2016, No. 3

Abstracts of Selected Recent NBER Working Papers

WP 22515
Do Hospital-Owned Skilled Nursing Facilities Provide Better Post-Acute Care Quality?
Momotazur Rahman, Edward Norton, David Grabowski

As hospitals are increasingly held accountable for patients' post-discharge outcomes under new payment models, hospitals may choose to acquire skilled nursing facilities (SNFs) to better manage these outcomes. This raises the question of whether patients discharged to hospital-based SNFs have better outcomes. In unadjusted comparisons, hospital-based SNF patients have much lower Medicare utilization in the 180 days following discharge relative to freestanding SNF patients. We solved the problem of differential selection into hospital-based and freestanding SNFs by using differential distance from home to the nearest hospital with a SNF relative to the distance from home to the nearest hospital without a SNF as an instrument. We found that hospital-based SNF patients spent roughly 5 more days in the community and 6 fewer days in the SNF in the 180 days following their original hospital discharge with no significant effect on mortality or hospital readmission.

WP 22538
The More We Die, The More We Sell? A Simple Test of the Home-Market Effect
Arnaud Costinot, Dave Donaldson, Margaret Kyle, Heidi Williams

The home-market effect, first hypothesized by Linder (1961) and later formalized by Krugman (1980), is the idea that countries with larger demand for some products at home tend to have larger sales of the same products abroad. In this paper, we develop a simple test of the home-market effect using detailed drug sales data from the global pharmaceutical industry. The core of our empirical strategy is the observation that a country’s exogenous demographic composition can be used as a predictor of the diseases that its inhabitants are most likely to die from and, in turn, the drugs that they are most likely to demand. We find that the correlation between predicted home demand and sales abroad is positive and greater than the correlation between predicted home demand and purchases from abroad. In short, countries tend to be net sellers of the drugs that they demand the most, as predicted by Linder (1961) and Krugman (1980).

WP 22542
Are Publicly Insured Children Less Likely to be Admitted to Hospital than the Privately Insured (and Does It Matter?)
Diane Alexander, Janet Currie

There is continuing controversy about the extent to which publicly insured children are treated differently than privately insured children, and whether differences in treatment matter. We show that on average, hospitals are less likely to admit publicly insured children than privately insured children who present at the ER and the gap grows during high flu weeks, when hospital beds are in high demand. This pattern is present even after controlling for detailed diagnostic categories and hospital fixed effects, but does not appear to have any effect on measurable health outcomes such as repeat ER visits and future hospitalizations. Hence, our results raise the possibility that instead of too few publicly insured children being admitted during high flu weeks, there are too many publicly and privately insured children being admitted most of the time.

WP 22568
Legal Access to Alcohol and Criminality
Benjamin Hansen, Glen Waddell

Previous research has found strong evidence that legal access to alcohol is associated with sizable increases in criminality. We revisit this relationship using the census of judicial records on criminal charges filed in Oregon Courts, the ability to separately track crimes involving firearms, and to track individuals over time. We find that crime increases at age 21, with increases mostly due to assaults lacking in premeditation, and alcohol-related nuisance crimes. We find no evident increases in rape or robbery. Among those with no prior criminal records, increases in crime are 50 percent larger; still larger for the most socially costly crimes of assault and drunk driving. This suggests that deterring criminality through increased punishments would likely prove difficult.

WP 22582
Direct-to-Consumer Advertising and Online Search
Matthew Chesnes, Ginger Zhe Jin

Beginning in 1997, the Food and Drug Administration (FDA) allowed television advertisements to make major statements about a prescription drug, while referring to detailed drug information on the internet (FDA 1997; 2015). The hope was that consumers would seek additional information online to fully understand the risks and benefits of taking the medication. To better understand the effects of the policy, we analyze direct-to-consumer advertising (DTCA) and search engine click-through data on a set of drugs over a three-year period. Regression analysis shows that advertising on a prescription drug serves to increase the frequency of online search and subsequent clicks for that drug, as well as search for other drugs in the same class. We find the relationship between DTCA and search is stronger for younger drugs, for those drugs that treat acute conditions, those drugs that are less likely to be covered by insurance, and those whose searcher population tends to be older. These findings suggest that DTCA motivates consumers to search online for drug information, but the magnitude of the effect is heterogeneous and potentially associated with clicks on websites that are more promotional in nature.

WP 22600
Hospital Network Competition and Adverse Selection: Evidence from the Massachusetts Health Insurance Exchange
Mark Shepard

Health insurers increasingly compete on their covered networks of medical providers. Using data from Massachusetts' pioneer insurance exchange, I find substantial adverse selection against plans covering the most prestigious and expensive "star" hospitals. I highlight a theoretically distinct selection channel: these plans attract consumers loyal to the star hospitals and who tend to use their high-price care when sick. Using a structural model, I show that selection creates a strong incentive to exclude star hospitals but that standard policy solutions do not improve net welfare. A key reason is the connection between selection and moral hazard in star hospital use.

WP 22610
Substance Abuse Treatment Centers and Local Crime
Samuel Bondurant, Jason Lindo, Isaac Swensen

In this paper we estimate the effects of expanding access to substance-abuse treatment on local crime. We do so using an identification strategy that leverages variation driven by substance-abuse-treatment facility openings and closings measured at the county level. The results indicate that substance-abuse-treatment facilities reduce both violent and financially motivated crimes in an area, and that the effects are particularly pronounced for relatively serious crimes. The effects on homicides are documented across three sources of homicide data.

WP 22666
A Doctor Will See You Now: Physician-Patient Relationships and Clinical Decisions
Erin Johnson, M. Marit Rehavi, David C. Chan, Jr., Daniela Carusi

We estimate the effect of physician-patient relationships on clinical decisions in a setting where the treating physician is as good as randomly assigned. OBs are 25% (4 percentage points) more likely to perform a C-section when delivering patients with whom they have a pre-existing clinical relationship (their "own patients") than when delivering patients with whom they had no prior relationship. OBs' decisions are consistent with receiving greater disutility from their own patients' difficult labors. After a string of difficult labors, OBs are more likely to perform C-sections on their own patients, and this can explain the entire own patient effect.

WP 22684
Do Savings Increase in Response to Salient Information about Retirement and Expected Pensions?
Mathias Dolls, Philipp Doerrenberg, Andreas Peichl, Holger Stichnoth

How can retirement savings be increased? We explore a unique policy change in the context of the German pension system to study this question. As of 2004, the German pension authority started to send out annual letters providing detailed and comprehensible information about the pension system and individual expected pension payments. This reform did not change the level of pensions, but only manipulated the knowledge about and salience of expected pension payments. Using German tax return data, we exploit two discontinuities in the age cutoffs of receiving such a letter to study their effects on private retirement savings. Our results show that the letters increase private retirement savings. The effects are fairly sizable and persistent over several years. We further show that the letter increases labor earnings, and that the increase in savings partly crowds out charitable donations. Moreover, we present evidence suggesting that both information and salience drive the savings effect. Our paper adds to a recent literature showing that policies that go beyond the traditional neoclassical reasoning can be powerful to increase savings rates.

WP 22690
Economic Conditions and Mortality: Evidence from 200 Years of Data
David M. Cutler, Wei Huang, Adriana Lleras-Muney

Using data covering over 100 birth-cohorts in 32 countries, we examine the short- and long-term effects of economic conditions on mortality. We find that small, but not large, booms increase contemporary mortality. Yet booms from birth to age 25, particularly those during adolescence, lower adult mortality. A simple model can rationalize these findings if economic conditions differentially affect the level and trajectory of both good and bad inputs into health. Indeed, air pollution and alcohol consumption increase in booms. In contrast, booms in adolescence raise adult incomes and improve social relations and mental health, suggesting these mechanisms dominate in the long run.

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