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.
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.
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
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.
Advisor: Billy Pizer, Michelle Connolly | JEL Codes: Q5, Q54, I1, I10
The Neighborhood Effect on Health Outcomes for Women in Urban India
By Priyanka Venkannagari
The paper uses 2011 Indian Human Development Survey data to assess the impact of 5 categories of variables on health outcomes. It uses OLS models, interaction terms, instrumental variable models, fixed effects and random effects to investigate the existence of a neighborhood effect on health outcomes for women in urban India. This paper finds that various aspects of health practices, empowerment, amenities and financial security are relevant when looking at health outcomes. Interventions looking to address health outcomes should consider these variables and the compounding neighborhood effect.
Advisor: Charles Becker, Michelle Connolly, Kent Kimbrough | JEL Codes: C36, I1, I12, O18
The Cost-Effectiveness of Shared Medical Appointments for Type II Diabetes at Duke Family Medicine
By Lauren Nahouraii
With increasing healthcare expenditures above the rate of inflation, new health care delivery models are needed. Since care for chronic health conditions accounts for a majority of spending, more cost-effective ways to manage these conditions are especially necessary and could be the most effective in decreasing health care costs. Shared medical appointments (SMAs) are a promising solution because they increase patient education through group appointments while simultaneously increasing productivity by allowing a provider to see patients in a group but bill for them individually. In this study, 38 patient volunteers participated in an SMA as part of a pilot program at Duke Family Medicine (DFM). As part of this program, patients were randomly assigned to groups that offered varying versions of an SMA curriculum over the course of 3 years. Data collected included HbA1c scores, number and type of medications, type of insurance and payments, number and type of visit (including hospital admissions, emergency room visits, primary care and specialty visits), laboratory tests completed, and home address. Data was collected during, after, and for the six months prior to starting the SMAs. Data points from six months prior to the SMAs serve as a control. HbA1c served as the measure of health outcome while the rest of the data was used in estimating the total healthcare costs of control and treatment periods. Any changes in HbA1c were converted into changes in quality adjusted life years (QALYs) for the cost-effectiveness calculations. The estimated total costs and changes in QALYs were used to calculate the average cost-effectiveness of both the control and treatment periods. Given the small sample size, the SMAs appeared to be more cost-effective for patients that attended a majority of the SMA sessions. The cost-effectiveness comparison for all patients was inconclusive. This study’s calculations should be repeated once more patients complete SMAs in order to increase the power of the tests and provide conclusive results for all patients.
Advisor: Tracy Falba, Ralph Snyderman | JEL Codes: I10, I12, I13, I18
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.
Advisor: Charles Becker, Kent Kimbrough | JEL Codes: I1, I13, I14 | Tagged: Breast Cancer, Cancer Mortality, Health Outcomes, Inequality, Socioeconomic, Stage
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 and Jiten Solanki
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
