Thesis: Ph. D., Massachusetts Institute of Technology, Department of Economics, 2014. / Cataloged from PDF version of thesis. / Includes bibliographical references (pages 147-150). / The first chapter takes advantage of the evolution of the regulatory and pricing environment in the first years of a large federal prescription drug insurance program for seniors - Medicare Part D - to explore interactions among adverse selection, switching costs, and regulation. I document evidence of both adverse selection of beneficiaries across contracts and switching costs for beneficiaries in changing contracts within Medicare Part D. Using an empirical model of contract choice and contract pricing, I show that in the present environment, on net, switching costs help sustain an adversely-selected equilibrium with large differences in risks between more and less generous contracts. I then simulate how switching costs may alter the impact of "filling" the Part D donut hole as implemented under the Affordable Care Act. I find that absent any switching costs, this regulation would have eliminated the differences in risks across contracts; however, in the presence of the switching costs that I estimate, the effect of the policy is largely muted. The second chapter (co-authored with Francesco Decarolis and Stephen Ryan) explores federal subsidy policies in Medicare Part D. We estimate an econometric model of supply and demand that incorporates the regulatory pricing distortions in the insurers' objective functions. Using the model, we conduct counterfactual analyses of what the premiums and allocations would be in this market under different ways of providing the subsidies to consumers. We show that some of the supply-side regulatory mechanisms, such as the tying of premiums and subsidies to the realization of average "bids" by insurers in a region, prove to be welfare-decreasing empirically. The third chapter studies two competing systems that comprise the German health insurance landscape. The two systems differ in the ability of insurers to underwrite individual-specific risk. In contrast to the community rating of the statutory insurance system, enrollees of the private plans face full underwriting and may be rejected by the insurers. I empirically assess to what extent the selection of "good risks" dominates the interaction between the two systems, using a regression discontinuity design based on statutory insurance enrollment mandates. I do not find compelling evidence of cream-skimming by private insurers from the statutory system. Motivated by this finding, I quantify the change in consumer welfare that would result if the government relaxed the statutory insurance mandate to lower income levels. / by Maria A. Polyakova. / Ph. D.

Thesis: M. Eng., Massachusetts Institute of Technology, Department of Electrical Engineering and Computer Science, 2018. / This electronic version was submitted by the student author. The certified thesis is available in the Institute Archives and Special Collections. / Cataloged from student-submitted PDF version of thesis. / Includes bibliographical references (pages 49-51). / The development of mobile technology and machine learning tools has made it easier than ever to monitor health without visiting a doctor. In this thesis, we explore the use of iris imaging as a medical diagnostic tool. We implement a system in which images captured using a mobile device can be uploaded to and analyzed by a central server. With this platform, we hope to build a large database of standard iris images with labeled medical data and facilitate studies of iris diagnostics. In our implementation, the feature extraction and classification tools built are applied to predict diabetes, through a study conducted in collaboration with researchers at Swami Vivekananda Yoga Anusandhana Samsthana (SVYASA). The results show improvement in prediction accuracy and encourage further development of the server platform for future, large-scale studies. / by Tania Weidan Yu. / M. Eng.

Thesis: Ph. D., Massachusetts Institute of Technology, Department of Economics, 2014. / Cataloged from PDF version of thesis. / Includes bibliographical references. / The first chapter studies how incentives drive adoption by looking at a technology that generates revenue for hospitals: the practice of submitting detailed documentation about patients. After a 2008 reform, hospitals were able to raise their total Medicare revenue over 2% by always specifying a patient's type of heart failure. I find that hospitals only captured around half of this revenue. The key barrier to take-up is a principal agent problem, since doctors supply the valuable information but are not paid for it. Exploiting the fact that many doctors practice at multiple hospitals, I find that four-fifths of the dispersion in adoption reflects differences in the ability of hospitals to extract documentation from physicians. Hospital adoption is also robustly correlated with the ability to generate survival for heart attack patients and the use of inexpensive survival-raising standards of care. My results suggest that agency conflicts may drive disparities in health care performance more generally. The second chapter (co-authored with Amitabh Chandra, Amy Finkelstein, and Chad Syverson) challenges the conventional wisdom in health economics that large differences in average productivity across hospitals are the result of idiosyncratic, institutional features of the healthcare sector which dull the role of market forces. Strikingly, 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. We also find evidence against the conventional wisdom that the healthcare sector does not operate like an industry subject to standard market forces. In particular, we find that hospitals that are more productive at treating heart attacks have higher market shares at a point in time and are more likely to expand over time. These facts suggest that the healthcare sector may have more in common with "traditional" sectors than is often assumed. The third chapter explores whether hospitals change their treatment decisions when they are paid more for certain treatment approaches. I exploit a Medicare reform that altered payment rates depending on whether patients were relatively healthy or sick. Looking at three treatment approaches for lung cancer patients, I demonstrate economically significant own-price elasticities and right-signed cross-price elasticities - though these estimates sometimes lack statistical power and should be interpreted with caution due to concerns about endogeneity. These findings indicate that payment reforms, including movements toward capitation and away from fee-for-service, may have large effects on the intensity of care that patients receive in the hospital. / by Adam Jon Sacarny. / Ph. D.

Thesis: Ph. D., Massachusetts Institute of Technology, Department of Economics, 2015. / Cataloged from PDF version of thesis. / Includes bibliographical references (pages 85-91). / This thesis is a compilation of three empirical studies exploring significant but underexamined health and development challenges of the late 20th and early 21st centuries in South Asia. Chapter One investigates the effects of the expansion of ultrasound technology throughout India in the 1980s on the childbearing decisions of parents and the marriage market dynamics of exposed children. While ample work has documented the relationship between access to sex selection technology and heavily male-skewed child sex ratios, we know little about how such exposure translates into later life marriage market outcomes of children in highly sex-skewed regions, nor about how parental choice regarding sex selection is affected by such shifts in their children's marital prospects. I build on a theory proposed by Edlund (1999) that, in environments where hypergamy is practiced and parents derive utility from married children, a male-skewed sex ratio can generate a permanent female underclass. By examining the relationship between the child sex ratio of couples of childbearing age and that of their contemporaneous marriage market, I offer evidence that parents do indeed internalize the marriage prospects of their unborn children and adjust their use of sex selection technology accordingly. Importantly, this adjustment occurs significantly more amongst poor families than wealthy families. By exploiting spatial and temporal variation in exposure to ultrasound technology, I then examine the implications of such socioeconomically skewed ultrasound use on the marital outcomes of children in regions with high ultrasound access. I find that, relative to her unexposed counterpart, the average exposed married female has significantly poorer health and less education; there exists a wider marriage and education gap between herself and her husband; and she reports lower autonomy, less decision making power, and more abuse, among other bargaining outcomes. While existing literature suggests that scarcity of females in a marriage market should increase their bargaining power, I offer evidence to the contrary in this nationwide setting of endogenous and socioeconomically stratified sex selection. This exercise underscores the intergenerational welfare consequences of poorly regulated access to sex selection technology: not only upon the millions of 'missing women' lost to sex selection, but upon surviving females as well. Chapter Two explores the impact of a 1999 public health campaign in Bangladesh, which sought to protect millions of individuals from exposure to arsenic-contaminated water, on infant and child mortality. The study was motivated by the dearth of literature on the effects of arsenic exposure on children (whereas its effects on adults, often manifested in the cancer arsenicosis, are well known). It quickly evolved into an examination of the unintended consequences of a highly influential but poorly planned public health campaign. Exploiting the local random nature of arsenic contamination of groundwater in Bangladesh, paired with the timing of child births and thus exposure to such contaminated water, we find that households in which children were exposed to arsenic for a shorter duration (because the household responded to the health campaign by switching away from arsenic-contaminated groundwater sources) in fact experience significantly higher rates of infant and child mortality relative to their counterparts. We present evidence that this unanticipated rise in mortality is due to the quality of alternatives that a switching household faced: households had to choose between arsenic-laden but easily accessible shallow tubewell water, which was protected from fecal bacteria; arsenic-free and easily accessible surface water, which was heavily exposed to fecal bacteria; or distant and inconvenient potable water, which was more likely to be exposed to bacteria at the point-of-use. As bacterial contamination is a leading cause of infant and child death in Bangladesh, we argue through a series of exercises that this is a likely driver of the rise in mortality rates amongst young children whose families switched away from arsenic-contaminated tubewells. In determining their water source, households were essentially trading off arsenic exposure and the resulting rise in old-age mortality with bacterial exposure and the resulting rise in the mortality of their young. The study motivates caution in the execution of large-scale public health and behavioral change campaigns when alternatives to the discouraged behavior are poorly understood. While my first two chapters investigate household health behavior, a demand-side component of the healthcare market, the next chapter explores a critical player on the supply side. Chapter Three studies the impact of a nine-month generalized training program on the knowledge and performance of private informal healthcare providers in West Bengal, India. These providers, colloquially referred to as "quacks" and described here as "informal providers" (IPs), constitute nearly 80% of the Indian healthcare provider market. However, none possess medical degrees and few have any formal certification to practice medicine. They have been the focus of considerable debate in recent years, with many pushing for their elimination while others propose their integration into the public healthcare system. To inform the debate, it is important to understand whether the quality of healthcare provided by IPs can be improved sufficiently for effective and welfare-increasing integration. The training program examined in this study was the first of its kind to be rigorously evaluated for its impact on IP knowledge and quality of care. We employ a randomized controlled trial (RCT) design, in which we randomly assigned 152 IPs to treatment and 152 IPs to control. Treatment IPs were invited to attend the program, which was taught by certified doctors and consisted of two two-hour classes per week over nine months. Endline data was collected twelve to fourteen months after the start of training. Standardized patient data, corroborated by clinical observations, demonstrate that those IPs offered the program spent significantly more time with their patients, completed a more thorough set of history questions and examinations, and provided more effective treatments. However, we see no shift in the frequency with which they practiced polypharmacy nor the dispensation of unnecessary antibiotics, two harmful practices which plague both the private and public healthcare system. We conclude that training offers a low cost, highly effective method to improve the quality of care delivered by IPs, but that deeper knowledge failures or misaligned incentives may be driving practices such as polypharmacy, for which training may not be a sufficiently powerful intervention. / by Reshmaan Nahar Hussam. / Ph. D.

<p> Health care technology workers play an increasingly important role in meeting regulatory requirements, improving patient care and containing health care costs. However, their perceptions of work and job satisfaction are lightly studied in comparison to other health care workers such as physicians or nurses. This exploratory study used heuristic inquiry to investigate the perceptions of health care technology workers with regard to their feelings of task significance, mission valence, work meaning, and job satisfaction. </p><p> Nine research participants representing three not-for-profit, secular hospital systems which were selected to have variation in geographic scope and organization size were interviewed. All participants were full-time, senior professional, non-executive, employees with a minimum of five years of experience in health care technology and three years with their current employer. </p><p> Thematic analysis revealed themes within four categories: organization culture, organization mission, interactions with clinicians and perceived contribution. These organizations have strong cultures in which staff members police the cultural norms. The inculcation to the culture includes helping health care technology workers connect to the organization&rsquo;s mission of patient care, and these employees perceive the mission to have high valence. While these employees feel that the mission of patient care is important and valuable, they have a conflicted relationship with physicians who they perceive as resistant to the adoption of new technology. Finally, health care technology workers recognized that their work tasks may not directly impact patient care; however, they felt their contribution was meaningful, in particular when they were able to contribute their unique talents. </p><p> Study conclusions and recommendations included how job rotations allowing health care technology workers to work at a care provider site provides an opportunity for health care companies to increase workers&rsquo; feelings of task significance and task identity, and therefore, job satisfaction. Contributing one&rsquo;s unique gift is perceived as meaningful, and workers seek opportunities to do so. Recognizing the importance of these workers and facilitating improved interactions between health care technology workers and physicians particularly with regard to adoption of new technology is seen as critical for ensuring effective and efficient health care delivery.</p>

This study demonstrates that hybrid methods can be used for measuring the risk severity of technology-induced errors (TIE) that result from use of health information technology (HIT). The objectives of this research study include: 1. Developing an integrated conceptual risk assessment model to measure the risk severity of technology-induced errors. 2. Analyzing the criticality and risk thresholds associated with TIE’s contributing factors. 3. Developing a computer-based simulation model that could be used to undertake various simulations of TIE’s problems and validate the results. Using data from published papers describing three sample problems related to usability and technology-induced errors, hybrid methods were developed for assessing the risk severity and thresholds under various simulated conditions. A risk assessment model (RAM) and its corresponding steps were developed. A computer-based simulation of risk assessment using the model was also developed, and several runs of the simulation were carried out. The model was tested and found to be valid. Based on assumptions and published statistics obtained by publically available databases, we measured the risk severity and analyzed its criticality to classify risks of contributing factors into four different classes. The simulation results validated the efficiency and efficacy of the proposed methods with the sample problems. / Graduate / 0723 / 0680 / 0769 / tschio2011@gmail.com

The concept of the project taken from Telemedicine. It is a rapidly developing application of clinical medicine where medical information is transferred through interactive audiovisual media for the purpose of consulting, and sometimes remote medical procedures or examinations. Telemedicine may be as simple as two health professionals discussing a case over the telephone, or as complex as using satellite technology and videoconferencing equipment to conduct a real-time consultation between medical specialists in two different countries. Telemedicine generally refers to the use of communications and information technologies for the delivery of clinical care. Care at a distance (also called in absentia care), is an old practice which was often conducted via post. There has been a long and successful history of in absentia health care which, thanks to modern communication technology, has evolved into what we know as modern telemedicine. In its early manifestations, African villagers used smoke signals to warn people to stay away from the village in case of serious disease. In the early 1900s, people living in remote areas in Australia used two-way radios, powered by a dynamo driven by a set of bicycle pedals, to communicate with the Royal Flying Doctor Service of Australia / Advances in sensor technology, personal mobile devices, and wireless broadband communications are enabling the development of an integrated personal mobile health monitoring system that can provide patients with a useful tool to assess their own health and manage their personal health information anytime and anywhere. Personal mobile devices, such as PDAs and mobile phones, are becoming more powerful integrated information management tools and play a major role in many people's lives. Here I focus on designing a Mobile health-monitoring system for people who stay alone at home or suffering from Heart Disease. This system presents a complete unified and mobile platform based connectivity solution for unobtrusive health monitoring. Developing a hardware which will sense heart rate and temperature of a patient, using Bluetooth modem all information lively transmitted to smart phone, from smart phone all information transmitted to server using GPRS. At server the received data compared with the standard threshold minimum and maximum value. The normal range of heart rate is 60 to 135 and the temperature of the patient is said to be normal above 95^F and below 104^F. If at all the rate increases above 145 or decreases below 55,it may be fatal and if it crossed this threshold limit then SMS will be sent to the relative of patient and Doctors along with measured values. The build-in GPS further provides the position information of the monitored person. The remote server not only collects physiological measurements but also tracks the position of the monitored person in real time. For transmitting data from Smartphone to the server using GPRS, here we need to create a website on data will be continuously transmitted from Smartphone to the website and from website data will be downloaded continuously on the server. Thus the system helps in tracking down the patient without getting the patient into any sort of communication. Undue mishaps can be avoided within the golden hours after a patient is struck with a heart attack.

Increasing health information technology (HIT) adoption has led to growth in research on its implementation and use, the majority of which has been conducted in primary care and medical specialty settings. This thesis comprises three research projects that expand the knowledge base about HIT in surgery. A systematic review summarized the evidence about the effects of major categories of HIT (e.g., electronic health records, computerized order entry) on surgical outcomes and demonstrated improvement in the quality of surgical documentation, increased adherence to guidelines for perioperative prophylactic medication administration, and improvements in patient care with provider alerts. The review identified gaps in the literature about consumer HIT use by surgical patients and providers. A second study demonstrated modest use of a patient portal by surgical patients during hospitalizations and found increased inpatient use for patients who were white, male, and had longer lengths of stay. This study showed that a patient portal designed for the outpatient setting could be employed by surgical patients during hospitalizations. A third study analyzed the nature of the communications in patient portal messages threads between surgeons and their patients. Two-thirds of message threads involved medical care with predominantly straightforward and low complexity decision-making. This study highlighted the need for expanded models for compensation of online care. This thesis provides insights into the use and effects of HIT in surgical practice. As HIT continues to evolve, the unique perspectives of surgical providers and patients should be represented in the design, implementation, evaluation, and regulation of its use.

The adoption rate of health information technology (HIT) remains low in developing countries, where healthcare institutions experience high operating costs and loss of revenue, which are related to systems and processes inefficiency. The purpose of this case study was to explore strategies leaders in Zimbabwe used to implement HIT. The conceptual framework of the study was Davis's technology acceptance model (TAM). Data were gathered through observations, review of organizational documents (i.e., policies, procedures, and guidelines), and in-depth interviews with a purposive sample of 10 healthcare leaders and end-users from hospitals in Zimbabwe who had successfully implemented HIT. Transcribed interview data were coded and analyzed for emerging themes. Implementation strategies, overcoming barriers to adoption, and user acceptance emerged as the themes most healthcare leaders associated with successful HIT projects. Several subthemes also emerged, including: (a) the importance of stakeholder involvement, (b) the importance of management buy-in, and (c) the low level of IT literacy among healthcare workers. The strategies identified in this study may provide a foundation on which healthcare leaders in developing countries can successfully adopt and implement HIT. The recommendations from this study could lead to positive social change by providing leaders with knowledge and skills to use information technology strategies to deliver better healthcare at lower costs while creating employment for local communities.

<p> Mortality rates in the United States are higher for men than they are for women as a result of chronic diseases such as heart disease, cancer, and diabetes. Despite these disproportionate rates, few health interventions are targeted to men, and limited knowledge exists regarding the specific components needed to design technology health tools to appeal to men. The purpose of this quantitative study was to examine the relationship between the use of technology health tools and the role of self-efficacy in men and the influence on participation in healthy lifestyle behaviors. A quasi-experimental design was used to analyze data collected from the Health Information National Trends Survey (<i>N</i> = 990). A group of men (<i>n</i> = 323) who used technology health tools were compared to a control group of men (<i> n</i> = 667) who did not use technology health tools. Results from the regression analysis indicated that the use of technology health tools for self-management of health behavior had a significant effect on participation in healthy lifestyle behavior (<i>p</i> = .026). Self-efficacy was also found to mediate the relationship between technology health tools and participation in healthy lifestyle behavior (<i>p</i> = .018). This study supports the United States federal government's Healthy People 2020 objective to increase the proportion of people who use Internet health management tools. The implications for positive social change include knowledge for developing targeted technology health interventions to increase the participation of men in healthy lifestyle behavior, reduce the number of men with chronic diseases, improve chronic disease management, and reduce healthcare costs in the United States.</p>