Provider-Insurer Integration and Healthcare Delivery (Job Market Paper) [paper]

I examine how integration between healthcare providers and insurers affects care delivery. Unlike stand-alone providers, integrated providers bear financial responsibility as insurers, which may incentivize them to limit resource-intensive services or better coordinate care. In the Massachusetts Individual Exchange, I find that integration reduces utilization, mainly by reducing patients' visits to specialists. Integration lowers both the likelihood of patients visiting a specialist by 10 percentage points and, for those who do, the likelihood of seeking second opinions by 2.5 percentage points. This shift is accompanied by patients changing to new primary care practitioners (PCPs) who are more likely to be integrated with the insurer. To assess whether the reduction in specialist visits stems from integrated PCPs' stricter gatekeeping or improved PCP-specialist coordination, I develop and estimate a physician referral model. Model estimates show that integrated PCPs are stricter in referral, but see more accurate information related to referral. Counterfactual analyses reveal that while most of the reduction in specialist visits is explained by gatekeeping, integration increases the likelihood of patients choosing a best-match specialist conditional on visiting a specialist.

Limiting For-Profit Provision in Nursing Home Markets (with Hans Zhu) [paper]

We examine whether policies that ban for-profit providers, allowing for subsequent takeovers by not-for-profits in regulated markets such as health and education can be effective at addressing quality shortfalls. We consider the US nursing homes industry, where quality provision has been a concern for many decades. Our motivating evidence suggests that not-for-profit providers choose higher-quality inputs than their for-profit counterparts but are more prevalent in higher socioeconomic markets and serve less needy residents. Thus, for-profit providers play an important role in providing access. To explain these facts and explore counterfactual policies we estimate a structural model of nursing home demand and supply which allows firms to have non-pecuniary motives and costs that differ across provider types. We find that not-for-providers offer a higher priced, higher quality and higher overall cost product which is more suited to serving less needy residents. For-profit providers offer a lower priced, lower quality and lower overall cost product which is more suited to serving more needy residents. Banning for-profit providers without takeovers decreases consumer surplus in a large range of scenarios, and is likely to result in large losses in nursing home care for needier residents. Banning for-profit providers while allowing for takeovers also tends to reduce consumer surplus as not-for-profits that takeover the for-profits raise prices significantly to cover their higher costs.

The Value of Staying at Home: Long-Term Care at Home vs. Facility [paper]

As the world population ages, understanding efficient ways to deliver long-term care becomes increasingly important. I compare the efficacy of the two most common modes of care: facility-based and home-based care. To control for patients' selection into different types of care, I exploit a natural experiment in the South Korean national long-term care insurance scheme and its detailed administrative data. I find that facility-based care increases first-year mortality by 19% compared to home-based care for compliers. Mortality is concentrated among individuals with physical impairments and access to informal care at the time of transitioning into facilities. I identify two potential mechanisms: (1) poor quality facility care due to understaffing or negligence results in life-threatening conditions, and (2) loss of a sense of community negatively impacts the physical health of old and frail residents. I show that further expanding home-based care improves chronic care management without increasing spending. These findings suggest that policies subsidizing home-based care would result in better health outcomes at lower costs.

Vertical Integration and Medical Loss Ratio Regulation

Regulated Prices and Labor Shortages (with Hans Zhu)

Provider-Sponsored Plans in the United States [data | slides]

I construct a data set of provider-sponsored plans in the United States and summarize enrollment and market outcomes.

I worked as a teaching assistant for Kellogg’s various Full-time and Executive MBA courses. [evaluations]