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Category Archives: I1

The Effect of Early Life Economic Conditions on Child Health in Post-Soviet Russia

By Hemal Pragneshbhai Patel

The effect of the economic collapse on health has been extensively documented in Russia since the dissolution of the Soviet Union. The proportion of stunted children in Russia increased substantially in this period, but no study has investigated the mechanisms by which this economic collapse impacted child health outcomes. This paper uses an OLS regression followed by a Binder-Oaxaca decomposition to determine the specific economic factors that significantly contributed to this decrease in child heights.

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Advisors: Professor Charles Becker | JEL Codes: I1; I14; J13

The Effect of Tourism on Child Health Outcomes in Roatán, Honduras

By Hemal Pragneshbhai Patel

Increased tourism, especially in developing economies, brings with it more economic opportunities and avenues for development. In Roatán, the largest of Honduras’ Caribbean Bay Islands, tourism has brought economic development that the island had never before experienced. However, the impact of this economic development brought by increasing cruise ship tourism on child health has yet to be investigated. The increase in economic development is expected to improve child health through improved absorbed nutrition, and this paper uses an OLS regression model to examine how differential exposure to tourism development during a child’s crucial early life developmental window impacts later life health outcomes, proxied by height-for-age Z-scores.

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Advisors: Professor Dennis Clements, Professor Michelle Connolly | JEL Codes: I1; I15; Z32

Evidence of Stalinist Terror in Modern Adult Height Data

By David Blauser Henderson

Adult height is often used to evaluate standards of living experienced in childhood, as it is highly dependent on early-life nutrition (Komlos and Baten, 1998). I employ adult height data collected by the Russian Longitudinal Monitoring Survey (RLMS) to measure well-being among the population of the USSR during two periods of Stalinist repression: The Great Terror from 1937- 1938, and dekulakization, which led directly to the Great Famine of 1932-1933. Heights are normalized by gender and birth year using data from the Survey of Health, Ageing, and Retirement in Europe. I find that both the Great Terror and Great Famine had significant negative impacts on health. In particular, I find the impact of famine on adult height was greatest for those of low socioeconomic status and those born in rural areas. The Great Terror, however, primarily impacted the health of those of high socioeconomic status, those born in urban areas, and those born in areas that were heavily targeted by repression campaigns.

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Advisors: Professor Charles Becker, Professor Michelle Connolly | JEL Codes: N5, N54, I15

Assessing the Impacts of an Aging Population on Rising Healthcare and Pharmaceutical Expenditures within the United States

By Rahul Sharma 

This paper studies the impact of aging on rising healthcare and pharmaceutical expenditures in the United States with the goal of contextualizing the future burden of public health insurance on the government. Precedent literature has focused on international panels of multiple countries and hasn’t identified significant correlation between age and healthcare expenditures. This paper presents a novel approach of identifying this correlation by using a US sample population to determine if age impacts an individual’s consumption of healthcare services and goods. Results suggest that age has a significant impact on healthcare and pharmaceutical expenditures across private and public insurance.

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Advisors: Gilliam D. Saunders-Schmidler and Grace Kim | JEL Codes: H51, H53, I12, I13, I18, I38

The Effect of Competition on Strategic Discharge at Long-Term Acute-Care Hospitals

By Michael Karamardian

Because Medicare’s prospective payment system for long-term acute-care hospitals (LTCHs) makes a large lump-sum form of payment once patients reach a minimum length-ofstay threshold, LTCHs have a unique opportunity to maximize profits by strategically discharging patients as soon as the payment is received. This analysis explores how the level of competition between LTCHs in geographic markets affects the probability of a patient being strategically discharged. The results show that patients at LTCHs in more competitive markets have a lower probability of being strategically discharged than at those in less competitive markets, suggesting increased competition could help save Medicare funding.

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Advisors: Kent Kimbrough and James Roberts | JEL Codes: D22, I11, I18

Global Warming and Obesity: The Effect of Ambient Temperature on BMI

By Aakash Jain

Previous research has shown that ambient temperature affects human metabolism and behavior. Inspired by these findings, this study examines the effect of lagged annual temperatures in the United States on average reported BMI. The results indicate that higher temperatures in the future will lead to increases in average BMI. A conservative estimate suggests that a 1 °C increase in temperature sustained for 10 years would result in a 0.15 unit increase in average BMI and an additional $15.5 billion in annual health care expenditure.

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Advisor: Billy Pizer | JEL Codes: Q5, Q54, I1, I10

The Professor and the Coal Miner: The effect of socioeconomic and geographical factors on breast cancer diagnosis and survival outcome

By Shelley Chen

Previous studies reported that patients who live farther from cancer centers do not necessarily experience delayed cancer detection and shortened survival. However, the results are biased because of the incomplete observation of patient survival, which cannot be properly accounted for with the multivariable regression model. In this thesis, I isolated the effect of the breast cancer patient’s distance to a comprehensive cancer center on the stage of diagnosis and survival using the Cox Proportional Hazards model. I linked data from the Kentucky Surveillance, Epidemiology, and End Results 18, the Kentucky Life Tables, and the Kentucky Area Health Resource Files and identified 37654 patients diagnosed with breast cancer. I estimated the effect of distance on marginal probability of cancer mortality, controlling for non-cancer related death, socioeconomic status, and demographic factors in patients. After controlling for covariates, travel distance between the patient and the nearest comprehensive cancer center was statistically significantly on the breast cancer mortality probability, but not on the stage of diagnosis. In the Kentucky population, patients who were located farther from comprehensive cancer centers experience an increased marginal probability of mortality (proportional hazard = 1.004; 95% CI: [1.000502 1.007311]). The linkage of SEER 18 and AHRF data provided more comprehensive information on the socioeconomic risk factors of cancer mortality than past study datasets. For the stage of diagnosis, a low physician to population ratio and high county-level Medicaid coverage were associated with more advanced stages of diagnosis. In turn, a more advanced stage of diagnosis, lower physician to population ratio, and identification as African American increased the marginal probabilities of mortality.

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Advisor: Charles Becker, Kent Kimbrough | JEL Codes: I1, I13, I14 | Tagged: Breast Cancer, Cancer Mortality, Health Outcomes, Inequality, Socioeconomic, Stage

Medicare’s Prospective Payment System: Do Differences in the Reimbursement Rate Affect Quantity of Care Delivered and Hospital Billing Practices?

By Russell Hollis

When the government changes Medicare policy, payment structures often accommodate the change through lowering reimbursement rates. Changes in reimbursements raise the question of what effect changes have on patient care. Using data sets from the Center for Medicare and Medicaid Services, I examine the diagnosis of major replacement or reattachment of the lower extremity and how the length of stay for patients responds to changing reimbursement rates. I extend my investigation of price incentives to monitor fraudulent coding by hospitals. In a sample of over 470,000 patients in 2,696 hospitals for fiscal year 2012, I find that a 1% increase in reimbursement leads to a .007% increase in length of stay for DRG 470 (without complications) patients and a .057% percent increase for DRG 469 (with complications) patients. I then find that a 10% decrease in reimbursement for DRG 470 or one percent increase for DRG 469 leads to a .0011 increase in fraction of DRG 469 patients in a particular hospital. Lastly, I comment on these results, which point to the evidence of price incentives in quantity of care an the possibility of “upcoding”1.

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Advisor: Allan Collard-Wexler | JEL Codes: H50, H51, I11, I13, I18 | Tagged: Diagnosis Related Group, Length of Stay, Medicare, Reimbursement, “Upcoding”

Understanding Financial Incentive Health Initiatives: The Impact of the Janani Suraksha Yojana Conditional Cash Transfer Program on Institutional Delivery Rates and Out-of- Pocket Health Expenditure

By Ritika Jain

Demand-side financing is a policy tool used by nations to incentivize utilization of public institutions, and India’s Janani Suraksha Yojana (JSY) is one of the largest such financial incentive programs in the world. The program pays eligible pregnant women to deliver their babies in health institutions partnered with the program. This paper studies the impact of the JSY on changes in mothers’ health-seeking behavior to deliver in-facility and on the out-of-pocket expenditure (OOPE) for delivery that they incur. Using data from the most recent wave of India’s District-Level Household Survey conducted in 2007-08, this paper finds that the overall introduction of the program in districts in India does not lead to significant changes in institutional delivery or out-ofpocket expenditure outcomes. Further analysis of subpopulations shows that marginalized populations are responsive to JSY introduction in their district with increased probability of delivering in-facility of 1.10 – 3.40 percentage points. Lastly, results show that receiving JSY payments leads to a 1.34 percentage point increase in the probability of incurring OOPE, but a 4.81 percent decrease in the amount of OOPE incurred. The JSY is helping to reduce overall out-of-pocket spending on deliveries. However, the majority of program benefits are not reaching poor pregnant women as the JSY aims, communicating the need for improvement in population targeting.

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Advisor: Alison Hagy, Kent Kimbrough, Manoj Mohanan | JEL Codes: C22, I12, I18 | Tagged: Conditional Cash Transfer, Demand-side Financing, Difference-in-difference-in-differences, Difference-in-differences, Healthcare Reform, Maternal Health

Has Tort Reform Been Effective in Abating the Medical Malpractice Crisis? An Empirical Analysis from 1991-2012

By Raj Singh

This paper evaluates the impact of malpractice reforms on average malpractice payment awards, frequency of malpractice claims, and malpractice premiums for internists, surgeons, and OB/GYNS. We also empirically test the physician-induced demand (PID) hypothesis in the context of the medical malpractice environment. Our results suggest that caps on noneconomic damages and total damages as well as patient compensation funds are successful in reducing average payments, while damage caps and collateral source rule reform were found to lower malpractice claim incidence. When grouping claims by severity level, we find that noneconomic damage caps and patient compensation funds are more effective at reducing average payment with increasing severity level, while total damage caps induce the greatest reductions in payments for cases of medium severity. Also, non-economic damage caps were found to only significantly decrease the incidence of medium severity claims. With regards to malpractice premiums, we found that implementation of total damage caps as well as modification of joint-and-several liability were associated with lower premiums for all specialists. Finally, we evaluate the notion of ‘defensive medicine’ by studying whether higher malpractice premiums result in greater Medicare payments. Based on our model, increases of $10,000 in OB/GYN premiums are estimated to result in a 0.81% rise in total spending. Of the reforms studied, modification of joint-and-several liability had the most significant and consistent effects in reducing Medicare reimbursements for all categories of spending analyzed, and total damage caps were also estimated to effectively slow the growth of spending in specifications without premiums.

Honors Thesis

Data Set 1

Data Set 2

Advisor: Tracy Falba | JEL Codes: I1, I18, I19 | Tagged: Defensive Medicine, Medical Malpractice, Tort Reform

Questions?

Undergraduate Program Assistant
Jennifer Becker
dus_asst@econ.duke.edu

Director of the Honors Program
Michelle P. Connolly
michelle.connolly@duke.edu