Assistant Professor, University of Minnesota
Impeding Access or Promoting Efficiency? Effects of Rural Hospital Closure on the Cost and Quality of Care.
Abstract: This paper studies the effect of hospital closure on the cost and quality of health care in rural markets. Hospital closure can be welfare improving if it reallocates patients to more efficient facilities but can also lead to treatment delay and worsened health outcomes. I find support for both sides of this debate. Using a difference-in-differences analysis of Medicare claims, I exploit variation in the effects of hospital closure within local markets: I compare enrollees who lost their closest hospital as a result of closure to enrollees who lost their second closest hospital, as a result of the same closure. I show that rural hospital closure led to both a decrease in Medicare spending and an increase in mortality among enrollees with time-sensitive health conditions. I study implications of forestalling hospital closure in the context of the Critical Access Hospital (CAH) program, a large-scale payment reform that increased Medicare revenues for nearly half of all rural hospitals. I show that the CAH program led to a reduction in hospital closures and an improvement in mortality, but the program’s expenditures were substantial relative to these effects.
Physician Response to Malpractice Allegations: Evidence from Florida Emergency Departments
(with David Cutler and Anupam Jena)
Abstract: A substantial literature has studied the influence of malpractice pressure on physician behavior. However, these studies generally focus on variation in state laws governing malpractice exposure. In this project, we test how physicians respond to malpractice allegations made against them. Our sample is Emergency Department physicians in Florida, where we have the universe of data on patients and how they are treated along with a census of malpractice complaints. We find that physicians oversee 7% fewer discharges after malpractice allegations and treat each discharge about 5% more expensively after an allegation. These effects are true for both allegations that result in money paid and allegations which are dropped. Further, the increase in treatment is not limited to patients with conditions similar to what the physician is sued for. The results thus suggest significant, if modest, generalized impacts of malpractice claims on medical practice.
Effects of Episode-Based Payment on Health Care Spending and Utilization: Evidence from Perinatal Care in Arkansas.
(with Michael Chernew, A. Mark Fendrick, Joseph Thompson and Sherri Rose)
Journal of Health Economics, 2018
Abstract: We study how physicians respond to financial incentives imposed by episode-based payment (EBP), which encourages lower spending and improved quality for an entire episode of care. Specifically, we study the impact of the Arkansas Health Care Payment improvement Initiative, a multi-payer program that requires providers to enter into EBP arrangements for perinatal care, covering the majority of births in the state. Unlike fee-for-service reimbursement, EBP holds physicians responsible for all care within a discrete episode, rewarding physicians for efficient use of their own services and for efficient management of other health care inputs. In a difference-in-differences analysis of commercial claims, we find that perinatal spending in Arkansas decreased by 3.8% overall under EBP, compared to surrounding states. The decrease was driven by reduced spending on non-physician health care inputs, specifically the prices paid for inpatient facility care. We additionally find a limited improvement in quality of care under EBP.
- Featured in NBER Bulletin on Aging and Health
The Affordable Care Act’s Coverage Expansions Will Reduce Differences In Uninsurance Rates By Race And Ethnicity
(with Lisa Clemans-Cope, Genevieve Kenney, Matthew Buettgens and Fredric Blavin)
Health Affairs, 2012
Abstract: There are large differences in US health insurance coverage by racial and ethnic groups, yet there have been no estimates to date on how implementation of the Affordable Care Act will affect the distribution of coverage by race and ethnicity. We used a microsimulation model to show that racial and ethnic differentials in coverage could be greatly reduced, potentially cutting the eight-percentage-point black-white differential in uninsurance rates by more than half and the nineteen-percentage-point Hispanic-white differential by just under one-quarter. However, blacks and Hispanics are still projected to remain more likely to be uninsured than whites. Achieving low uninsurance under the Affordable Care Act will depend on effective state policies to attain high enrollment in Medicaid and the Children’s Health Insurance Program and the new insurance exchanges. Coverage gains among Hispanics will probably depend on adoption of strategies that address language and related barriers to enrollment and retention in California and Texas, where almost half of Hispanics live. If uninsurance is reduced to the extent projected in this analysis, sizable reductions in long-standing racial and ethnic differentials in access to health care and health status are likely to follow.