Robert Nathenson

Sample attrition increases the risk of statistical bias and hinders the ability to plausibly estimate
causal effects when patterns of nonresponse are correlated with key variables of interest.
Drawing on Leverage-Salience Theory and other work in the behavioral psychology field, we
empirically capture the impact of distinct motivational appeals on the survey response rates of
elementary education teachers in a large urban school district in the northeastern United States.
During… Show more

Sample attrition increases the risk of statistical bias and hinders the ability to plausibly estimate
causal effects when patterns of nonresponse are correlated with key variables of interest.
Drawing on Leverage-Salience Theory and other work in the behavioral psychology field, we
empirically capture the impact of distinct motivational appeals on the survey response rates of
elementary education teachers in a large urban school district in the northeastern United States.
During Spring 2017, teachers were randomized to receive one of six motivational appeals and
were re-randomized to receive a different appeal each subsequent week, conditional on not
having completed the survey. We observe the results on four different margins, which range in
their time intensity (open email and click, start, and complete survey). We find that extrinsic
rewards improved teacher response across all four margins and the social norm of reciprocity
substantially improved teacher response along margins of lower time-intensity. As researchers
continue to conduct multi-treatment arm studies and large-scale evaluations that can suffer from
serious issues of sample attrition, this work highlights the contribution of message framing in
survey response. Show less

Parity in coverage for mental health services has been a longstanding policy aim at the
state and Federal levels and is a regulatory feature of the Affordable Care Act. Despite
the importance and legislative effort involved in these policies, evaluations of their
effects on patients yield mixed results. I leverage the Employee Retirement Income
Security Act (ERISA) and unique claims-level data that includes information on
employers’ self-insurance status to shed new light in this… Show more

Parity in coverage for mental health services has been a longstanding policy aim at the
state and Federal levels and is a regulatory feature of the Affordable Care Act. Despite
the importance and legislative effort involved in these policies, evaluations of their
effects on patients yield mixed results. I leverage the Employee Retirement Income
Security Act (ERISA) and unique claims-level data that includes information on
employers’ self-insurance status to shed new light in this area after the implementation of
two state parity laws in 2007 and federal parity a few years later. My empirics reveal
evidence of strategic avoidance on behalf of insurers in both states prior to the passage of
state parity as well as positive increases in mental health care utilization after parity laws
are implemented – but context matters. Policy heterogeneity across states and strategic
behaviors by employers and commercial insurers substantively shape the benefits that
ultimately flow to patients. Insights from this research have broad relevance to ongoing
health policy debates, particularly as states retain great discretion over many health
coverage decisions and as federal policy continues to evolve. Show less

Direct-to-consumer advertising (DTCA) for prescription drugs is a relatively unique feature of the US health care system and a source of tens of billions of dollars in annual spending. It has also garnered the attention of researchers and policymakers interested in its implications for firm and consumer behavior. However, few economic studies have explored the DTCA response to public policies, especially those mandating coverage of these products. We use detailed advertising expenditure data to… Show more

Direct-to-consumer advertising (DTCA) for prescription drugs is a relatively unique feature of the US health care system and a source of tens of billions of dollars in annual spending. It has also garnered the attention of researchers and policymakers interested in its implications for firm and consumer behavior. However, few economic studies have explored the DTCA response to public policies, especially those mandating coverage of these products. We use detailed advertising expenditure data to assess if pharmaceutical firms increase their marketing efforts after the implementation of relevant state and federal health insurance laws. We focus on mental health parity statutes and related drug therapies—a potentially ripe setting for inducing stronger consumer demand. We find no clear indication that firms expect greater value from DTCA after these regulatory changes. DTCA appears driven by other considerations (e.g., product debut); however, it remains a possibility that firms respond to these laws through other, unobserved channels (e.g., provider detailing). Show less

Objective: The study examines how healthcare utilization patterns change as youths diagnosed with autism spectrum disorder (ASD) transition into the adult healthcare system.

Methods: Data come from the ClinformaticsTM Data Mart Database, a nationally diverse, clinically rich, private insurance claims database. The analytic sample consists of youths 16-23 diagnosed with ASD (N=16,338). Cross-sectional multivariate linear regressions determine if service usage differs by age across the… Show more

Objective: The study examines how healthcare utilization patterns change as youths diagnosed with autism spectrum disorder (ASD) transition into the adult healthcare system.

Methods: Data come from the ClinformaticsTM Data Mart Database, a nationally diverse, clinically rich, private insurance claims database. The analytic sample consists of youths 16-23 diagnosed with ASD (N=16,338). Cross-sectional multivariate linear regressions determine if service usage differs by age across the home, office/outpatient, inpatient, and emergency department (ED) settings.

Results: The proportion of youths with ASD who receive services declines with age in each setting other than the ED. A similar reduction exists in the total number of visits in the office/outpatient and inpatient settings, while home and ED visits remain stable. Youths with co-occurring intellectual disability experience a faster decline in service utilization.

Conclusions: There is a notable decline in service utilization across multiple settings as youths with ASD transition from pediatric to adult healthcare. Show less

OBJECTIVES: To describe and compare pediatric and adult specialty physician networks in marketplace plans.

METHODS: Data on physician networks, including physician specialty and address, in all 2014 individual marketplace silver plans were aggregated. Networks were quantified as the fraction of providers in the underlying rating area within a state that participated in the network. Narrow networks included none available networks (ie, no providers available in the underlying area) and… Show more

OBJECTIVES: To describe and compare pediatric and adult specialty physician networks in marketplace plans.

METHODS: Data on physician networks, including physician specialty and address, in all 2014 individual marketplace silver plans were aggregated. Networks were quantified as the fraction of providers in the underlying rating area within a state that participated in the network. Narrow networks included none available networks (ie, no providers available in the underlying area) and limited networks (ie, included <10% of the available providers in the underlying area). Proportions of narrow networks between pediatric and adult specialty providers were compared.

RESULTS: Among the 1836 unique silver plan networks, the proportions of narrow networks were greater for pediatric (65.9%) than adult specialty (34.9%) networks (P < .001 for all specialties). Specialties with the highest proportion of narrow networks for children were infectious disease (77.4%) and nephrology (74.0%), and they were highest for adults in psychiatry (49.8%) and endocrinology (40.8%). A larger proportion of pediatric networks (43.8%) had no available specialists in the underlying area when compared with adult networks (10.4%) (P < .001 for all specialties). Among networks with available specialists in the underlying area, a higher proportion of pediatric (39.3%) than adult (27.3%) specialist networks were limited (P < .001 except psychiatry).

CONCLUSIONS: Narrow networks were more prevalent among pediatric than adult specialists, because of both the sparseness of pediatric specialists and their exclusion from networks. Understanding narrow networks and marketplace network adequacy standards is a necessary beginning to monitor access to care for children and families. Show less

Recent demographic trends show Latino immigrants moving to “emerging destinations” outside traditional Latino enclaves. Immigrants in emerging destinations with limited English proficiency (LEP) may experience greater challenges finding health care services oriented to their linguistic needs than those in traditional enclaves, especially if the supply of language resources in these areas has not kept pace with new demand. This study uses an experimental audit design to directly compare the… Show more

Recent demographic trends show Latino immigrants moving to “emerging destinations” outside traditional Latino enclaves. Immigrants in emerging destinations with limited English proficiency (LEP) may experience greater challenges finding health care services oriented to their linguistic needs than those in traditional enclaves, especially if the supply of language resources in these areas has not kept pace with new demand. This study uses an experimental audit design to directly compare the ability of uninsured Spanish-speaking LEP adults to access interpreter services and to obtain new patient primary care appointments at Federally Qualified Health Centers (FQHCs) across traditional and emerging destinations. We additionally compare the appointment rates of English-proficient uninsured and English-proficient Medicaid patients across these destinations that contacted the same FQHCs. Results indicate that LEP Spanish-speaking patients within emerging destinations are 40% less likely to receive an appointment than those in traditional destinations. English-proficient groups, by contrast, experience similar levels of access across destinations. Disparities in safety net provider access by destination status are consistent with differences in the availability of bilingual services. Ninety-two percent of FQHCs in traditional destinations offered appointments with either Spanish-speaking clinicians or other translation services, while only 54% did so in emerging destinations. LEP patients denied care in emerging destinations must also travel farther distances than in traditional destinations to reach the next available safety net provider. Our findings highlight that current language resources in emerging destinations may be inadequate for keeping up with the transforming needs of the patient population. As the Latino immigrant population continues to expand and diffuse, better accommodation within the health care safety net is likely to increase in importance. Show less

A young child’s unparalleled belief in the invincibility of his hometown team, the palpable tension of a fanbase in anticipation of their ace’s next pitch, the thrill of a late-August pennant race…these are the sacrosanct moments etched onto the landscape of America’s favorite pastime.

A century ago, winning the pennant meant a berth in the World Series. Players were paid little and had other careers, and fans used words such as integrity to describe the game. Sometime between that era… Show more

A young child’s unparalleled belief in the invincibility of his hometown team, the palpable tension of a fanbase in anticipation of their ace’s next pitch, the thrill of a late-August pennant race…these are the sacrosanct moments etched onto the landscape of America’s favorite pastime.

A century ago, winning the pennant meant a berth in the World Series. Players were paid little and had other careers, and fans used words such as integrity to describe the game. Sometime between that era and this one, the game changed. Free agency, salary jumps, playoff expansion, lucrative media contracts, and instant replay; the modern era of baseball began. Show less