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Category Archives: I

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

Measuring the Long-term Effects of Orphanhood

By Nicholas Thomas Gardner

This paper works towards developing the narrative of orphans whose parent or parents died from natural disaster. By taking advantage of the unanticipated nature of death from the 2004
Indonesian tsunami, orphanhood can be treated as much closer to random than similar literature using data centered on HIV/AIDS related deaths. We use a community level fixed effects model to attempt to derive a causal relationship between orphanhood and both education and log wages. Our models suggest that orphaned males aged 14 and older at baseline complete 1-2 fewer years of education than their cohorts. The adverse effects persist in the long-term, as these orphans earn 26% less than non-orphan cohorts.

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Advisors: Duncan Thomas and Kent Kimbrough | JEL Codes: I24, I25, I31, J24, J31

24K Magic: Evidence on Maternal Asset Ownership and Children’s Long Term Outcomes in Indonesia

By Maya Durvasula

Household resource allocation in response to economic shocks is of central importance for policy makers, especially given widely documented evidence of gender biases. In this paper, I exploit a
plausibly exogenous shock to maternal asset holdings in Indonesia to examine gender biases in resource allocation in the wake of the 1998 East Asian Financial Crisis. Using insights from
anthropology, I separate assets in the hands of women from those controlled by men and interpret findings in the context of a household decision-making framework that allows preferences of parents to differ. Taking household-specific heterogeneity into account with fixed effects, I find significant evidence of efforts to shield male children from the effects of the crisis in both contemporaneous educational attainment and longer-term labor market outcomes, a remarkable trend given minimal evidence of a pro-son bias in Indonesia prior to the crisis. Finally, inferring preferences from maternal resource allocation, I find suggestive evidence of an old age security motive in women’s investment decisions.

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Advisor: Duncan Thomas | JEL Codes: D13, I0, J13, J16

Determinants of SAT Scores in North Carolina

By Abby Snyder

This paper examines the effects of different school and district characteristics on SAT scores across North Carolina from 2007 to 2014. Such characteristics include demographics, poverty and wealth indicators, measures of classroom environment, and achievement levels. A pooled time series panel across districts and schools with fixed effects is used to determine the strength of influence these variables have on scores. Ultimately, this paper identifies which characteristics lead to over or underperformance relative to predicted values; further, it considers the implications of the SAT being more of an “achievement” test versus an “aptitude” test.

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Advisor: Charles Becker | JEL Codes: I2, I24 | Tagged: Achievement Gap, Aptitude Test, Education, SAT

The Effects of Global Oil Price on Government Investment the Nigerian Agricultural Sector

By Chuka Obiofuma

Nigeria’s heavy dependence on oil makes it a prime target for the resource curse. The occurance of this phenomenon in Nigeria could mean that there is capital flight from the agricultural sectors of the economy when the oil sector increases in profitability. This would disproportionately hurt the poor of Nigeria who depend on agriculture for their livelihood. This work investigates whether or not the Nigerian government, the largest investor into the Agricultural sector, tends to increase or decrease its investment in the agricultural sector as global oil prices rise. Using data from the years 1978-2014, the results of this paper show that as oil prices increase so too does the Nigerian government’s investment in its agricultural sector.

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Advisor: Alison Hagy, Gale Boyd | JEL Codes: I28, O13, Q43 | Tagged:  Agriculture, Energy, Government Policy

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). 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

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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

Early Identification of Students at Risk for High School Dropout

By Derek Lindsey

For years, many have hoped to identify why high school students drop out. Typically, studies focus on factors identified in high school or middle school. By tracking a cohort of North Carolina students from third grade onward, we attempt to identify areas for intervention even earlier in order to prevent dropouts. Indeed, we find that variables that can be viewed as indicators of high risk for drop out in middle school are already measurably present as early as third grade. This suggests interventions can begin when students are still very young and when treatment is likely to be more effective.

Honors Thesis

Advisor: Thomas Nechyba | JEL Codes: I2, I20 | Tagged: Dropout, Education, Elementary School, Graduation, High School, Middle School

Questions?

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

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