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.
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.
Advisors: Kent Kimbrough and James Roberts | JEL Codes: D22, I11, I18
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.
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.
Advisor: Tracy Falba | JEL Codes: I1, I18, I19 | Tagged: Defensive Medicine, Medical Malpractice, Tort Reform
Marijuana Pricing Structure and State-Level Price Determinants
By Rebecca Li
This study uses the PriceofWeed.com data set first examined in Thies (2012) to analyze the price-quantity relationship for marijuana transactions and to determine the effect of various state-level factors on marijuana prices. By applying the cost-based full fixed cost recovery pricing model developed by Britney, Kuzdrall, and Fartuch (1983), this paper finds support for an inverse price-quantity relationship for marijuana rather than a logarithmic or linear relationship. User-rated quality is robust and significant across all models, and price-quantity discount elasticity of -0.220 is observed empirically. An analysis of state-level legal, demand-side, and supply-side determinants of marijuana price demonstrates that medical marijuana has a negative relationship with price, perhaps due to the reduction in risk faced by suppliers when medical marijuana is legalized.
Advisor: Michael Munger, Phil Cook | JEL Codes: D04, I18, K42 | Tagged: Marijuana, Price, Quality, Transaction Size
Trauma Center Eficacy: Certification Status and its Effect on Traffic Fatalities at Varying Radii
By Robert Van Dusen
The goal of the paper is to better inform policy makers on the optimal placement of trauma center facilities. Below, I examine the effect of Californian trauma centers vs. standard emergency departments on traffic fatalities for 2002 to 2008. Hospital addresses are geocoded and compared to the geographic coordinates of fatal car accidents provided through USDOT in order to create a dependent fatality density variable for every hospital at different radii. Demographic controls for different radii are constructed using ArcGIS
to serve as a model for traffic fatalities.
Advisor: Frank Sloan, Kent Kimbrough | JEL Codes: I1, I10, I18 | Tagged: Healthcare,
Trauma, Trauma Center
Incentives and Characteristics that Explain Generic Prescribing Practices
By Rahul Nayak
This study uses the National Ambulatory Medical Care Survey (2006-2010) and Health Tracking Physician Survey (2008) to study the incentives and characteristics that explain physician generic prescribing habits. The findings can be characterized into four main categories: (1) financial/economic, (2) informational, (3) patient- dependent and (4) drug idiosyncratic effects. Physicians in practices owned by HMOs or practices that had at least one managed care contract are significantly more likely to prescribe generic medicines. Furthermore, physicians who have drug industry influence are less likely to prescribe generic medicines. This study also finds consistent evidence that generic prescribing is reduced for patients with pri- vate insurance compared to self-pay patients. Drug-specific characteristics play an important role for whether a drug is prescribed as a generic or brand-name – in- cluding not only market characteristics, such as monopoly duration length, public familiarity with the generic and the quality of the generic, but also non-clinical drug characteristics, such as the length of the generic name compared the length of the brand-name. In particular, the public’s familiarity with the generic has a large effect on the generic prescribing rate for a given drug. There are few differences between the generic prescribing habits of primary care physicians and specialists after controlling for the drugs prescribed.
Advisor: Frank Sloan | JEL Codes: D82, D83, I11, I13, I18 | Tagged: Drug Market Charac- teristics, Efficient Prescribing, Electronic Prescribing, Generic Prescribing, HTPS, Industry Influence, NAMCS, Patient Preferences, Physician Incentives, Principle- Agent Problem
Debunking the Cost-Shifting Myth: An Analysis of Dnamic Price Discrimination in California Hospitals
By Omar Nazzal
Cost-shifting, a dynamic form of price discrimination, is a phenomenon in which hospitals shift the burden of decreases in government-sponsored healthcare reimbursement rates to private health insurers. In this paper, I construct a data set spanning 2007 – 2011 that matches financial metrics of California hospitals to hospital- and market-specific characteristics with theoretical implications in price discrimination. The subsequent analysis is split into three stages. In the first and second stages, I use a fixed-effects OLS model to derive a point estimate of the inverse correlation between private revenue and government revenue that is consistent with recent empirical work in cost-shifting, a body of literature almost entirely reliant upon fixed-effects and difference-in-difference OLS. These types of models are encumbered by the inherent causality loop connecting public and private payment sources. I address this endogeneity problem in the third stage by specifying a fixed-effects 2SLS model based on an instrument for government revenue constructed with data from the California Department of Health Care Services and the U.S. Census. This instrument performed well in canonical tests for relevance and validity. I find that an increase in government payments causes an increase in private payments, and that the relationship is statistically-significant at all reasonable levels. In addition, I comment on properties of the data set that suggest that the original inverse correlation was due to inadequate measurements of market power. I conclude with policy implications and suggestions for future research.
Advisor: Frank Sloan | JEL Codes: I11, I13, I18, L11, L80 | Tagged: Health Insurance, Market Structure, Medicaid, Medicare, Price Discrimination