A large literature in medicine documents variation across areas in the use of surgical treatments that is unrelated to outcomes. Observers of this phenomenon have invoked “flat of the curve medicine” ...to explain it and have advocated for reductions in spending in high‐use areas. In contrast, we develop a simple Roy model of patient treatment choice with productivity spillovers that can generate the empirical facts. Our model predicts that high‐use areas will have higher returns to surgery, better outcomes among patients most appropriate for surgery, and worse outcomes among patients least appropriate for surgery, while displaying no relationship between treatment intensity and overall outcomes. Using data on treatments for heart attacks, we find strong empirical support for these and other predictions of our model and reject alternative explanations such as “flat of the curve medicine” or supplier‐induced demand for geographic variation in medical care.
We use six years of panel data on students and teachers to evaluate the effectiveness of recently hired teachers in the New York City public schools. On average, the initial certification status of a ...teacher has small impacts on student test performance. However, among those with the same experience and certification status, there are large and persistent differences in teacher effectiveness. Such evidence suggests that classroom performance during the first two years is a more reliable indicator of a teacher's future effectiveness. We also evaluate turnover among teachers by initial certification status, and the implied impact on student achievement of hiring teachers with predictably high turnover. Given modest estimates of the payoff to experience, even high turnover groups (such as Teach for America participants) would have to be only slightly more effective in each year to offset the negative effects of their high exit rates (I2, J24).
Recent theoretical and empirical advances have renewed interest in monopsonistic models of the labor market. However, there is little direct empirical support for these models. We use an exogenous ...change in wages at Department of Veterans Affairs (VA) hospitals as a natural experiment to investigate the extent of monopsony in the nurse labor market. We estimate that labor supply to individual hospitals is quite inelastic, with short‐run elasticity around 0.1. We also find that non‐VA hospitals responded to the VA wage change by changing their own wages.
In medicine, the reasons for variation in treatment rates across hospitals serving similar patients are not well understood. Some interpret this variation as unwarranted, and push standardization of ...care as a way of reducing allocative inefficiency. An alternative interpretation is that hospitals with greater expertise in a treatment use it more because of their comparative advantage, suggesting that standardization is misguided. A simple economic model provides an empirical framework to separate these explanations. Estimating this model with data for heart attack patients, we find evidence of substantial variation across hospitals in both allocative inefficiency and comparative advantage, with most hospitals overusing treatment in part because of incorrect beliefs about their comparative advantage. A stylized welfare-calculation suggests that eliminating allocative inefficiency would increase the total benefits from the treatment that we study by 44%.
Research on the relationship between teacher characteristics and teacher effectiveness has been underway for over a century, yet little progress has been made in linking teacher quality with factors ...observable at the time of hire. To extend this literature, we administered an in-depth survey to new math teachers in New York City and collected information on a number of nontraditional predictors of effectiveness, including teaching-specific content knowledge, cognitive ability, personality traits, feelings of self-efficacy, and scores on a commercially available teacher selection instrument. We find that only a few of these predictors have statistically significant relationships with student and teacher outcomes. However, the individual variables load onto two factors, which measure what one might describe as teachers' cognitive and noncognitive skills. We find that both factors have a moderately large and statistically significant relationship with student and teacher outcomes, particularly with student test scores.
Despite growing interest in evidence-based hospital referral for selected surgical procedures, there remains considerable debate about which measures should be used to identify high-quality ...providers.
To assess the usefulness of historical mortality rates and procedure volume as predictors of subsequent hospital performance with different procedures.
Using data from the national Medicare population, we identified all U.S. hospitals performing one of 4 high-risk procedures between 1994 and 1997. Hospitals were ranked and grouped into quintiles according to 1) operative mortality (adjusted for patient characteristics) and 2) procedure volume.
Risk-adjusted operative mortality in 1998 to 1999.
Although historical mortality and volume both predicted subsequent hospital performance, the predictive value of each varied by procedure. For coronary artery bypass graft surgery, mortality rates in 1998 to 1999 differed by 3.3% across quintiles of historical mortality (3.6% to 6.9%, best to worst quintile, respectively), but only by 1.0% across volume quintiles (4.8% to 5.8%). In contrast, for esophagectomy, mortality rates in 1998 to 1999 differed by 12.5% across volume quintiles (7.5% to 20.0%, best to worst quintile, respectively), but only by 1.5% across quintiles of historical mortality (11.4% to 12.9%). Historical mortality and procedure volume had comparable value as predictors of subsequent performance for pancreatic resection and elective abdominal aortic aneurysm repair. Our findings were similar when we repeated the analysis using data from later years.
Historical measures of operative mortality or procedure volume identify hospitals likely to have better outcomes in the future. The optimal measure for selecting high-quality providers depends on the procedure.
Concerns about physician shortages have led policy makers in the US public and private sectors to advocate for the greater use of nurse practitioners (NPs). We examined recent changes in demographic, ...employment, and earnings characteristics of NPs and the implications of those changes. In the period 2010-17 the number of NPs in the US more than doubled from approximately 91,000 to 190,000. This growth occurred in every US region and was driven by the rapid expansion of education programs that attracted nurses in the Millennial generation. Employment was concentrated in hospitals, physician offices, and outpatient care centers, and inflation-adjusted earnings grew by 5.5 percent over this period. The pronounced growth in the number of NPs has reduced the size of the registered nurse (RN) workforce by up to 80,000 nationwide. In the future, hospitals must innovate and test creative ideas to replace RNs who have left their positions to become NPs, and educators must be alert for signs of falling earnings that may signal the excess production of NPs.
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