AHPP 2023-24 Colloquium series, “Technology, Trust, and Healthy Aging”

Patient trust is an important driver of the demand for healthcare. But it may also impact supply: doctors who realize that patients may not trust them may adjust their behavior in response. We assemble a large dataset that assesses clinical performance using standardized-patients (akin to audit studies in economics) in low-income countries to investigate this possibility; most of these data are on healthcare providers who practice in the private sector on a fee-for-service basis. 

We establish that patients receive low quality of care, with a generous definition suggesting that fewer than 50% of cases are correctly managed, and between 70% and 90% of expenditures are medically unnecessary. Strikingly, and in contrast to the literature suggesting that the main problem with fee-for-service provision is over-treatment, the majority of these unnecessary expenditures are incurred because patients are incorrectly rather than over-treated. 

We then rule out two plausible explanations for low quality of care: low levels of medical knowledge and low market incentives to invest effort. In our data, there are many healthcare providers who know how to correctly treat the patient and could substantially increase their revenue by doing so given the price-quality gradients we estimate, but still treat the patient incorrectly. 

A model of the patient-provider relationship in which patients have incomplete information about the quality of providers generates predictions consistent with our findings. The theory additionally suggests that issuing a credible signal of quality should raise the average quality of care among providers, even if their underlying ability remains unchanged. 

We assess this prediction through an evaluation of a highly publicized training program with informal healthcare providers in West Bengal, India. The program has no impact on knowledge, yet substantially raises the quality of care, leading to an increase in the likelihood of correct treatment, a 19% decline in unnecessary expenditures for patients and a 9% increase in revenues for providers. We conclude that low trust undermines clinical performance in an economically and medically significant manner.

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Reshmaan Hussam is an assistant professor of business administration in the Business, Government and International Economy Unit at Harvard University's Business School, a Faculty Research Fellow at the National Bureau of Economic Research (NBER), and a faculty affiliate at the Abdul Latif Jameel Poverty Action Lab (J-PAL) and the Bureau for Research and Economic Analysis of Development (BREAD).

Her research explores questions at the intersection of development and behavioral economics, with research in three areas: migration, health, and finance.  Her most recent work engages refugee populations including the Rohingya in Bangladesh, examining the psychosocial value of employment in contexts of mass unemployment, the role of home in migration decision-making, and refugee preferences for repatriation, integration, and resettlement. In her work in health, which involves field experiments across South Asia, she considers the puzzle of the ubiquitously low adoption of low-cost, high-return goods, behaviors, and technologies in the developing world, exploring the role of learning and habit formation in behavior change. Her work in finance explores how to identify high-return microentrepreneurs using local community knowledge in India and how to increase credit access and returns to capital among refugee communities in Uganda.

Prior to joining HBS, Professor Hussam was a postdoctoral fellow at the Economic Growth Center at Yale University. She received her SB and PhD in economics from MIT.

Laurence Baker is a Health Policy professor, a senior fellow with Stanford Institute for Economic Policy Research, and an Economics professor (by courtesy). His research focuses on the impacts of changing financial incentives, regulations, and organizational structures on health care provision and costs. He studies the impacts of managed care and related insurance arrangements on things like health care costs, prices for health insurance, and the availability/utilization of medical technologies. 

Sylvia Plevritis is a professor of Biomedical Data Science, a professor of Radiology, and the chair of Biomedical Data Science. Her research program focuses on genomics, biocomputation, imaging and population sciences and works to decipher properties of cancer progressions to guide advances in early detection and treatment response. 

Joe Selby was a founding executive director of the Patient-Centered Outcomes Research Institute (PCORI). Much of his research has focused on diabetes outcomes and quality improvement, as well as primary care delivery, colorectal cancer screening strategies, and disparities in diabetes mellitus treatment effectiveness. 

Katie Attwell is an associate professor with the University of Western Australia School of Social Sciences. Katie specializes in mandatory vaccination policy in Europe, Australia, and the US, focusing on the tactics governments use to motivate people to get vaccinated and how policies are designed. 

Mark Navin is a professor and chair of philosophy at Oakland University (Rochester, MI) and Clinical Ethicist at Corewell Health. His research is primarily in clinical ethics and ethics in public health.  

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Laura Carstensen is a professor of psychology at Stanford, where she's the founding director of the Stanford Center on Longevity. Her research focuses on ways in which motivational changes influence emotional experience and cognitive processing. 

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Abstract: Along virtually any dimension, older people report better emotional well-being than younger generations. Considering the many losses older people experience, these findings are referred to as “the paradox of aging.” Socioemotional selectivity theory offers an account based on motivational shifts associated with perceived time horizons. This talk will overview the theory and evidence generated by tests of related hypotheses. 

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Talk Title: What Makes Care Integration So Hard and What To Do About It

Care integration remains a seemingly intractable challenge in health care. In this seminar, we’ll examine why, probing deeper for explanations than simply that care is badly fragmented (which it is), so hard to integrate. By considering findings across multiple studies, methods, and theories, we will derive insights and explore promising solutions.

Sara Singer is a Primary Care and Population Health professor at Stanford. Her research focuses on ensuring patient safety, integrating services and service providers, implementing technological innovations that enhance the value of health care, and determining how policymakers can make changes to ensure higher-quality, more affordable healthcare. 

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Laura Hatfield is an associate professor of health care policy (biostatistics) at Harvard. She is currently working to improve methods for control group selection in observational health services and outcomes research, and her research focuses on developing statistical methods that incorporate multiple information sources and loss functions to improve decision making.