Essays in health economics

Abstract

This aims at better understanding the drivers behind the volume-outcome rela- tionship found in many studies in the medical and health-economics literature. In the first chapter I investigate the relationship between workload and choice of treatment. Using detailed microdata on childbirth, I exploit a quasi-random assignment of patients attempting to have a natural delivery to different ratios of patients-to-midwives and compare their likelihood of changing delivery method. I find that women who face a ratio higher than 1.33 are 34% more likely to give birth by cesarean section (C-sections). This effect is larger for patients who were already admitted with a higher risk of C-section, since provision of proper and timely care matters more for these patients. Because C-sections are faster than vaginal deliveries, the medical team may find it appealing to do more C-sections when time constrained. Using civil status as a proxy for bargaining power -assuming single women are on average more likely to be alone-, I find that only single patients are subjected to unnecessary surgery. The second chapter documents the existence of `learning-by-doing' effects in physicians' performance. More specifically, I test whether cesarean-section surgeons who have performed more procedures in the recent-past observe an improvement in performance. By using data from the Italian health care system, where patients are not allowed to choose a physician, I eliminate concerns regarding possible bias from selective referral -a problem in previous studies. Using four years of birth certificates data from one large hospital I find that, for emergent cases, performing one additional procedure reduces the likelihood of neonatal intensive care unit admission by nearly 1.2 percentage points (5.5%) and of being born with a low Apgar Score by about 1.1 percentage points (10%), all else equal.