patient admission we find that the marginal hospital admission increases the number of hospital days by seven days and increases charges by $42,000 but has no effect on the risk of death in the course of the next year. The marginal hospitalization also reduces the risk of another emergency department visit in the next 30 days but increases outpatient visits over the same time horizon with no overall impact on charges. Longer term effects also include increased outpatient visits but effects on patient costs and health outcomes over the next year are minimal. Overall, these results lend support to the argument that in many cases the marginal hospitalization is unnecessary.
Terminating Cost-Sharing Reduction Subsidy Payments: The Impact Of Marketplace Zero-Dollar Premium Plans On Enrollment
Coleman Drake & David Anderson
Health Affairs, January 2020, Pages 41-49
Abstract:
The termination of cost-sharing reduction subsidy payments to insurers in 2017 by the administration of President Donald Trump resulted in a proliferation of Marketplace plans having zero-dollar premiums in 2018 and 2019. While it is known that lower premiums increase Marketplace enrollment, it is not clear whether a zero-price effect exists in which enrollment spikes when health insurance is free. We examined whether such an effect exists and found that increased availability of zero-dollar premium plans would have caused a 14.1 percent enrollment increase among lower-income Marketplace enrollees in 2019. If zero-dollar premium plans had not been available in 2019, our simulation results suggest that enrollment in the federally facilitated Marketplace would have decreased by roughly 200,000 enrollees. When we accounted for this zero-price effect, we found that variation in premiums above zero dollars was not associated with enrollment changes. These results suggest that efforts to insure lower-income populations should focus on making health insurance free to potential enrollees, instead of simply reducing premiums. However, increased enrollment in zero-dollar premium plans could result in increased cost sharing among Marketplace enrollees and increased federal outlays for Advance Premium Tax Credits.
International evaluation of an AI system for breast cancer screening
Scott Mayer McKinney et al.
Nature, 2 January 2020, Pages 89–94
Abstract:
Screening mammography aims to identify breast cancer at earlier stages of the disease, when treatment can be more successful. Despite the existence of screening programmes worldwide, the interpretation of mammograms is affected by high rates of false positives and false negatives. Here we present an artificial intelligence (AI) system that is capable of surpassing human experts in breast cancer prediction. To assess its performance in the clinical setting, we curated a large representative dataset from the UK and a large enriched dataset from the USA. We show an absolute reduction of 5.7% and 1.2% (USA and UK) in false positives and 9.4% and 2.7% in false negatives. We provide evidence of the ability of the system to generalize from the UK to the USA. In an independent study of six radiologists, the AI system outperformed all of the human readers: the area under the receiver operating characteristic curve (AUC-ROC) for the AI system was greater than the AUC-ROC for the average radiologist by an absolute margin of 11.5%. We ran a simulation in which the AI system participated in the double-reading process that is used in the UK, and found that the AI system maintained non-inferior performance and reduced the workload of the second reader by 88%. This robust assessment of the AI system paves the way for clinical trials to improve the accuracy and efficiency of breast cancer screening.
Effects Of Medicaid Expansion On Postpartum Coverage And Outpatient Utilization
Sarah Gordon et al.
Health Affairs, January 2020, Pages 77-84
Abstract:
Timely postpartum care is associated with lower maternal morbidity and mortality, yet fewer than half of Medicaid beneficiaries attend a postpartum visit. Medicaid enrollees are at higher risk of postpartum disruptions in insurance because pregnancy-related Medicaid eligibility ends sixty days after delivery. We used Medicaid claims data for 2013–15 from Colorado, which expanded Medicaid under the Affordable Care Act, and Utah, which did not. We found that after expansion, new mothers in Utah experienced higher rates of Medicaid coverage loss and accessed fewer Medicaid-financed outpatient visits during the six months postpartum, relative to their counterparts in Colorado. The effects of Medicaid expansion on postpartum Medicaid enrollment and outpatient utilization were largest among women who experienced significant maternal morbidity at delivery. These findings provide evidence that expansion may promote the stability of postpartum coverage and increase the use of postpartum outpatient care in the Medicaid program.
Health Care Hotspotting — A Randomized, Controlled Trial
Amy Finkelstein et al.
New England Journal of Medicine, 9 January 2020, Pages 152-162
Background: There is widespread interest in programs aiming to reduce spending and improve health care quality among “superutilizers,” patients with very high use of health care services. The “hotspotting” program created by the Camden Coalition of Healthcare Providers (hereafter, the Coalition) has received national attention as a promising superutilizer intervention and has been expanded to cities around the country. In the months after hospital discharge, a team of nurses, social workers, and community health workers visits enrolled patients to coordinate outpatient care and link them with social services.
Methods: We randomly assigned 800 hospitalized patients with medically and socially complex conditions, all with at least one additional hospitalization in the preceding 6 months, to the Coalition’s care-transition program or to usual care. The primary outcome was hospital readmission within 180 days after discharge.
Results: The 180-day readmission rate was 62.3% in the intervention group and 61.7% in the control group. The adjusted between-group difference was not significant (0.82 percentage points; 95% confidence interval, −5.97 to 7.61). In contrast, a comparison of the intervention-group admissions during the 6 months before and after enrollment misleadingly suggested a 38-percentage-point decline in admissions related to the intervention because the comparison did not account for the similar decline in the control group.
Mandatory Disclosure: Theory and Evidence from Industry-Physician Relationships
Daniel Chen et al.
Journal of Legal Studies, June 2019, Pages 409-440
Abstract:
The interaction of disclosure laws and the targeted behavior is typically unknown since data on disclosed activity rarely exist in the absence of disclosure laws. We exploit legal settlements disclosing pharmaceutical company payments across the United States. Strong-disclosure states (requiring publicly available data) had reduced payments among doctors accepting less than $100 and increased payments among doctors accepting greater than $100. Weak-disclosure states (requiring reporting to state authorities), despite imposing administrative compliance costs to industry, were indistinguishable from nondisclosure states, which suggests physicians’ disclosure aversion as a primary mechanism. Additional analyses holding fixed the cost for pharmaceutical companies of disclosing data and a differences-in-discontinuities model in distribution of payments at the disclosure threshold among strong- and weak-disclosure states support this interpretation. Significant disclosure aversion reducing conflicts of interest is consistent with the policy goals of mandatory disclosure, though the increased payments among those receiving large payments may have been unintended.
Among Low-Income Adults Enrolled In Medicaid, Churning Decreased After The Affordable Care Act
Anna Goldman & Benjamin Sommers
Health Affairs, January 2020, Pages 85-93
Abstract:
Coverage disruptions and coverage loss occur frequently among Medicaid enrollees and are associated with delayed health care access and reduced medication adherence. Little is known about the effect on churning of the expansion of eligibility for Medicaid under the Affordable Care Act (ACA), which had the potential to reduce coverage disruptions as a result of increased outreach and more generous income eligibility criteria. We used a difference-in-differences framework to compare rates of coverage disruption in expansion versus nonexpansion states, and in subgroups of states that used alternative expansion strategies. We found that among low-income Medicaid beneficiaries ages 19–64, disruption in coverage decreased 4.3 percentage points in the post-ACA period in expansion states compared to nonexpansion states, and there was a similar decrease in the share of people who experienced a period without any insurance. Men, people of color, and those without chronic illnesses experienced the largest improvements in coverage continuity. Coverage disruptions declined in both traditional expansion states and those that used Section 1115 waivers for expansion. Our quasi-experimental study provides the first nationwide evidence that Medicaid expansion led to decreased rates of coverage disruption. We estimate that half a million fewer adults experienced an episode of churning annually.
Mergers in Medicare Part D: Assessing market power, cost efficiencies, and bargaining power
Anna Chorniy, Daniel Miller & Tilan Tang
International Journal of Industrial Organization, forthcoming
Abstract:
We empirically examine horizontal mergers amongst Part D insurers with the aim of assessing how market power, cost efficiencies, and bargaining power affect premiums and coverage characteristics, including drug access and out-of-pocket (OOP) cost. Our results reveal that market power raises premiums, but this is only a local effect that occurs in markets where the merging firms overlap. Mergers alter the bargaining process with upstream suppliers at both local and national levels, affecting drug access and OOP cost. We find evidence of cost efficiencies when firms restructure by consolidating their plan offerings.
The Impact Of Decision Aids On Adults Considering Hip Or Knee Surgery
Vanessa Hurley et al.
Health Affairs, January 2020, Pages 100-107
Abstract:
Trials of decision aids developed for use in shared decision making find that patients engaged in that process tend to choose more conservative treatment for preference-sensitive conditions. Shared decision making is a collaborative process in which clinicians and patients discuss trade-offs and benefits of specific treatment options in light of patients’ values and preferences. Decision aids are paper, video, or web-based tools intended to help patients match personal preferences with available treatment options. We analyzed data for 2012–15 about patients within the ten High Value Healthcare Collaborative member systems who were exposed to condition-specific decision aids in the context of consultations for hip and knee osteoarthritis, with the intention that the aids be used to support shared decision making. Compared to matched patients not exposed to the decision aids, those exposed had two-and-a-half times the odds of undergoing hip replacement surgery and nearly twice the odds of undergoing knee replacement surgery within six months of the consultation. These findings suggest that health care systems adopting decision aids developed for use in shared decision making, and used in conjunction with hip and knee osteoarthritis consultations, should not expect reduced surgical utilization.
Medical professionals and health care fraud: Do they aid or check abuse?
Rajeev Goel
Managerial and Decision Economics, forthcoming
Abstract:
This paper examines the role of health care professionals in combating health care fraud. It is not overall clear whether the share of the health professionals help control abuse. Using data across U.S. states, our econometric results show that greater employment of nurses consistently reduced health fraud, whereas more physicians did not have a significant impact. Further, more urbanized states and states with a greater proportion of the elderly experienced greater health scams. Identity thefts facilitated health care fraud, whereas different dimensions of health insurance (including the share of the population with Medicare, managed care, and no insurance) and hospital occupancy rates did not matter.