1. Saynisch PA, Huckman R, Trichakis N. Decomposing Volume’s Impact on Judgment and Skill: Lessons from Kidney Transplantation (Job Market Paper)
In markets for credence goods, such as medical care, suppliers act as not only as providers but also as expert advisors: they diagnose a buyer’s need for a service (i.e., judgment) before providing it (i.e., skill). This dual role of the supplier introduces a crucial complication to learning-by-doing explanations of the volume-outcome relationship, as the observed improvements in outcomes may result from better decision-making or better execution. This paper aims to explore an area of medicine - kidney transplantation - where clinical judgment and surgical skill are clearly delineated and separately observable. We find that greater lagged volume for a given transplant center is predictive of lower rates of organ offer acceptance across the spectrum of organ quality. To assess center performance, we evaluate outcomes along two dimensions following decisions to refuse an offered organ: (1) whether the potential recipient accepted a better-quality organ within one year of a refusal and (2) whether the potential recipient died or was removed from the transplant waitlist for medical reasons within one year of a refusal. We find that larger centers perform worse on both dimensions. We then assess how volume relates to post-surgical outcomes and find evidence of reduced rates of post-transplant death or graft failure within one year at larger transplant centers. This tension between improved skill and reduced judgment quality implies that practice may not make perfect in the context of complex medical care. Experience may need to be supplemented with decision support or other tools to improve outcomes.
2. Saynisch PA, David G, Ukert B, Agiro A, Scholle S, Oberlander T. Model Homes: Evaluating Approaches to Patient-Centered Medical Home Implementation (under review)
The Patient Centered Medical Home (PCMH) is a model of clinical practice improvement for primary care, encouraging expanded electronic and in-person access to providers, improved coordination, and use of information technology for guiding and tracking the care delivered. Practices can achieve recognition by self-selecting a subset of improvements to implement, leading to substantial heterogeneity among practices, and recent work has found that different approaches to achieving PCMH recognition yielded varying impacts on patient outcomes. In this study we utilize a hierarchical clustering methodology to group practices based on the specific capabilities adopted, analyzing proprietary data from an insurer spanning the period of 2006 to 2016 that includes information on over 6,000 practices. The cluster methodology points to one low-performing and two high-performing clusters, with the two high-performing clusters distinguished by the choice to emphasize on electronic communications capabilities or not. We assess the PCMH impact on healthcare utilization and expenditures using a generalized difference-in-differences approach based on the staggered timing of PCMH adoption by practices in our sample. With respect to the general PCMH level recognition level effect, we find significant reductions in emergency department (ED) utilization as well as in outpatient care generally, with specific reductions in both generalist and specialist physician visits, and both lab and imaging services. In our practice cluster results we find that while the reduction in outpatient care is significant across all three clusters, we find a reduction in ED utilization is driven entirely by the high performance (electronic communication) cluster, suggesting a possible substitution between ED visits and use of expanded contact options with primary care practices. These reductions in utilization are accompanied by significant reductions in overall expenditures.