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Author:Alexander, Diane 

Newsletter
The Recent Rise in Health Care Inflation
Health care services inflation was consistently at or above 3% per year in the early 2000s, declined from around 3% at the end of the 2000s to under 1% in 2015, and then rebounded to just under 2% in early 2018. The low point in 2015 was a near-historical low, with health care services price growth bottoming out at a rate not seen since 1961.
AUTHORS: Alexander, Diane
DATE: 2018

Working Paper
Just What the Nurse Practitioner Ordered: Independent Prescriptive Authority and Population Mental Health
We examine whether relaxing occupational licensing to allow nurse practitioners (NPs)?registered nurses with advanced degrees?to prescribe medication without physician oversight is associated with improved population mental health. Exploiting time-series variation in independent prescriptive authority for NPs from 1990?2014, we find that broadening prescriptive authority is associated with improvements in self-reported mental health and decreases in mental-health-related mortality, including suicides. These improvements are concentrated in areas underserved by psychiatrists and among populations traditionally underserved by mental health providers. Our results demonstrate that extending prescriptive authority to NPs can help mitigate physician shortages and extend care to disadvantaged populations.
AUTHORS: Alexander, Diane; Schnell, Molly
DATE: 2016-12-20

Working Paper
How do Doctors Respond to Incentives? Unintended Consequences of Paying Doctors to Reduce Costs
Billions of dollars have been spent on pilot programs searching for ways to reduce healthcare costs. I study one such program, where hospitals pay doctors bonuses for reducing the total hospital costs of admitted Medicare patients (a ?bundled payment?). Doctors respond to the bonuses by becoming more likely to admit patients whose treatment can generate high bonuses, and sorting healthier patients into participating hospitals. Conditional on patient health, however, doctors do not reduce costs or change procedure use. These results highlight the ability of doctors to game incentive schemes, and the risks of basing nationwide healthcare reforms on pilot programs.
AUTHORS: Alexander, Diane
DATE: 2017-03-09

Working Paper
The Impact of Car Pollution on Infant and Child Health: Evidence from Emissions Cheating
Car exhaust is a major source of air pollution, but little is known about its impacts on population health. We exploit the dispersion of emissions-cheating diesel cars?which secretly polluted up to 150 times as much as gasoline cars?across the United States from 2008-2015 as a natural experiment to measure the health impact of car pollution. Using the universe of vehicle registrations, we demonstrate that a 10 percent cheating-induced increase in car exhaust increases rates of low birth weight and acute asthma attacks among children by 1.9 and 8.0 percent, respectively. These health impacts occur at all pollution levels and across the entire socioeconomic spectrum.
AUTHORS: Alexander, Diane; Schwandt, Hannes
DATE: 2019-06-13

Working Paper
Does Physician Pay Affect Procedure Choice and Patient Health? Evidence from Medicaid C-section Use
I investigate the relationship between physician pay, C-section use, and infant health, using vital statistics data and newly collected data on Medicaid payments to physicians. First, I confirm past results?when Medicaid pays doctors relatively more for C-sections, they perform them more often. I bolster the causal interpretation of this result by showing that salaried doctors do not respond to this pay differential, and by using a much larger sample of states and years. Second, unlike past work, I look at how changing physician pay affects infant health outcomes. I find that increased C-section use is associated with fewer infant deaths for births likely covered by Medicaid, suggesting that C-section rates may be too low for some groups. Taken together, these findings suggest that policies aimed at decreasing costs by lowering procedure use may have adverse health consequences, especially for low-income patients.
AUTHORS: Alexander, Diane
DATE: 2015-07-31

Working Paper
Closing the Gap: The Impact of the Medicaid Primary Care Rate Increase on Access and Health
The difficulties that Medicaid beneficiaries face accessing medical care are often attributed to the program?s low reimbursement rates relative to other payers. There is little evidence, however, as to the actual effects of Medicaid payment rates for providers on access and health outcomes for beneficiaries. In this paper, we exploit time-series variation in Medicaid reimbursement rates primarily driven by the Medicaid fee bump?a provision of the Affordable Care Act mandating that states raise Medicaid payments to match Medicare rates for primary care visits for 2013 and 2014?to quantify the impact of physician payment on access to treatment. As Medicaid rates are set by states and vary considerably in generosity, the policy had large and heterogeneous impacts across states. We find that increasing Medicaid payments to primary care doctors is associated with improvements in access, better self-reported health, and fewer school days missed among beneficiaries.
AUTHORS: Schnell, Molly; Alexander, Diane
DATE: 2017-05-03

Working Paper
Check Up Before You Check Out: Retail Clinics and Emergency Room Use
Retail clinics are an innovation that has the potential to improve competition in health care markets. We use the universe of emergency room (ER) visits in New Jersey from 2006-2014 to examine the impact of retail clinics on ER usage. We find significant effects of retail clinics on ER visits for both minor and preventable conditions; Residents residing close to an open clinic are 4.1-12.3 percent less likely to use an ER for these conditions. Our estimates suggest annual cost savings from reduced ER usage of over $70 million if retail clinics were made readily available across New Jersey.
AUTHORS: Currie, Janet; Alexander, Diane; Schnell, Molly
DATE: 2017-09-08

Newsletter
Check Up Before You Check Out
Retail clinics offer convenient, low-cost preventive health care and treatment for minor injury and illness. When a retail clinic opens, the rate of visits to the emergency room for these low-severity conditions declines for people who live in close proximity.
AUTHORS: Alexander, Diane; Currie, Janet; Schnell, Molly; Camner McKay, Lisa
DATE: 2019

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