Department of Economics
Brigham Young University
Provo, UT 84602
NBER Working Papers and Publications
|February 2017||Sticking Points: Common-Agency Problems and Contracting in the U.S. Healthcare System|
with Michael Powell, James B. Rebitzer: w23177
We propose a "common-agency" model for explaining inefficient contracting in the U.S. healthcare system. In our setting, common-agency problems arise when multiple payers seek to motivate a shared provider to invest in improved care coordination. Our approach differs from other common-agency models in that we analyze "sticking points," that is, equilibria in which payers coordinate around Pareto-dominated contracts that do not offer providers incentives to implement efficient investments. These sticking points offer a straightforward explanation for three long observed but hard to explain features of the U.S. healthcare system: the ubiquity of fee-for-service contracting arrangements outside of Medicare; problematic care coordination; and the historic reliance on small, single specialty pr...
|January 2017||Causes and Consequences of Fragmented Care Delivery: Theory, Evidence, and Public Policy|
with Leila Agha, James B. Rebitzer: w23078
Fragmented health care occurs when care is spread out across a large number of poorly coordinated providers. We analyze care fragmentation, an important source of inefficiency in the US healthcare system, by combining an economic model of regional practice styles with an empirical study of Medicare enrollees who move across regions. Roughly sixty percent of cross-regional variation in care fragmentation is independent of patients’ clinical needs or preferences for care. A one standard deviation increase in regional fragmentation is associated with a 10% increase in care utilization. We distinguish between two sources of care fragmentation: primary care fragmentation, where a patient’s care is split across many general practitioners, and specialty fragmentation, where a patient’s care is sp...
|April 2014||Structuring Incentives Within Organizations: The Case of Accountable Care Organizations|
with James B. Rebitzer: w20034
Accountable Care Organizations (ACOs) are new organizations created by the Affordable Care Act to encourage more efficient, integrated care delivery. To promote efficiency, ACOs sign contracts under which they keep a fraction of the savings from keeping costs below target provided they also maintain quality levels. To promote integration and facilitate measurement, ACOs are required to have at least 5,000 enrollees and so must coordinate across many providers. We calibrate a model of optimal ACO incentives using proprietary performance measures from a large insurer. Our key finding is that free-riding is a severe problem and causes optimal incentive payments to exceed cost savings unless ACOs simultaneously achieve extremely large efficiency gains. This implies that successful ACOs w...
|March 2009||Did Vietnam Veterans Get Sicker in the 1990s? The Complicated Effects of Military Service on Self-Reported Health|
with Joshua D. Angrist, Stacey H. Chen: w14781
The veterans disability compensation (VDC) program, which provides a monthly stipend to disabled veterans, is the third largest American disability insurance program. Since the late 1990s, VDC growth has been driven primarily by an increase in claims from Vietnam veterans, raising concerns about costs as well as health. We use the draft lottery to study the long-term effects of Vietnam-era military service on health and work in the 2000 Census. These estimates show no significant overall effects on employment or work-related disability status, with a small effect on non-work-related disability for whites. On the other hand, estimates for white men with low earnings potential show a large negative impact on employment and a marked increase in non-work-related disability rates. The different...
Published: Angrist, Joshua D. & Chen, Stacey H. & Frandsen, Brigham R., 2010. "Did Vietnam veterans get sicker in the 1990s? The complicated effects of military service on self-reported health," Journal of Public Economics, Elsevier, vol. 94(11-12), pages 824-837, December. citation courtesy of