Published Papers
Accountable Care Organizations and Physician Antibiotic Prescribing Behavior
Social Science & Medicine, 2022, 294, pp 114707
(with Sebastian Linde and Brandon Norton)
Physician accountable care organization (ACO) affiliation has been found to reduce cost and improve quality across metrics that are directly measured by the ACO shared savings program. However, little is known about potential spillover effects from this program onto non-measured physician behavior such as antibiotic over-prescribing. Using a two-part structural selection model that accounts for selection into treatment (ACO group), and non-treatment (control group), we compare physician/nurse antibiotic prescribing across these groups with adjustment for geographic, physician, patient and institutional characteristics. We also estimate heterogeneous treatment responses across specialties, focusing on physicians with a primary specialty of internal medicine and family or general practice, as well as nurse practitioners. We find that ACO affiliation helps reduce antibiotic prescribing by 23.9 prescriptions (about 19.4 percent) per year. The treatment effects are found to vary with specialty with internal medicine physicians experiencing an average decrease of 19 percent, family and general practice physicians a decrease of 16 percent, and nurse practitioners a reduction of 12.5 percent in their antibiotic prescribing per year. In terms of selection into treatment, we show that failure to account for selection on physician unobservable characteristics results in an understating of the average treatment effects. In assessing the impact of programs, such as the ACO Shared Savings Program, which act to augment how physicians interact with each other and their patients, it is important to account for spillover effects. As an example of such spillover effect - our study finds that ACO affiliation has had a measurable impact on physician antibiotic prescribing.
Association of Multiple Hospital Affiliations With Clinician Service Use, Breadth of Procedures, and Costs
JAMA Network Open, 2021, 4(12)
(with Sebastian Linde)
There is a growing literature studying the effect that providers’ institutional affiliations have on their service utilization and costs. However, the possible effects that provider fragmentation (one provider working across multiple teams and organizations) can have on provider practice style and cost remains unknown. Drawing on provider affiliation data, along with data on all final-action Medicare Part B claims in 2016 and 2017, we find that physicians with multiple practice affiliations on average utilize 8.2% more medical services per patient, draw on a 5.4% wider set of procedures within their medical care, and incur 8.6% more in medical costs. In comparing extensive and intensive margins of hospital affiliation we find that all are significant, and that the intensive margins range from about 36% - 57% of the extensive margin depending on the outcome measure. These findings suggest that provider affiliations ought to be considered as part of our health care delivery design and potential cost containment strategies.
Pharmaceutical Opioid Marketing and Physician Prescribing Behavior
Health Economics, 2021, 30, pp 3159-3185
(with Sebastian Linde)
Physicians’ relationships with the pharmaceutical industry have recently come under public scrutiny, particularly in the context of opioid drug prescribing. This study examines the effect of doctor-industry marketing interactions on subsequent prescribing patterns of opioids using linked Medicare Part D and Open Payments data for the years 2014-2017. Results indicate that both the number and the dollar value of marketing visits increase physicians’ patented opioid claims. Furthermore, direct-to-physician marketing of safer abuse-deterrent formulations of opioids is the primary driver of positive and persistent spillovers on the prescribing of less safe generic opioids - a result that may be driven by insurance coverage policies. These findings suggest that pharmaceutical marketing efforts may have unintended public health implications.
New Evidence on Factors Affecting the Level and Growth of US Health Care Spending
Applied Economics Letters, 2016, 23(1), pp 15-18
(with James Thornton)
The dual problems of high and rising medical care expenditures and substantial differences in spending across geographic regions have long plagued the US health care system. We provide new evidence to explain why some states and regions of the country spend much more on medical care than others, and why health care spending for the nation as a whole has been growing rapidly over the last several decades. To do this, we estimate a health care spending panel data model using annual data on all 50 states for the period 1993–2009. Our model includes a number of socio-economic, health care provider, lifestyle and environmental variables that past studies indicate may affect the level or growth of aggregate health care spending. We exploit the time effect component of our model to obtain an upper-bound estimate of the effect of advances in medical technology. Our findings indicate that the most important factors influencing the level of spending are availability of providers, income, excessive alcohol consumption, Medicaid coverage, HMO health plans and the proportion of the population elderly and African-American. The principal drivers of growth have been the continual introduction of new medical technologies, and the growth of providers and income.
Pathways and Hidden Benefits of Healthcare Spending Growth in the US
Atlantic Economic Journal, 2016, 44(3), pp 363-375
(with James Thornton)
After a brief reprieve, healthcare spending in the United States is expected to once again rise rapidly, continuing the trend of the past half-century. To inform the debate about whether policymakers should take action to contain high and rising medical care costs, we use panel data on all 50 states for the period 1993 to 2009 to estimate a healthcare spending model. Our framework, which includes a structural spending equation and a health production function, identifies the pathways through which medical technology and income affect healthcare costs and the potential health benefits they produce. We find evidence that medical technology and income are important factors fueling rising healthcare costs in the United States. However, our results also indicate they generate large health benefits in the form of lower mortality that may outweigh the costs and increase social economic welfare.
Social Science & Medicine, 2022, 294, pp 114707
(with Sebastian Linde and Brandon Norton)
Physician accountable care organization (ACO) affiliation has been found to reduce cost and improve quality across metrics that are directly measured by the ACO shared savings program. However, little is known about potential spillover effects from this program onto non-measured physician behavior such as antibiotic over-prescribing. Using a two-part structural selection model that accounts for selection into treatment (ACO group), and non-treatment (control group), we compare physician/nurse antibiotic prescribing across these groups with adjustment for geographic, physician, patient and institutional characteristics. We also estimate heterogeneous treatment responses across specialties, focusing on physicians with a primary specialty of internal medicine and family or general practice, as well as nurse practitioners. We find that ACO affiliation helps reduce antibiotic prescribing by 23.9 prescriptions (about 19.4 percent) per year. The treatment effects are found to vary with specialty with internal medicine physicians experiencing an average decrease of 19 percent, family and general practice physicians a decrease of 16 percent, and nurse practitioners a reduction of 12.5 percent in their antibiotic prescribing per year. In terms of selection into treatment, we show that failure to account for selection on physician unobservable characteristics results in an understating of the average treatment effects. In assessing the impact of programs, such as the ACO Shared Savings Program, which act to augment how physicians interact with each other and their patients, it is important to account for spillover effects. As an example of such spillover effect - our study finds that ACO affiliation has had a measurable impact on physician antibiotic prescribing.
Association of Multiple Hospital Affiliations With Clinician Service Use, Breadth of Procedures, and Costs
JAMA Network Open, 2021, 4(12)
(with Sebastian Linde)
There is a growing literature studying the effect that providers’ institutional affiliations have on their service utilization and costs. However, the possible effects that provider fragmentation (one provider working across multiple teams and organizations) can have on provider practice style and cost remains unknown. Drawing on provider affiliation data, along with data on all final-action Medicare Part B claims in 2016 and 2017, we find that physicians with multiple practice affiliations on average utilize 8.2% more medical services per patient, draw on a 5.4% wider set of procedures within their medical care, and incur 8.6% more in medical costs. In comparing extensive and intensive margins of hospital affiliation we find that all are significant, and that the intensive margins range from about 36% - 57% of the extensive margin depending on the outcome measure. These findings suggest that provider affiliations ought to be considered as part of our health care delivery design and potential cost containment strategies.
Pharmaceutical Opioid Marketing and Physician Prescribing Behavior
Health Economics, 2021, 30, pp 3159-3185
(with Sebastian Linde)
Physicians’ relationships with the pharmaceutical industry have recently come under public scrutiny, particularly in the context of opioid drug prescribing. This study examines the effect of doctor-industry marketing interactions on subsequent prescribing patterns of opioids using linked Medicare Part D and Open Payments data for the years 2014-2017. Results indicate that both the number and the dollar value of marketing visits increase physicians’ patented opioid claims. Furthermore, direct-to-physician marketing of safer abuse-deterrent formulations of opioids is the primary driver of positive and persistent spillovers on the prescribing of less safe generic opioids - a result that may be driven by insurance coverage policies. These findings suggest that pharmaceutical marketing efforts may have unintended public health implications.
New Evidence on Factors Affecting the Level and Growth of US Health Care Spending
Applied Economics Letters, 2016, 23(1), pp 15-18
(with James Thornton)
The dual problems of high and rising medical care expenditures and substantial differences in spending across geographic regions have long plagued the US health care system. We provide new evidence to explain why some states and regions of the country spend much more on medical care than others, and why health care spending for the nation as a whole has been growing rapidly over the last several decades. To do this, we estimate a health care spending panel data model using annual data on all 50 states for the period 1993–2009. Our model includes a number of socio-economic, health care provider, lifestyle and environmental variables that past studies indicate may affect the level or growth of aggregate health care spending. We exploit the time effect component of our model to obtain an upper-bound estimate of the effect of advances in medical technology. Our findings indicate that the most important factors influencing the level of spending are availability of providers, income, excessive alcohol consumption, Medicaid coverage, HMO health plans and the proportion of the population elderly and African-American. The principal drivers of growth have been the continual introduction of new medical technologies, and the growth of providers and income.
Pathways and Hidden Benefits of Healthcare Spending Growth in the US
Atlantic Economic Journal, 2016, 44(3), pp 363-375
(with James Thornton)
After a brief reprieve, healthcare spending in the United States is expected to once again rise rapidly, continuing the trend of the past half-century. To inform the debate about whether policymakers should take action to contain high and rising medical care costs, we use panel data on all 50 states for the period 1993 to 2009 to estimate a healthcare spending model. Our framework, which includes a structural spending equation and a health production function, identifies the pathways through which medical technology and income affect healthcare costs and the potential health benefits they produce. We find evidence that medical technology and income are important factors fueling rising healthcare costs in the United States. However, our results also indicate they generate large health benefits in the form of lower mortality that may outweigh the costs and increase social economic welfare.
Working Papers
From Loans to Little Ones: The Financial Path to In Vitro Fertilization
(with Matthew Schaffer)
With a significant rise in infertility rates, there is heightened concern over declining fertility. While in vitro fertilization, noted for its effectiveness, has seen a marked improvement in success rates, the high costs associated with the procedure pose substantial barriers and limit access for many couples. In this paper, we use an exogenous policy change to estimate the causal effect of access to credit on infertility services utilization. Specifically, we examine the effect of 1997 liberalization of home equity lending in Texas, that eased access to household credit, on the number of in vitro fertilization procedures using county-level data for 1995 – 2003.
Inertia and Switching in Health Insurance Plans
A growing number of studies indicate that consumers do not understand the basics of health insurance, make inefficient plan choices, and may hesitate to switch plans even when it is optimal to do so. I seek to examine health insurance choice of families and individuals employed by a large Midwestern public university during the years 2012-2016, and to evaluate cost-effectiveness in plan choice over time. I identify unanticipated, exogenous health shocks in the health insurance claims data in order to examine their effect on families' plan choices and switching behavior.
(with Matthew Schaffer)
With a significant rise in infertility rates, there is heightened concern over declining fertility. While in vitro fertilization, noted for its effectiveness, has seen a marked improvement in success rates, the high costs associated with the procedure pose substantial barriers and limit access for many couples. In this paper, we use an exogenous policy change to estimate the causal effect of access to credit on infertility services utilization. Specifically, we examine the effect of 1997 liberalization of home equity lending in Texas, that eased access to household credit, on the number of in vitro fertilization procedures using county-level data for 1995 – 2003.
Inertia and Switching in Health Insurance Plans
A growing number of studies indicate that consumers do not understand the basics of health insurance, make inefficient plan choices, and may hesitate to switch plans even when it is optimal to do so. I seek to examine health insurance choice of families and individuals employed by a large Midwestern public university during the years 2012-2016, and to evaluate cost-effectiveness in plan choice over time. I identify unanticipated, exogenous health shocks in the health insurance claims data in order to examine their effect on families' plan choices and switching behavior.