There is growing evidence that inappropriate prescribing is harming patients and raising costs in the US health care system. Through a partnership between the federal government and academics, we seek to develop evidence on reducing this prescribing. We conduct several randomized letter interventions targeting high-volume prescribers of drugs that can harm patients. We take a continuous improvement approach, rapidly evaluating each round and using the results to inform subsequent work. The first round of letters yielded no effects, and we responded with new interventions that are now under evaluation. We discuss lessons our work provides for future government-academic partnerships.

We study a 2008 policy reform in which Medicare revised its hospital payment system to better reflect patients’ severity of illness. We construct a simulated instrument that predicts a hospital’s policy-induced change in reimbursement using pre-reform patients and postreform rules. The reform led to large persistent changes in Medicare payment rates across hospitals. Hospitals that faced larger gains in Medicare reimbursement increased the volume of Medicare patients they treated. The estimates imply a volume elasticity of 1.2. To accommodate greater volume, hospitals increased nurse employment, but also lowered length of stay.

We develop a framework to measure the role of hospital allocation in racial disparities in health care and use it to study Black and white heart attack patients. Black patients receive care at lower-performing hospitals than white patients. However, over two decades, the performance gap between hospitals treating Black and white patients shrank by over two-thirds. This progress is due to more rapid performance improvement at hospitals that tended to treat Black patients rather than reallocation of patients. Hospital improvement is correlated with adoption of a productivity-raising input, beta blockers. Our work highlights reallocation and performance improvement as future disparity-reduction levers.

The conventional wisdom for the healthcare sector is that idiosyncratic features leave little scope for market forces to allocate consumers to higher performance producers. However, we find robust evidence - across several different conditions and performance measures - that higher quality hospitals have higher market shares and grow more over time. The relationship between performance and allocation is stronger among patients who have greater scope for hospital choice, suggesting that patient demand plays an important role in allocation. Our findings suggest that healthcare may have more in common with "traditional" sectors subject to market forces than often assumed.

The conventional wisdom in health economics is that large differences in average productivity across US hospitals are the result of idiosyncratic features of the healthcare sector which dull the role of market forces. Strikingly, however, we find that productivity dispersion in heart attack treatment across hospitals is, if anything, smaller than in narrowly defined manufacturing industries such as ready-mixed concrete. While this fact admits multiple interpretations, it suggests that healthcare may have more in common with “traditional” sectors than is often assumed, and relatedly, that insights from research on productivity and allocation in other sectors may enrich analysis of healthcare.

Administrative barriers to social insurance program take-up are pervasive, including in subsidized health insurance. We conducted a randomized controlled trial with Massachusetts' Affordable Care Act marketplace to reduce these barriers and other behavioral frictions. We find that a “check the box” streamlined enrollment intervention raises enrollment by 10.5%, more than personalized reminder letters (7.6% increase) or generic reminder letters (4.3% increase). Effects are concentrated among individuals eligible for zero-premium plans, who faced no further administrative burdens of setting up payments. Producing this enrollment effect through premium reduction would cost about $7 million in subsidies, highlighting the importance of these burdens.

Despite the continuing U.S. hospital merger wave, it remains unclear how mergers change, or fail to change, hospital behavior and performance. We open the black box of hospital practices through a megamerger between two for-profit chains. Benchmarking the merger's effects against the acquirer's stated aims, we show they achieved some of their goals, harmonizing electronic medical records and sending managers to target hospitals. Postacquisition managerial processes were similar across the merged chain. However, these interventions failed to drive detectable gains in performance. Our findings demonstrate the importance of organizations for merger research in health care and the economy more generally.