Trick or Treated
Life Course Patterns of Prescription Drug Use in the United States
Demography, October 2023, Pages 1549-1579
Prescription drug use has reached historic highs in the United States -- a trend linked to increases in medicalization, institutional factors relating to the health care and pharmaceutical industries, and population aging and growing burdens of chronic disease. Despite the high and rising prevalence of use, no estimates exist of the total number of years Americans can expect to spend taking prescription drugs over their lifetimes. This study provides the first estimates of life course patterns of prescription drug use using data from the 1996-2019 Medical Expenditure Panel Surveys, the Human Mortality Database, and the National Center for Health Statistics. Newborns in 2019 could be expected to take prescription drugs for roughly half their lives: 47.54 years for women and 36.84 years for men. The number of years individuals can expect to take five or more drugs increased substantially. Americans also experienced particularly dramatic increases in years spent taking statins, antihypertensives, and antidepressants. There are also important differences in prescription drug use by race and ethnicity: non-Hispanic Whites take the most, Hispanics take the least, and non-Hispanic Blacks fall in between these extremes. Americans are taking drugs over a wide and expanding swathe of the life course, a testament to the centrality of prescription drugs in Americans' lives today.
Geographic Variation in Healthcare Utilization: The Role of Physicians
Ivan Badinski et al.
NBER Working Paper, October 2023
We study the role of physicians in driving geographic variation of US healthcare utilization. We estimate a model that separates variation in average utilization of Medicare beneficiaries due to physicians, non-physician supply side factors, and patient demand. The model is identified by migration of patients and physicians across areas, as well as by variation in within-area matching. We find that physicians vary greatly in the intensity with which they treat otherwise similar patients, and that at least a third of geographic differences in healthcare utilization can be explained by differences in average physician treatment intensity. Conservatively, physicians are three times as important as non-physician supply-side factors in explaining geographic variation. Around three-fifths of physicians' role comes from differences across areas in physician practice styles within the same specialty, while the other two-fifths reflects differences across areas in physician specialty mix.
The Impact of Hospital Closures on Medical Debt in Collections: Analysis Using Consumer Credit Bureau Data
Jennifer Andre et al.
Urban Institute Working Paper, September 2023
This study presents new evidence on the potential detrimental effects of hospital closures. We examine how hospital closures affect the likelihood of incurring medical debt. Hospital closures can increase market concentration by removing a competitor from the market. Closures can also have negative spillover effects on the local economy and affect the population's ability to pay their bills. We combine 2011-2020 consumer credit bureau data with information on hospital closures from 2014-2018 to assess the relationship between closures and medical debt. Using a stacked event study approach, we find that a closure that reduces hospital supply in a Hospital Referral Region (HRR) by 10 percent is associated with a 4 percent increase in the share of consumers with medical debt, with larger effects in HRRs that are urban and have higher rates of poverty. Moreover, we find that a hospital closure is associated with about a 6-8 percent increase in hospital market concentration. These findings suggest that the primary mechanism through which hospital closures affect medical debt is by reducing hospital competition in local markets.
The Effect of Hospital Maternity Ward Closures on Maternal and Infant Health
American Journal of Health Economics, forthcoming
In recent years, many hospitals, primarily in rural areas, have eliminated maternity care. The loss of maternity wards could affect births in multiple ways. Increased travel distance following closure could decrease utilization of prenatal care or increase out-of-hospital births. At the same time, closures could expose women to providers with more experience or better practices. I study the impact of maternity ward closures on births in the United States using national Vital Statistics data and a matched difference-in-differences research design. I find evidence that maternity ward closures yielded benefits. I document a large decline in Cesarean births among low-risk women, with null effects on infant health outcomes. My findings suggest hospitals that closed maternity wards were over-performing Cesarean sections.
Health outcomes and provider choice under full practice authority for certified nurse-midwives
Lauren Hoehn-Velasco et al.
Journal of Health Economics, December 2023
Full practice authority grants non-physician providers the ability to manage patient care without physician oversight or direct collaboration. In this study, we consider whether full practice authority for certified nurse-midwives (CNMs/CMs) leads to changes in health outcomes or CNM/CM use. Using U.S. birth certificate and death certificate records over 2008-2019, we show that CNM/CM full practice authority led to little change in obstetric outcomes, maternal mortality, or neonatal mortality. Instead, full practice authority increases (reported) CNM/CM-attended deliveries by one percentage point while decreasing (reported) physician-attended births. We then explore the mechanisms behind the increase in CNM/CM-attended deliveries, demonstrating that the rise in CNM/CM-attended deliveries represents higher use of existing CNM/CMs and is not fully explainable by improved reporting of CNM/CM deliveries or changes in CNM/CM labor supply.
Seeing is Believing: The Effects of Optometrist Scope of Practice Expansion
Kihwan Bae, Edward Timmons & Protik Nandy
West Virginia University Working Paper, August 2023
We examine how the emergence of optometrists as new "eye doctors" due to a scope of practice expansion affected population eye health outcomes and optometrist earnings in the United States. Using the staggered adoption of optometrist prescription authority across states, we find suggestive evidence that optometrist scope of practice expansion reduced vision impairment and mitigated racial and ethnic disparities in eye health. We also find that the policy change is associated with an increase in hourly wages among optometrists who are not self-employed. These findings imply that allowing optometrists to use medications for eye treatments effectively expanded the primary eye care workforce and therefore improved public eye health.
The Corporatization of Independent Hospitals
Elena Andreyeva et al.
NBER Working Paper, October 2023
Between 2000 and 2020, the share of US hospital bed capacity under multi-unit firms (systems) increased from 58% to 81% - a rapid corporatization of a sector with $1.3 trillion in annual spend. However, little is known about how system ownership affects hospital profitability and quality. We combine novel, patient-level transaction price data from a large commercial insurer, Medicare claims, and New York hospital discharges between 2012 and 2018 to study changes at over 100 independent hospitals that transition to system ownership. The targets obtain differentially higher prices than a matched comparison group, but the operating cost reductions, primarily obtained by reducing employees in support functions, capital, and financing costs, are far greater and exhibit significant economies of scale with acquirer firm size. In contrast, we detect small and statistically insignificant effects on operating costs at 135 system-owned hospitals acquired by other systems, suggesting that the switch to system ownership is the key to achieving these savings. However, corporatization may worsen quality of care on some dimensions.
A Critical Examination of Independent Medical Review Decision-making for Cardiovascular Procedures Shows Low Rate of Evidence Citation in Reviews
Sara Varadharajulu et al.
Medical Care, November 2023, Pages 737-743
Background: The California Independent Medical Review (IMR) program was created in 2001 to provide an independent, external evaluation of insurers' denials of coverage of health services.
Objective: We sought to evaluate the quality and comprehensiveness of data used to support IMR decision-making between 2015 and 2020.
Results: Of the 159 cases submitted to IMR regarding denials of cardiovascular procedures, 52% of these denials were overturned by IMR, thus restoring coverage. Despite a state-wide requirement that specific references to medical and scientific evidence should be provided in IMR reviews, fewer than a quarter of reviews cited any evidence to support decision-making. Slightly more than one third of IMR review decisions were inconsistent with recommendations from professional societies and peer-reviewed evidence; the primary reason for these inconsistencies was that invasive interventions were often recommended by reviewers before utilizing guideline-directed medical or less invasive therapies.
The Effect of Organizations on Physician Prescribing: The Case of Opioids
Kate Bundorf, Daniel Kessler & Sahil Lalwani
NBER Working Paper, October 2023
In theory, there are several reasons why physician organizational form might affect the price, quantity, and quality of physician services. In this paper, we examine the effect of three aspects of physician organizational form on opioid prescribing: the number of physicians in the physician's group (if any); the physician's integration with or employment by a hospital or hospital system; and the average age of the other physicians in the physician's group. We present three key findings. First, all else held constant, group physicians prescribe far fewer opioids, and prescribe them more appropriately, than do solo physicians. Second, although physicians who are employed by a hospital or practice in a hospital-owned group prescribe fewer opioids than do independent physicians, there is evidence that this difference may be due to differences in the other characteristics of physicians who are hospital-integrated rather than a causal effect. Third, we find substantial peer effects on opioid prescribing. Physicians in groups with a higher average age (excluding the physician him- or herself) prescribe more intensively and are more likely to write inappropriate opioid prescriptions than physicians in younger groups - holding constant the physician's own age and other characteristics of his or her group.