Essays on Healthcare Information in Hospital Outpatient, Nursing Home, and Pharmaceutical Settings
This dissertation explores how healthcare information policies and practices shape hospital outpatient care, nursing home regulation, and direct-to-physician marketing. Emergency department patients are increasingly placed in observation status, a form of extended monitoring that can expose them to high out-of-pocket costs. In Chapter 1, I leverage the staggered adoption of state policies that require hospitals to give patients observation status information in real-time. Though similar information interventions have proven effective across policy settings, my event study results suggest that state notice policies have no effect on observation care processes or outcomes. My estimates rule out meaningful increases in admission from observation, and I find no decline in discharges to skilled nursing facilities overall. These findings suggest that additional policy protections may be necessary to reduce the financial risks associated with hospital observation status. Direct care workers greatly influence the quality of care provided in nursing homes, making staffing information critical to regulators and residents alike. In Chapter 2, I explore the implementation of a wage-verifiable reporting tool, which replaced the collection of sparse, self-reported staffing data. When the data in these systems were compared, self-reported staffing generally exceeded verifiable levels, leading to the public perception of overreporting. I use facility-level variation in these staffing level discrepancies to explore the effect of reputational shocks on nursing home outcomes. In the years following the data system transition, I find greater increases in direct care worker staffing levels for facilities with greater reputational exposure. This staffing response does not, however, influence quality of care. Over the last decade, several biosimilar competitors have entered the biologic drug market. Though biosimilars generally launch at lower prices than the reference biologic, take-up has been uneven. Because physicians typically purchase, prescribe, and administer these drugs, the information exchanged during a direct-to-physician marketing encounter can play a unique role. Chapter 3, joint with Colleen Carey, describes the direct-to-physician marketing activities of six reference biologics facing biosimilar competition. The results show that manufacturers of reference biologics reduce direct-to-physician marketing after the first biosimilar launches, making this an unlikely explanation for the persistence of these drugs. Biosimilar manufacturers generally engage in low levels of direct-to-physician marketing, despite the promise of such activities to inform and engage physicians.