Essays on radiology services utilization in the United States
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This dissertation investigates how policies and financial incentives may affect the use of services within the United States health care system. The research consists of two distinct parts: Part I comprises two studies examining the impact of recently enacted state legislation regarding dense breast tissue on the use of downstream imaging; Part II delves into changes in physician reimbursement and their effect on health care delivery. Dense breast tissue is a common finding that decreases the sensitivity of mammography in detecting cancer. Some states have passed legislation requiring health care providers to notify patients with dense breast tissue that identification of early cancers may be compromised. Others have also aimed to increase access to supplemental screening tests by requiring health plans to include such follow-up options in covered benefits. The legislation has been controversial because supplemental imaging following a negative screening mammogram for patients with no other risk factors provides little benefit compared to its substantial cost. In the first study, we analyzed whether the dense breast tissue notification laws affected the probability of screening mammography follow-up by ultrasound and magnetic resonance imaging (MRI). We found strong evidence that implementing the notification legislation led to an increase in the probability of downstream breast ultrasound imaging in most states, and to an increase in the probability of downstream breast MRI in some states. In the second study, we identified specific characteristics of various state-level dense breast policies that were associated with increased use of downstream breast ultrasound imaging. In Part II of the dissertation, we assessed the extent to which changes in health care prices affect the provision of health services by physicians in various medical and surgical specialties in both Medicare and the private sector. We exploited the considerable changes in the Medicare Physician Fee schedule due to procedural code bundling that happened between 2010 and 2014 as the source of variation in health care prices. Our results showed that volume responses to changes in health care prices are inelastic and vary in both direction and magnitude by specialty and sector.
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