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  5. The Doctor Is In: The Changing Landscape of Healthcare Delivery
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The Doctor Is In: The Changing Landscape of Healthcare Delivery

Paper Session

Friday, Jan. 3, 2025 2:30 PM - 4:30 PM (PST)

Clift Royal Sonesta, Calder Room
Hosted By: Health Economics Research Organization
  • Chair: Kosali Simon, Indiana University

Physician Consults in the Hospital

Zachary Templeton
,
University of Pennsylvania

Abstract

Physician consultations are an important yet understudied facet of hospital care delivery. Consults occur when the primary attending physician formally requests the help of another physician in the diagnosis or treatment of a patient. Because most non-surgical, hospitalized patients are treated by hospitalists or other general medicine physicians, consults are the main mechanism by which specialty care is delivered in the inpatient setting. Previous work finds that more than half of all hospitalizations among traditional Medicare beneficiaries involved at least one consultation, and more than 20% involved consultations of two or more specialties. Consults could improve quality of care if they increase diagnostic accuracy, change patient management, or provide access to treatments and services not otherwise available. On the other hand, consults could represent “flat-of-the-curve” medicine if they do not improve care, result in unnecessary tests and procedures, and increase patients’ length of stay in the hospital.

Despite their importance and frequency, there is little high-quality evidence on the effects of consults on health and utilization outcomes. Because consults are ostensibly requested when the primary team has a question or needs help, they are highly correlated with severity of illness and clinical information not commonly observed in administrative datasets. To address the endogeneity of consults, I conduct an instrumental variable analysis using detailed electronic medical record data from a large health system in Pennsylvania over 2017-2022. Specifically, I exploit variation in demand for infectious disease (ID) consults during the first 24 hours of admission to the general medicine service. I show that patients are less likely to receive a consult when consultants are busier due to consult requests made by other physicians. Estimation of the effect of an ID consult on 30-day readmission via OLS gives a 2 percentage point (pp) increase, which reflects omitted variable bias.

How Loyal are Patients to their Primary Providers? Evidence from Changes in Health Insurance Network

Jessica Chang
,
Health Care Cost Institute

Abstract

With rising US health care spending, policies to control rising health expenditures have increasingly relied on consumer engagement. Consumer engagement initiatives incentivize consumers to choose low-cost providers (or services) through a combination of higher patient cost sharing, price transparency, and narrow provider networks. Both price transparency and narrow networks rely on the economic assumption that given information on health care prices, consumers can be induced to switch to lower-priced providers or services. In practice, however, high deductible health plans and price transparency initiatives have been shown ineffective at persuading consumers to switch to lower priced providers. One potential explanation is that consumers prefer to stay with their current physicians despite the higher cost. Moreover, continuity of care from the same providers may be associated with better health outcomes. To date, the stickiness of the provider-patient relationship in choice among commercially insured population have been understudied in the literature.
In this paper, I study the effects of a sudden and plausibly exogenous increase in the out-of-pocket cost for visits to a consumer’s established provider to quantify consumer inertia in provider choice. Using commercial claims data between from the Health Care Cost Institute between 2012 and 2019, I estimate the impact of network status switch from in-network to out-of-network for a consumer’s established provider on whether consumers shift to new in-network providers, overall use of outpatient and inpatient care, and retainment of established and now out-of-network provider in post-period compared to consumers whose established providers did not experience network change. Furthermore, I calculate variables such as comorbidity indexes to account for heterogeneity in clinical profiles. A switch from in-network to out-of-network yielded an average increase of roughly $57.31 in out-of-pocket for an office visit with the established provider, which signifies a 308% increase in out-of-pocket amounts for an office visit.

The Incentive to Treat: Physician Agency and the Expansion of the 340B Drug Pricing Program

Danea Horn
,
Stanford University

Abstract

The 340B Drug Pricing Program incentivizes healthcare providers to increase medication use. It does this by allowing certain safety-net hospitals and clinics to purchase outpatient drugs at considerable discounts from manufacturers but be reimbursed at full price by payers. Yet, previous literature has left largely unstudied how the 340B program influences physician prescribing behavior. In this paper, I provide evidence of physician agency among 340B providers in the treatment of breast cancer. I leverage the staggered diffusion of the program to identify the impact of 340B participation on physician prescribing behavior and patient outcomes. Physicians who join the 340B program increase the share of patients who receive pharmaceutical treatments and increase the intensity of per-patient prescribing. I also find significant increases in prescribing medications that are not included in clinical treatment recommendations and medications to treat side effects. Despite more intensive treatment use, I find no change in patient survival.

The Impacts of TRAP Laws on the Supply of Maternal Care Providers

Quan Qi
,
University at Albany-State University of New York

Abstract

Maternal healthcare represents a pivotal concern within the U.S., highlighted by an alarming trend: the maternal mortality rate is threefold higher than that of other high-income nations, with this disparity broadening over time. Notably, the number of abortion providers has declined from 1,819 in 2000 to 1,603 in 2020. This reduction along with the overturning of Roe v. Wade case in 2022 provides a key context for understanding the impact of Targeted Regulation of Abortion Providers (TRAP) laws. These laws impose stringent regulations on facilities and personnel and have led to the closure of many abortion clinics and are likely a barrier to the opening of new ones. Amidst growing concerns over healthcare accessibility, this study delves into the critical but understudied impact of TRAP laws on the supply of maternal healthcare providers.
We compiled data on the enactment and enforcement of TRAP laws across states from 2000 to 2017 and traced block years to 2020 based on Jones and Pineda-Torres (2024) and Austin and Harper (2019) and used propensity score matching to obtain a suitable control group for each treatment unit to ensure parallel trend. Utilizing county-level physician data from the Area Health Resources Files and employing a stacked difference-in-difference approach with staggered treatment timings, our findings indicate a marked decrease in the availability of Obstetricians and Gynecologists (OB/GYNs) by 1.58 per 100,000 women of childbearing age post-TRAP law, specifically in office-based settings. This decline is particularly pronounced among OB/GYNs aged 55-64 in rural areas. Conversely, we observed no impact on nurse midwives and osteopathic OB/GYNs. Future investigations will include the anticipated impacts and effects on other types of maternal healthcare providers. Our research sheds light on the consequences of regulation policy on the accessibility of maternal health services, emphasizing the need for informed healthcare policies.

Discussant(s)
Danea Horn
,
University of California-San Francisco
Rebecca Staiger
,
University of California-Berkeley
W. David Bradford
,
University of Georgia
Orgul Ozturk
,
University of South Carolina
JEL Classifications
  • I0 - General
  • H0 - General