Brendon P. Andrews

Working Papers
Physician Quality and the Flexner Report of 1910
If patients can be persuaded to switch between licensed providers on the basis of authoritative opinions, policy-makers can harness such reporting as a tool to implement incentives for high-quality care. I employ the landmark Flexner Report (1910) medical school evaluations to show that existing consumer beliefs and market-specific capital such as established reputations are primary threats to effective reporting. This historic report did not target specific physicians, but ruthlessly disparaged the quality of American medical schools and recommended the vast majority be closed. Using linked individual-level data from medical directories, I show that doctors who recently entered a local geographic market and who attended poorly-reviewed schools -- not just the recent graduates thereof -- were about three times more likely to relocate or retire after the report's release. Expert recommendations have considerably less impact when providers have established themselves in a local area, and no impact on market exit can be detected. These heterogeneous effects imply that policy-makers are unlikely to dramatically alter consumer demand with expert quality information when trust and reputation are important market features.

Economic Evaluation under Ambiguity and Structural Uncertainties
Healthcare technologies are often appraised under considerable ambiguity over the size of incremental benefits and costs, and thus how decision-makers combine unclear information to make recommendations is of considerable public interest. This paper provides a conceptual foundation for such decision-making under ambiguity, formalizing and differentiating the decision problems of a representative policy-maker reviewing the results from an economic evaluation. A primary result is that presenting information to regulators in an incremental cost-effectiveness ratio or cost-effectiveness analysis (CEA) format instead of a net monetary benefit or cost-benefit analysis (CBA) framework may induce errors in decision-making when there exists ambiguity in incremental benefits and decision-makers use well-known decision rules to combine information. Ambiguity in incremental costs or the value of the cost-effectiveness threshold do not distort decision-making in my framework. In specific settings, I show that the CEA framing may result in the approval of fewer technologies relative to CBA framing. I interpret these results as predictions on how the presentation of information from economic evaluations to regulators may frame and distort recommendations. All the results extend to non-healthcare contexts.

Medical Ethics and Physician Motivations
This paper provides an institutional economics framework for analyzing medical ethics: ethical policies are partitions of a set of possible physician actions into ethical and unethical subsets, where unethical actions are unavailable (or sufficiently heavily penalized) in future decision making. Individual doctors' preferences over these policies combined with a political process determine equilibrium constraints. Examining a general model of physician support for `liberal' versus `restrictive' ethics, I show that altruism for one's own patients and concern for all patients have different implications. The latter motivation may justify restrictions on physician behavior, but this argument rests on heavy assumptions. Even identical physicians might ban actions they would otherwise select for reasons varying from solving commons-type problems in patient welfare to differences in the costs of maintaining ethical policies, but heightened altruism for others' patients makes the former reasoning less credible. Novel models for the ethics `Provide Free Care to Physicians' and `Duty to Treat in a Pandemic' demonstrate how shifting economic parameters predict the realized evolution of formal ethical rules. Key model predictions include: (i) rising physician income can explain long-run weakening of both formal ethics in the United States; and (ii) the duty to treat can deteriorate as the ability for a small number of physicians to improve pandemic outcomes increases.

Physician Preferences for Consultation Restrictions in the Late 19th Century
Physicians often disagree on medical policies, but data limitations due to anonymous voting and coordinated action prevent understanding which doctors dissent. This paper harnesses a unique setting for which comprehensive individual-level data on physician support for a collective policy exists: whether regular doctors be permitted to consult with homeopaths in the early 1880s state of New York. As homeopaths and similar non-regular physicians represented more than 10% of the market for physician services, the pre-existing national ban was a signicant restriction on physician behavior. Combining information from many sources, I use a novel dataset of about 5,000 physicians to show that physician eminence, distance to competitors, and private economic costs associated with a change in policy are associated with physician voting behavior. While contemporary arguments highlight patient welfare, the results suggest that at least some doctors: (i) value distant patient benet to a lesser degree than local patient benet; or (ii) exhibit minimal concern for all patients. Finally, I further demonstrate that prior exposure to homeopathy in the city where a physician attended medical school signicantly increases their advocacy for liberalization in consultation policy, suggesting that increased social ties within a professional market can mitigate certain forms of collusive behavior. While it is not possible to determine if this relationship is driven by selection, I nd that prior exposure increases political agitation among physicians favoring the ban, a result consistent with a polarization channel and the updating of physician beliefs.