Decision-Making in Health Care: The Influence of Technology, Leadership, and Governance Restricted; Files Only

Abstract

This dissertation investigates how key decision-makers in health care respond to structural and policy changes, shaping hospital operations, patient care, and competition in hospital markets. Across three studies, I examine the effects of technology adoption, executive leadership, and board governance on hospital and physician behavior, providing insights relevant to policymakers and health care administrators.

The first chapter investigates how the adoption of electronic health records (EHRs) affects physician labor market outcomes. Physicians working in hospitals are more likely to exit clinical work or shift to office-based settings following EHR adoption in their hospital, while those who remain in hospitals increase their patient load. These findings suggest that while EHRs may improve efficiency in patient care, they also impose costs on physicians that influence career choices, raising considerations for future technology adoption.

The second chapter examines the role of clinical experience on hospital executive teams on hospitals' response to financial incentives on quality. Hospitals led by non-clinical executives respond more drastically to financial incentives on quality than those led by clinicians, suggesting that non-clinical teams are more profit-driven while clinical teams are more patient-driven. These results highlight the importance of leaders in aligning financial and care objectives, with implications for policy initiatives aimed at improving hospital value.

The third chapter establishes the existence of overlapping board members in competing nonprofit hospitals in the US. A significant portion of nonprofit hospitals have overlapping board members, and a significant portion of hospital markets have board overlap within them. Having an overlapping board member is correlated with quality metrics and investment decisions of the hospital, though I do not draw a causal link. These findings highlight an understudied mechanism through which hospitals form affiliations, potentially affecting patient and market outcomes. 

Table of Contents

Contents

1 Labor Markets and Technological Change: Evidence from Electronic Health Records 1

1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.2 Institutional Details . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

1.2.1 EHRs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

1.2.2 Hospitalists and Labor Market Decisions . . . . . . . . . . . . . . . . 8

1.3 Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

1.3.1 Sample Construction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

1.3.2 Summary Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

1.4 Empirical Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

1.4.1 Identification Assumptions . . . . . . . . . . . . . . . . . . . . . . . . 18

1.5 Effect of EHR Exposure on Labor Market Outcomes . . . . . . . . . . . . . . 19

1.5.1 No Longer Seeing Patients . . . . . . . . . . . . . . . . . . . . . . . . . 19

1.5.2 Work Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

1.5.3 Patient Count and Billing Activity . . . . . . . . . . . . . . . . . . . . 23

1.6 Alternative Explanations and Robustness Checks . . . . . . . . . . . . . . . . 26

1.6.1 Changes Related to the ACA . . . . . . . . . . . . . . . . . . . . . . . 26

1.6.2 Other Hospital Changes . . . . . . . . . . . . . . . . . . . . . . . . . . 27

1.6.3 Hospital Firing or Re-allocation of Hospitalists . . . . . . . . . . . . . 30

1.6.4 Re-allocation of Patients . . . . . . . . . . . . . . . . . . . . . . . . . . 32

1.6.5 Evaluating Pre-Trends and Specification Charts . . . . . . . . . . . . 32

1.6.6 Lee Bounds for Sample Selection . . . . . . . . . . . . . . . . . . . . . 33

1.7 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

2 Does Hospital Leadership Matter? Evidence from Pay-for-Performance 36

2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

2.2 Theoretical Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

2.3 Setting and Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

2.3.1 Nonprofit Hospital Executives . . . . . . . . . . . . . . . . . . . . . . 43

2.3.2 Pay-for-Performance Policies Targeting Readmission and Mortality

Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

2.3.3 Summary Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

2.4 Effect of Clinically Trained Executives on Response to Financial Incentives

on Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

2.4.1 Intensive Margin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

2.5 Are Clinical Executives Less Profit Driven? . . . . . . . . . . . . . . . . . . . 54

2.6 Signaling vs. Managing Decomposition . . . . . . . . . . . . . . . . . . . . . 57

2.6.1 Analysis of Executive Team Changes . . . . . . . . . . . . . . . . . . 58

2.6.2 Estimation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

2.7 Heterogeneity by Physician Specialty . . . . . . . . . . . . . . . . . . . . . . 61

2.8 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

3 Board Overlap in US Hospitals 65

3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

3.2 Related Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

3.2.1 Overlapping Board Members . . . . . . . . . . . . . . . . . . . . . . . 67

3.2.2 Common Ownership . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

3.2.3 Consolidation in Hospitals . . . . . . . . . . . . . . . . . . . . . . . . 71

3.2.4 Informing Hospital Behaviors . . . . . . . . . . . . . . . . . . . . . . . 73

3.3 Documenting Overlapping Board Members in US Hospitals . . . . . . . . . 74

3.3.1 Data Construction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

3.3.2 Summary Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

3.3.3 Correlations with Hospital Behaviors . . . . . . . . . . . . . . . . . . 81

3.4 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

Appendix A Labor Markets and Technological Change: Evidence from Electronic

Health Records 87

A.1 Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

A.1.1 Physician Specialties by Tax Code . . . . . . . . . . . . . . . . . . . . 87

A.1.2 CMS Shared Patient Data . . . . . . . . . . . . . . . . . . . . . . . . . 88

A.1.3 Pair-Level Variables . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88

A.1.4 Physician Labor Market Activity . . . . . . . . . . . . . . . . . . . . . 90

A.2 Sensitivity Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

A.2.1 Alternative Estimators . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

A.2.2 Heterogeneity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

A.2.3 Coding Activity as Cause for Work Setting Shift . . . . . . . . . . . . 95

A.2.4 Various Changes to Specification . . . . . . . . . . . . . . . . . . . . . 97

A.2.5 Parallel Trends Assumption . . . . . . . . . . . . . . . . . . . . . . . . 103

Appendix B Does Hospital Leadership Matter? Evidence from Pay-for-Performance109

B.1 Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109

B.1.1 Gathering Hospital Leadership Names . . . . . . . . . . . . . . . . . 109

B.1.2 Executive Team Changes . . . . . . . . . . . . . . . . . . . . . . . . . 114

B.1.3 Merging to Other Hospital Data . . . . . . . . . . . . . . . . . . . . . 114

B.1.4 Additional Summary Statistics . . . . . . . . . . . . . . . . . . . . . . 115

B.2 HRRP and HVBP Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118

B.3 Supplemental Analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120

B.3.1 Binned Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120

B.3.2 Selective Patient Practices . . . . . . . . . . . . . . . . . . . . . . . . . 122

B.3.3 Results By Condition . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123

B.3.4 Robustness to Other Estimations . . . . . . . . . . . . . . . . . . . . . 124

Bibliography 130

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School	Laney Graduate School
Department	Economics
Degree	Ph.D.
Submission	Dissertation
Language	English
Research Field	Economics, General
Palabra Clave	health economics
Committee Chair / Thesis Advisor	Ian McCarthy, Emory University
Committee Members	Evan Saltzman, Florida State University Matthew Grennan, Emory University Sara Markowitz, Emory University

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