Amitabh Chandra

• Harvard University

Healthcare and education exhibit wide variation in spending that is loosely associated with outcomes. We study supply-side explanations for such variation in in healthcare, and extend this discussion to how it might apply to education. In both sectors, variation in risk-adjusted rates could arise from some providers or educators doing too much (ove...

-Cardiovascular disease is often studied through patient self-report and administrative data. Yet, these two sources provide different information, and few studies have compared them. -We compared data from a longitudinal nationally-representative survey of older Americans with matched Medicare claims. Self-reported acute myocardial infarction (AMI...

Surgeons increasingly use robot-assisted minimally invasive surgery for a variety of medical conditions. For hospitals, the acquisition and maintenance of a robot requires a significant investment, but financial returns are not linked to any improvement in long-term patient outcomes in the current reimbursement environment. Kidney cancer provides a...

There have been significant improvements in both treatment and screening efforts for many types of cancer over the past decade. However, the effect of these advancements on the survival of cancer patients is unknown, and many question the value of both new treatments and screening efforts. This study uses a retrospective analysis of SEER Registry d...

BACKGROUND Payers are penalizing hospitals for high readmission rates. It is unknown whether major changes in population insurance coverage can affect readmission rates, despite the Affordable Care Act's coverage expansions coming into effect this year. OBJECTIVE To evaluate the impact of a large-scale insurance expansion on hospital readmissions,...

Proposed payment reforms in the US healthcare system would hold providers accountable for the care delivered to an assigned patient population. Annual hemoglobin A1c (HbA1c) tests are recommended for all diabetics, but some patient populations may face barriers to high quality healthcare that are beyond providers' control. The magnitude of fine-gra...

Medical professional liability (MPL) remains a significant burden for physicians, in general, and cardiologists, in particular, as recent research has shown that average MPL defense costs are higher in cardiology than other specialties. Knowledge of the clinical characteristics and outcomes of lawsuits against cardiologists may improve quality of c...

In Reply The purpose of our study¹ was to assess whether differences in income between male and female physicians present in the late 1980s are still present today. We found that gender differences in physician earnings have not substantively changed in 25 years. Dr Ambati notes that physician earnings come from a number of sources (eg, relative va...

Greater patient cost-sharing could help reduce the fiscal pressures associated with insurance expansion by reducing the scope for moral hazard. But it is possible that low-income recipients are unable to cut back on utilization wisely and that, as a result, higher cost-sharing will lead to worse health and higher downstream costs through increased...

Objective: To characterize malpractice risk among US pediatricians. Methods: We analyzed malpractice claims of all pediatricians and other physicians covered by a nationwide liability insurer from 1991 to 2005 (n = 1630 pediatricians; 40 916 total physicians). We characterized annual malpractice risk among pediatricians compared with other physi...

The US malpractice system is widely regarded as inefficient, in part because of the time required to resolve malpractice cases. Analyzing data from 40,916 physicians covered by a nationwide insurer, we found that the average physician spends 50.7 months-or almost 11 percent-of an assumed forty-year career with an unresolved, open malpractice claim....

N early 24 million children (younger than 5 years) worldwide experience severe acute malnutrition (SAM). The vast majority is located in Africa and Asia (8 million are in India alone). A child with SAM is 10 times more likely to die than a well-nourished child. SAM is one of the top 3 nutrition-related causes of death in children younger than 5 yea...

The United States is in the throes of the most serious recession in postwar history. Despite improving employment numbers, the official unemployment rate still exceeded 8% in June 2012. Amid this malaise, the health care sector is one of the few areas of steady growth.(1) It may seem natural to think that if this sector is one of the bright spots i...

In this analysis of defense costs associated with malpractice claims closed between 1995 and 2005, the mean defense cost per claim was about $23,000. Costs were higher for claims resulting in an indemnity payment, and defense costs varied widely across specialties.

Greater patient cost-sharing could help reduce the fiscal pressures associated with insurance expansion by reducing the scope for moral hazard. But it is possible that low-income recipients are unable to cut back on utilization wisely and that, as a result, higher cost-sharing will lead to worse health and higher downstream costs through hospitaliz...

To examine the impact of cigarette excise taxes and smoke-free legislation on tobacco use among households with school-age children and adolescents as well as disparities in children's secondhand smoke exposure. We compare the results from models using causal inference techniques to those from cross-sectional models. We linked families of 6-17-year...

In the United States, two patients with the same medical condition can receive drastically different treatments. In addition, the same patient can walk into two physician offices and receive equally disparate treatments. This chapter attempts to understand why. It focuses on three areas: the patient, the physician, and the clinical situation. Speci...

Recently, the Centers for Medicaid and Medicare Services announced a scheduled cut in Medicare physician fees of 27.4% for 2012. This cut stems from the sustainable growth rate (SGR) formula used by the physician-payment system. Implemented in 1998 to curb the growth in expenditures on physicians' services, the SGR formula is used to determine annu...

No abstract available.

Background: Maternal smoking during pregnancy is a major contributor of babies born low birthweight (LBW); however, changing maternal behaviors remains a significant challenge and little is known about whether tobacco control policies may indirectly affect infant outcomes. Methods: We examined the impact of cigarette excise taxes and smoke-free l...

Using the 2010 pilot study of the Longitudinal Aging Study in India (LASI), the authors examine the socioeconomic and behavioral risk factors for poor cardiovascular health among middle-aged and older Indians, focusing on self-reported and directly measured hypertension. The LASI pilot survey (N=1,683) was fielded in four states: Karnataka, Kerala,...

Does an expansion of health insurance increase or decrease use of the emergency department (ED)? Both predictions can be justified logically. On the one hand, research on patient cost sharing predicts that by reducing the out-of-pocket costs of an ED visit, expanded insurance coverage, especially in the face of physician shortages, could result in...

There is growing concern over the rising share of the US economy devoted to health care spending. Fueled in part by demographic transitions, unchecked increases in entitlement spending will necessitate some combination of substantial tax increases, elimination of other public spending, or unsustainable public debt. This massive increase in health s...

Data are lacking on the proportion of physicians who face malpractice claims in a year, the size of those claims, and the cumulative career malpractice risk according to specialty. We analyzed malpractice data from 1991 through 2005 for all physicians who were covered by a large professional liability insurer with a nationwide client base (40,916 p...

Demographic Variables for Subjects with and without MRI Scans and/or Income. (DOC)

Additional Demographic Summary for full sample (based on Wave 1 data). (DOC)

(DOCX)

Facets of the post-natal environment including the type and complexity of environmental stimuli, the quality of parenting behaviors, and the amount and type of stress experienced by a child affects brain and behavioral functioning. Poverty is a type of pervasive experience that is likely to influence biobehavioral processes because children develop...

All developed countries have been struggling with a trend toward health care absorbing an ever-larger fraction of government and private budgets. Adopting any treatment that improves health outcomes, no matter what the cost, can worsen allocative inefficiency by paying dearly for small health gains. One potential solution is to rely more heavily on...

In the United States, health care technology has contributed to rising survival rates, yet health care spending relative to GDP has also grown more rapidly than in any other country. We develop a model of patient demand and supplier behavior to explain these parallel trends in technology growth and cost growth. We show that health care productivity...

Following an acrimonious health care reform debate involving charges of "death panels," in 2010, Congress explicitly forbade the use of cost-effectiveness analysis in government programs of the Patient Protection and Affordable Care Act. In this context, comparative effectiveness research emerged as an alternative strategy to understand better what...

The most contentious aspect of the recent national health care reform is the individual insurance mandate. Data from Massachusetts may predict the mandate's additive effect on reducing adverse selection, beyond simply offering subsidized, community-rated insurance.

Improving the health of minority patients who have diabetes depends in part on improving quality and reducing disparities in ambulatory care. It has been difficult to measure these components at the level of actionable units. To measure ambulatory care quality and racial disparities in diabetes care across groups of physicians who care for populati...

We use simple economic insights to develop a framework for distinguishing between prejudice and statistical discrimination using observational data. We focus our inquiry on the enormous literature in healthcare where treatment disparities by race and gender are not explained by access, preferences, or severity. But treatment disparities, by themsel...

Concerns about reducing the rate of growth of health expenditures have reignited interest in medical liability reforms and their potential to save money by reducing the practice of defensive medicine. It is not easy to estimate the costs of the medical liability system, however. This article identifies the various components of liability system cos...

We investigated whether a price increase on regular (sugary) soft drinks and an educational intervention would reduce their sales. We implemented a 5-phase intervention at the Brigham and Women's Hospital cafeteria in Boston, Massachusetts. After posting existing prices of regular and diet soft drinks and water during baseline, we imposed several i...

Economic theory suggests that a natural tool to control medical costs is increased consumer cost sharing for medical care. While such cost sharing reduces “full insurance” (wherein patients are indifferent between falling sick or remaining healthy), a greater reliance on coinsurance and copayments can, in theory, stem patient and provider incentive...

In the Medicare program, increases in cost sharing by a supplemental insurer can exert financial externalities. We study a policy change that raised patient cost sharing for the supplemental insurer for retired public employees in California. We find that physician visits and prescription drug usage have elasticities that are similar to those of th...

To investigate the correlation between geographic variation in inpatient days, total spending, and spending growth in traditional Medicare versus the large-firm commercial sector. Retrospective descriptive analysis. Medicare spending data at the hospital referral region (HRR) level were obtained from the Dartmouth Atlas. Commercial claims data from...

Michael Chernew and colleagues write that the historical flow of valuable but costly medical advances raises a profound question: can that flow be maintained in future years without rates of spending increase that wreak economic havoc?

Much of the current debate about expanding health insurance coverage avoids addressing an uncomfortable trade-off: with a limited budget, making benefits more generous means being able to cover fewer people. Katherine Baicker and Amitabh Chandra discuss increasing the reach of limited public dollars.

Spending on health care in markets with a larger percentage of primary care physicians (PCPs) is lower at any point in time than is true in other markets. The relationship between physician workforce composition and the rate of spending growth is less clear. This analysis of market-level Medicare spending data between 1995 and 2005 reveals that the...

Dartmouth researchers have demonstrated that there is tremendous geographic variation in the efficiency of health care delivery systems, fostered by perverse incentives that penalize integration, reward fragmentation, and encourage the use of technologies in the "gray areas" of medicine. This research suggests that it is possible to deliver higher-...

Numerous studies in the United States have examined the association between quality and spending at the regional level. In this paper we evaluate this relationship at the level of individual hospitals, which are a more natural unit of analysis for reporting on and improving accountability. For all of the quality indicators studied, the association...

In his papers, Richard Cooper finds positive associations between health care quality and both specialist and generalist physicians, but he misinterprets his results. Instead of undermining the findings of our study, which found higher quality in areas with more generalists relative to specialists, his results bolster ours: they suggest that the ef...

Richard Cooper has shown a positive association between health care quality and "total spending" at the state level, but he does not appear to understand the limitations of this total spending measure; simply adjusting for median age causes the significant positive correlation to disappear. Cooper also finds that some third factor-we think that it...

Several myths about health insurance interfere with the diagnosis of problems in the current system and impede the development of productive reforms. Although many are built on a kernel of truth, complicated issues are often simplified to the point of being false or misleading. Several stem from the conflation of health, health care, and health ins...

Increased area-level medical spending is not correlated with improved patient outcomes or quality, thereby supporting the case for spending reductions in high-spending regions. However, all additional spending need not be wasteful. Examining the care of patients with colorectal cancer, we show that high-spending regions are more likely than other r...

Racial differences in healthcare are well known, although some have challenged previous research where risk-adjustment assumed covariates affect whites and blacks equally. If incorrect, this assumption may misestimate disparities. We sought to determine whether clinical factors affect treatment decisions for blacks and whites equally. We used data...

Mounting malpractice liability costs might affect physician practice patterns in many ways, such as increasing the use of diagnostic procedures while reducing major surgeries. This paper quantifies the association between malpractice liability costs and the use of physician services in Medicare. We find that higher malpractice awards and premiums a...

This paper provides a survey on studies that analyze the macroeconomic effects of intellectual property rights (IPR). The first part of this paper introduces different patent policy instruments and reviews their effects on R&D and economic growth. This part also discusses the distortionary effects and distributional consequences of IPR protection a...

A large literature in medicine documents variation across areas in the use of surgical treatments that is unrelated to outcomes. Observers of this phenomena have invoked "flat of the curve medicine" to explain these facts, and have advocated for reductions in spending in high-use areas. In contrast, we develop a simple Roy model of patient treatmen...

To obtain information about health outcomes in neonates in 9 subgroups of the Asian population in the United States. Cross-sectional comparison of outcomes for births to mothers of Cambodian, Chinese, Filipino, Indian, Japanese, Korean, Laotian, Thai, and Vietnamese origin and for births to non-Hispanic white mothers. Regression models were used to...

There is enormous geographic variation in the use of cesarean delivery: For births over 2,500 grams, adjusted cesarean rates vary fourfold between low- and high-use areas. Even for births under 2,500 grams, high-use counties have rates that are double those of low-use ones. Higher cesarean rates are only partially explained by patient characteristi...

We estimate the effect of rising health insurance premiums on wages, employment, and the distribution of part-time and full-time work using variation in medical malpractice payments driven by the recent "medical malpractice crisis." We estimate that a 10% increase in health insurance premiums reduces the aggregate probability of being employed by 1...

African Americans are more likely to be seen by physicians with less clinical training or to be treated at hospitals with longer average times to acute reperfusion therapies. Less is known about differences in health outcomes. This report compares risk-adjusted mortality after acute myocardial infarction (AMI) between US hospitals with high and low...

There is a great deal of public debate about potential reforms of the malpractice system. A closer look at available data suggests that some of the rhetoric surrounding this debate may be misleading. First, increases in malpractice payments do not seem to be the driving force behind increases in premiums. Second, increases in malpractice costs do n...

We estimate consumers%u2019 valuation of disability insurance using a stochastic lifecycle framework in which disability is modeled as permanent, involuntary retirement. We base our probabilities of worklimiting disability on 25 years of data from the Current Population Survey and examine the changes in the disability gradient for different demogra...

We used data from the National Practitioner Data Bank (NPDB) to study the growth of physician malpractice payments. Judgments at trial account for 4 percent of all malpractice payments; settlements account for the remaining 96 percent. The average payment grew 52 percent between 1991 and 2003 (4 percent per year) and now exceeds dollar 12 per capit...

Previous studies have documented racial disparities in treatment of acute myocardial infarction (AMI) among Medicare beneficiaries. However, the extent to which unobserved differences between hospitals explains some of these differences is unknown. The objective of this study was to determine whether the observed racial treatment disparities for AM...

It is common practice to use sensible rules of thumb for cleaning data. Measurement error is often the justification for removing (trimming) or recoding (winsorizing) observations where the dependent variable has values that lie outside a specified range. We consider a general measurement error process that nests many plausible models. Analytic res...

The growth of medical malpractice liability costs has the potential to affect the delivery of health care in the U.S. along two dimensions. If growth in malpractice payments results in higher malpractice insurance premiums for physicians, these premiums may affect the size and composition of the physician workforce. The growth of potential losses f...

In its study of racial and ethnic disparities in health care, the Institute of Medicine (IOM) concluded that there were large and significant disparities in the quality and quantity of health care received by minority groups in the United States. This article shows that where a patient lives can itself have a large impact on the level and quality o...

Productivity spillovers are often cited as a reason for geographic specialization in production. A large literature in medicine documents specialization across areas in the use of surgical treatments, which is unrelated to patient outcomes. We show that a simple Roy model of patient treatment choice with productivity spillovers can generate these f...

The quality of care received by Medicare beneficiaries varies across areas. We find that states with higher Medicare spending have lower-quality care. This negative relationship may be driven by the use of intensive, costly care that crowds out the use of more effective care. One mechanism for this trade-off may be the mix of the provider workforce...

The existence of overall racial and ethnic disparities in health care is well documented, but this average effect masks variation across regions and types of care. Medicare claims data are used to document the extent of these variations. Regions with high racial disparities in one procedure are not more likely to be high in other procedures. Unusua...

In the spirit of Polachek (1975) and the later work of Becker (1985) on the role of specialization within the family, we examine the relationship between fringe benefits and the division of labor within a married household. The provision of fringe benefits is complicated by their non-additive nature within the household, as well as IRS regulations...

I demonstrate that the literature on the racial wage gap has systematically overstated the gains made by African American men by ignoring their withdrawal from the labor force. Three sources of selection-bias are identified: imposing sample selection criteria based on labor supply, trimming wages on the basis of real-dollar cutoffs, and making infe...

An extensive literature has documented racial, ethnic, and socioeconomic disparities in health care and health outcomes. We argue that the influence of geography in medical practice needs to be taken seriously for both the statistical measurement of racial disparities, and in designing reforms to reduce disparities. Past research has called attenti...

We examine the relationship between large infrastructure spending, of the type implied by interstate highway construction, and the level of economic activity. By collecting historical data on interstate highway construction and economic activity in the United States at the county level we find that highways have a differential impact across industr...

We examine the relationship between large infrastructure spending, of the type implied by interstate highway construction, and the level of economic activity. By collecting historical data on interstate highway construction and economic activity in the United States at the county level we find that highways have a differential impact across industr...

Time and value are related concepts that influence human behaviour. Although classical topics in human thinking throughout the ages, few environmental economic non-market valuation studies have attempted to link the two concepts. Economists have estimated non-market environmental values in monetary terms for over 30 years. This history of valuation...

Because the tax savings of having a child are realized only if the birth takes place before midnight, January 1, the incentives for the "marginal" birth are substantial. Using a sample of children from the National Longitudinal Survey of Youth, we find that the probability that a child is born in the last week of December, rather than the first wee...

We use the April 1993 Current Population Survey to examine the health insurance coverage decisions of the unemployed and to simulate the potential effects of the new Kassebaum-Kennedy legislation. After controlling for demographic characteristics, COBRA eligibility raises the probability of health insurance coverage by 0.095, while eligibility for...

For the past several decades, John E. Wennberg and researchers from Dartmouth have documented wide regional variations in utilization, and a weak (or sometimes negative) association between higher rates of per capita Medicare expenditures and better health outcomes. Recently, a study by Hadley, Berenson, Waidmann, and Zuckerman (2006) has suggested...

We examine the parallel trends in technology growth and cost growth in health care. A simple model of provider behavior shows that the productivity of treatments depend critically on the heterogeneity of these effects across patients, the precise shape of the health production function, and the cost structure of procedures such as MRIs with high fi...

Spending on health care in markets with a larger percentage of primary care physicians (PCPs) is lower at any point in time than is true in other markets. The relationship between physician workforce composition and the rate of spending growth is less clear. This analysis of market-level Medicare spending data between 1995 and 2005 reveals that the...