| These essays investigate three aspects regarding the efficacy of medical service delivery and payment. They expand on the broad areas of preventive versus emergency care, physician incentives, and a relatively new type of facility---ambulatory surgical centers (ASCs).;The first chapter of this dissertation examines screening for colorectal cancer---the leading cause of cancer deaths after lung cancer. Using a regression discontinuity design, it investigates how public policy emphasis and coverage expansion by insurance institutions in recent years have impacted screening utilization. It examines differences between African Americans and Caucasians, since there are large disparities in colorectal cancer incidence and death between these two groups. To evaluate the increase in screening utilization, Markov cohort simulations are used to predict how changes in screening with colonoscopies affect the expected years of survival, colorectal cancer deaths, and costs.;The data suggest that policy encouragement to screen at age 50 increased screening rates more than twofold for both African Americans and Caucasians. Simulations indicate that had the people who received screenings in 1997 in fact screened as often as those in 2004 did, life expectancy would have increased by roughly 0.02% to 0.66%, depending on age. Additionally, the increase in screening was highly cost-effective for those below 70 years old.;The second chapter of this dissertation examines a particular type of physician incentive---physician board membership of medical facilities. Through recommendations and referrals, physicians influence the distribution of not only the population seeking care, but also the allocation of patients among different players in the medical care industry, such as: insurance companies, medical facilities, and pharmaceutical companies. Understanding physician relationships with these players and potential conflicts of interests is becoming increasingly important as health care costs rise. In particular, when physicians have special affiliations with medical facilities, physicians are subject to a conflict of interest, being an agent for both patients and facilities.;This chapter introduces a novel data set that exogenously identifies physicians who are board members of ambulatory surgical centers and hospitals, thereby, making it finally possible to identify the impact of a special relationship between physician and facility. The results contrast the often reported correlations and mean differences between physicians who are specially incentivized and those who are not to estimates from a physician fixed effects model and facility choice conditional logit model, which identify causal impacts. The data show that board membership is becoming a more popular form of contract. On average, physician board members treat nearly double the patients that non-board members treat, their patients are lower risk, and they refer their patients to facilities of which they are board members. However, many of these differences are explained by differences in the types of physicians who choose to become members.;The causal impact of board membership on patient volume is significantly different from zero, increasing the number of referrals by 11%. In addition, when physicians become board members, they begin to see more low-risk patients, while still maintaining their previous set of patients. In terms of welfare implications, results suggest that physicians are extracting a utility worth five or six miles to a patient when referring patients to facilities of which they are board members.;Finally, the third chapter investigates the dynamics surrounding the competition between one of the fastest growing Medicare-covered facilities---ambulatory surgical centers (ASCs)---and hospitals. It examines the local market environment before and after an ASC opens using an event study approach. It assesses how entry of these specialized, private, and for-profit facilities affects patient volume of competing facilities as well as the types of procedures provided, patient health levels, patient demographics, such as primary payer distributions, and physician-facility networks.;Contributing to the literature by scope and methodology, it exploits not only geographic variation but also variation over time in order to study competition dynamics, focusing on the pathway to equilibrium and mechanisms through which facilities deal with competition. The analysis documented suggests that patient volume initially shrinks in the second year after an ASC opens in the local market but bounces back by the end of the third year. Services that ASCs typically do not perform increase in share. In addition, ASCs open in places that are relatively not specialized, and after entering the market, competing facilities become more specialized in both services provided and types of primary payers.;This dissertation presents various analyses, including an event study, fixed effects and conditional logit models, a regression discontinuity design, and simulations. (Abstract shortened by UMI.)... |
