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The Efficiency of Slacking Off: Evidence from the Emergency Department

April 2, 2015 Comments off

The Efficiency of Slacking Off: Evidence from the Emergency Department (PDF)
Source: National Bureau of Economic Research (via Stanford)

Work schedules play an important role in time-sensitive production utilizing workers interchangeably. Studying emergency department physicians in shift work, I find two types of strategic behavior induced by schedules. First, on an extensive margin, physicians “slack off” by accepting fewer patients near end of shift (EOS). Second, on an intensive margin, physicians distort patient care, incurring higher costs as they spend less time on patients accepted near EOS. I demonstrate a tradeoff between these two strategic behaviors, by examining how they change with shift overlap. Accounting for both costs of physician time and patient care, I find that physicians slack off at approximately second-best optimal levels.

The Insurance Value of Medical Innovation

March 26, 2015 Comments off

The Insurance Value of Medical Innovation (PDF)
Source: National Bureau of Economic Research (via University of Chicago)

Economists think of medical innovation as a valuable but risky good, producing health benefits but increasing financial risk. This perspective overlooks how innovation can lower physical risks borne by healthy patients facing the prospect of future disease. We present an alternative framework that accounts for all these aspects of value and links them to the value of health insurance. We show that any innovation worth buying reduces overall risk, thereby generating positive insurance value on its own. We conduct two empirical exercises to assess the significance of our insights. First, we calculate that conventional methods underestimate the value of historical health gains by 30-80%. Second, we examine a large set of medical technologies and calculate that insurance value on average adds 100% to the conventional valuation of those treatments. Moreover, we find that the physical risk-reduction value of these technologies is ten times greater than the financial risk they pose and the corresponding value of health insurance that insures this financial risk. Our analysis also suggests standard methods disproportionately undervalue treatments for the most severe illnesses, where physical risk to consumers is most costly.

Patient Responses to Incentives in Consumer-directed Health Plans: Evidence from Pharmaceuticals

February 26, 2015 Comments off

Patient Responses to Incentives in Consumer-directed Health Plans: Evidence from Pharmaceuticals
Source: National Bureau of Economic Research

Prior studies suggest that consumer-directed health plans (CDHPs) -characterized by high deductibles and health care accounts- reduce health costs, but there is concern that enrollees indiscriminately reduce use of low-value services (e.g., unnecessary emergency department use) and high-value services (e.g., preventive care). We investigate how CDHP enrollees change use of pharmaceuticals for chronic diseases. We compare two large firms where nearly all employees were switched to CDHPs to firms with conventional health insurance plans. In the first firm’s CDHP, pharmaceuticals were subject to the deductible, while in the second firm pharmaceuticals were exempt. Employees in the first firm shifted the timing of drug purchases to periods with lower cost sharing and were more likely to use lower-cost drugs, but the largest effect of the CDHP was to reduce utilization. Employees in the second firm also reduced utilization, but did not shift the timing or use of low cost drugs.

Pricing in the Market for Anticancer Drugs

January 28, 2015 Comments off

Pricing in the Market for Anticancer Drugs
Source: National Bureau of Economic Research

Drugs like bevacizumab ($50,000 per treatment episode) and ipilimumab ($120,000 per episode) have fueled the perception that the launch prices of anticancer drugs are increasing over time. Using an original dataset of 58 anticancer drugs approved between 1995 and 2013, we find that launch prices, adjusted for inflation and drugs’ survival benefits, increased by 10%, or about $8,500, per year. Although physicians are not penalized for prescribing costly drugs, they may be reluctant to prescribe drugs with prices that exceed subjective standards of fairness. Manufacturers may set higher launch prices over time as standards evolve. Pricing trends may also reflect manufacturers’ response to expansions in the 340B Drug Pricing Program, which requires manufacturers to provide steep discounts to eligible providers.

Medicaid as an Investment in Children: What is the Long-Term Impact on Tax Receipts?

January 19, 2015 Comments off

Medicaid as an Investment in Children: What is the Long-Term Impact on Tax Receipts?
Source: National Bureau of Economic Research

We examine the long-term impact of expansions to Medicaid and the State Children’s Health Insurance Program that occurred in the 1980’s and 1990’s. With administrative data from the IRS, we calculate longitudinal health insurance eligibility from birth to age 18 for children in cohorts affected by these expansions, and we observe their longitudinal outcomes as adults. Using a simulated instrument that relies on variation in eligibility by cohort and state, we find that children whose eligibility increased paid more in cumulative taxes by age 28. These children collected less in EITC payments, and the women had higher cumulative wages by age 28. Incorporating additional data from the Medicaid Statistical Information System (MSIS), we find that the government spent $872 in 2011 dollars for each additional year of Medicaid eligibility induced by the expansions. Putting this together with the estimated increase in tax payments discounted at a 3% rate, assuming that tax impacts are persistent in percentage terms, the government will recoup 56 cents of each dollar spent on childhood Medicaid by the time these children reach age 60. This return on investment does not take into account other benefits that accrue directly to the children, including estimated decreases in mortality and increases in college attendance. Moreover, using the MSIS data, we find that each additional year of Medicaid eligibility from birth to age 18 results in approximately 0.58 additional years of Medicaid receipt. Therefore, if we scale our results by the ratio of beneficiaries to eligibles, then all of our results are almost twice as large.

Does the Environment Still Matter? Daily Temperature and Income in the United States

January 13, 2015 Comments off

Does the Environment Still Matter? Daily Temperature and Income in the United States (PDF)
Source: National Bureau of Economic Research (non-paywall version)

It is widely hypothesized that incomes in wealthy countries are insulated from environmental conditions because individuals have the resources needed to adapt to their environment. We test this idea in the wealthiest economy in human history. Using within-county variation in weather, we estimate the effect of daily temperature on annual income in United States counties over a 40-year period. We find that this single environmental parameter continues to play a large role in overall economic performance: productivity of individual days declines roughly 1.7% for each 1°C (1.8°F) increase in daily average temperature above 15°C (59°F). A weekday above 30°C (86°F) costs an average county $20 per person. Hot weekends have little effect. These estimates are net of many forms of adaptation, such as factor reallocation, defensive investments, transfers, and price changes. Because the effect of temperature has not changed since 1969, we infer that recent uptake or innovation in adaptation measures have been limited. The non-linearity of the effect on different components of income suggest that temperature matters because it reduces the productivity of the economy’s basic elements, such as workers and crops. If counties could choose daily temperatures to maximize output, rather than accepting their geographically- determined endowment, we estimate that annual income growth would rise by 1.7 percentage points. Applying our estimates to a distribution of “business as usual” climate change projections indicates that warmer daily temperatures will lower annual growth by 0.06-0.16 percentage points in the United States unless populations engage in new forms of adaptation.

Bias in Cable News: Real Effects and Polarization

January 12, 2015 Comments off

Bias in Cable News: Real Effects and Polarization (PDF)
Source: National Bureau of Economic Research (via Stanford University)

We jointly measure the persuasive effects of slanted news and tastes for like-minded news. The key ingredient is using channel positions as exogenous shifters of cable news viewership. Local cable positions affect viewership by cable subscribers. They do not correlate with viewership by local satellite subscribers, who are observably similar to cable subscribers. We estimate a model of voters who select into watching slanted news, and whose ideologies evolve as a result. We estimate that Fox News increases the likelihood of voting Republican by 0.9 points among viewers induced into watching four additional minutes per week by differential channel positions.

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