Essays on Healthcare Resource Allocation
Date of Award
Spring 2023
Document Type
Dissertation
Degree Name
Doctor of Philosophy (PhD)
Department
Economics
First Advisor
Abaluck, Jason
Abstract
The ever rising U.S. healthcare costs urgently call for technologies and policies to more efficiently allocate healthcare resources for improved outcomes. This thesis presents three angles we can tackle this problem from. If certain healthcare providers are especially proficient at treating certain types of patients, there may be large benefits to allocating patients to providers whose comparative advantages align with the patient’s type. In the first chapter, I propose a methodology to evaluate provider comparative advantages with a combination of observational data and quasi-experimental variation. Specifically, I derive a low-dimensional set of parameters that allows us to obtain these gains subject to provider capacity constraints. I show how these parameters can be identified using quasi-experiments in the data. Applying this methodology to the Veterans Health Administration data, I find considerable variation in provider skill in treating lower- and higher-risk patients. A provider who is one s.d. above average for lower-risk patients can reduce one-year mortality by 0.37 p.p. (a 26.8% reduction of the average rate). A provider who is one s.d. above average for higher-risk patients can reduce one-year mortality by 0.68 p.p. (a 14.8% reduction of the average rate). Optimal matching between providers and new primary care patients can reduce one-year mortality by 0.2 p.p. - 0.3 p.p. (a 10.9% - 14.6% reduction) compared with random patient assignment under provider capacity constraints. In the second chapter, I show that a policy that expands patient access to health care on top of a potentially high-value network they already have access to decreases mortality and reduces wait times. In this article co-authored with Hiroki Saruya, leveraging a policy at the Veterans Health Administration that generates discontinuity in private care access, we find that expanding coverage to private care increases private outpatient care by $53 (SE: 5) and decreases VA outpatient care by $20 (SE: 7), with no impact on inpatient care. The policy led to a 0.1 p.p. (2.8%, SE: 0.04) decrease in one-year mortality, possibly because of decreased wait times and increased access to certain specialty care. Given our estimates, the mortality benefit of access expansion significantly outweighs the increased costs. In the third chapter, in the paper co-authored with Jason Abaluck et. al, we show that provider adherence to guidelines can significantly reduce adverse clinical outcomes. We study guidelines for anticoagulant use to prevent strokes among atrial fibrillation patients. By text-mining physician notes, we identify when physicians start using guidelines. After mentioning guidelines, physicians become more guideline-concordant, but adherence remains far from perfect. To evaluate whether non-adherence reflects physicians’ superior information, we combine observational data on treatment choices with machine learning estimates of heterogeneous treatment effects from eight randomized trials. Most departures from guidelines are not justified by measurable treatment effect heterogeneity. Promoting stricter adherence to guidelines could prevent 22% more strokes, producing much larger gains than broader guideline awareness.
Recommended Citation
Zhu, Diana, "Essays on Healthcare Resource Allocation" (2023). Yale Graduate School of Arts and Sciences Dissertations. 1098.
https://elischolar.library.yale.edu/gsas_dissertations/1098
