Search

In my research, I use modern industrial organization theory and econometrics to study the impact of behavioral frictions among buyers and sellers in different market environments on market outcomes and welfare. Following the seminal works of Becker (1957) and Arrow (1972), it is common knowledge that market competition mitigates such non-cognitive frictions as employer taste-based prejudice. Hence, it is not surprising that today, almost half a century after Kahneman and Tversky (1979) introduced their Prospect Theory, many economists believe that market forces —the invisible hands of sophisticated profit-maximizing suppliers—mitigate supply-side cognitive-based frictions as well. In my research, I challenge these popular views and show that market forces do not necessarily compete away the effects of behavioral cognitive or non-cognitive frictions in firm pricing and employment.The dissertation consists of three chapters: (i) "Behavioral Professionals: Evidence From the Commercial Auto Insurance Industry," (ii) "Price and Prejudice: Customer Taste-Based Discrimination and Competition," and (iii) "The Lemons Gap: Demand For Insurance of Quality Uncertain Goods."In Chapter 1, I present my work "Behavioral Professionals: Evidence From the Commercial Auto Insurance Industry." A cornerstone of the IO study of selection markets is that competition disciplines sellers to customize coverage and premiums optimally. But is this the case? Using data from one of the largest Israeli commercial auto insurance providers, an affiliate of a multinational insurance company, I find there is too little adjustment in the intensive margin. Premiums barely change with expected costs as projected by pre-determined factors (vehicle age) and signals (claim history). At the same time, I find there is too much adjustment in the extensive margin, with an excessive denial of insurance in response to recent claims. Using unique grading documents, I integrate the insurer’s subjective risk assessment into the study of insurance markets. I find that the insurer's risk assessment outweighs recent claims and misevaluates vehicle age. Structural model estimates suggest that insurers enjoy incumbency advantages over their own customers, and clients are rationally inattentive to competitors’ pricing unless they are faced with a price increase. Both channels allow sub-optimal behavior to persist. Finally, I find that supply-side behavioral frictions, which result in excessive denial, mainly harm disadvantaged customers - single-fleet clients of old vehicles\textemdash and diminish with the client's fleet size. In Chapter 2, I present my work "Price and Prejudice: Customer Taste-Based Discrimination and Competition." This work investigates the effect of competition on the incidence of tastes for discrimination. The model shows that monopolistic sellers discipline discriminatory buyers by taxing their taste for discrimination. In equilibrium, monopolistic sellers hire a lower share of White workers and pay them a lower premium than sellers in a competitive market. These results are tested in the context of the US banking deregulation that affected product market competition, and I quantify its impact on customer-driven labor market discrimination. Using Census/ACS data from 1960 to 2010, O*NET measures of job requirements, and GSS measures of discriminatory attitudes against Black by state, I find that the Black-White wage and employment gaps increased following bank deregulation in jobs requiring intensive contact with clients, especially in states with high measures of prejudicial preferences.In Chapter 3, I present my work "The Lemons Gap: Demand For Insurance of Quality Uncertain Goods." This work studies the difference between insuring a quality uncertain good and a monetary loss. I integrate key insights from the pre-owned market into the analysis of the demand for insurance. I find that adverse selection in the resale market results in a missing insurance market. There's a gap between the insured vehicle and the resale market’s quality, especially for new vehicles. As a result, clients over-insure their quality uncertain goods, yet demand drops over the vehicle life cycle. The partial compensation further amplifies over-insurance patterns driven by behavioral attributes. The gap results in time trends. As the vehicle ages, demand drops, the insurance market is more adversely selected, and moral hazard increases. The incomplete compensation can result in context-dependence demand for insurance, customers' over-insurance limited risk, in general, and for durable goods, in particular.

The efficacy comparison of osteoporosis treatments can be hindered by the absence of head-to-head trials; instead, network meta-analyses (NMAs) have been used to determine comparative effectiveness. This study was the first to investigate the impact of time point-specific NMAs of osteoporosis treatments on variability in treatments' onset of action caused by their different mechanisms of actions and trial designs.A systematic literature review was conducted to identify randomized controlled trials (RCTs) of treatments for postmenopausal women with osteoporosis, including romosozumab (ROMO), teriparatide (TPTD), abaloparatide (ABL), alendronate (ALN), risedronate (RIS), ibandronate (IB), zoledronic acid/zoledronate (ZOL), denosumab (DEN), and raloxifene (RLX), on at least 1 fracture or bone mineral density (BMD) outcome. Of 100 RCTs identified in 5 databases, 27 RCTs were included for NMAs of new vertebral, nonvertebral, and hip fracture outcomes at 12, 24, and 36 months, and 47 RCTs were included for NMAs of BMD outcomes at lumbar spine, total hip, and femoral neck to compare the relative efficacy of osteoporosis treatments. Quality of included studies was assessed using the Cochrane Risk of Bias tool.For vertebral fractures, TPTD (83.63%), ABL (69.11%), and ROMO/ALN (78.70%) had the highest probability to be the most effective treatment at 12, 24, and 36 months, respectively. ROMO/ALN had the highest probability (54.4%, 64.69%, and 90.29%, respectively) to be the most effective treatment for nonvertebral fractures at 12, 24, and 36 months. For hip fractures, ROMO/ALN (46.31%), ABL (61.1%), and DEN (55.21%) had the highest probability to be the most effective treatment at 12, 24, and 36 months, respectively. ROMO had the highest probability (76.06%, 44.19%, and 51.78%, respectively) to be the most effective treatment for BMD outcomes at lumbar spine, total hip, and femoral neck.The importance of indirectly comparing available osteoporosis treatments using time point-specific NMAs was confirmed because indirect comparison results differed substantially across time points.

Supplemental Digital Content is available in the text., Background: Many health plans have outreach programs aimed at appropriately screening, evaluating, and treating women experiencing fragility fractures; however, few programs exist for men. Objective: The objective of this study was to develop, implement, and evaluate an osteoporosis outreach program for men with a recent fragility fracture and their physicians. Research Design and Subjects: A total of 10,934 male patients enrolled in a Medicare Advantage with Prescription Drug Plan with a recent fragility fracture were randomized to a program or control group. Patients and their physicians received letters followed by phone calls on osteoporosis and the importance of screening and treatment. The evaluation compared bone mineral density (BMD) test utilization and osteoporosis medication treatment (OPT) among patients who received the outreach versus no outreach at 12 months. The effect of the program was estimated through univariate and multivariable logistic regressions. Results: The program had a significant impact on BMD evaluation and OPT initiation. At 12 months, 10.7% of participants and 4.9% of nonparticipants received a BMD evaluation. The odds ratio (OR) (95% confidence interval) was 2.31 (1.94, 2.76), and the number needed to outreach to receive a BMD test was 18. OPT was initiated in 4.0% of participants and 2.5% of nonparticipants. The OR (95% confidence interval) of receiving OPT was 1.60 (1.24, 2.07), and the number needed to outreach was 69. Adjusted ORs were similar in magnitude and significance. Conclusion: The program was highly effective by more than doubling the rate of BMD evaluation; however, more intensive interventions may yield an even higher screening rate.

Background and objectives Calcimimetic drugs used to treat secondary hyperparathyroidism are being considered for inclusion in the Medicare ESRD Prospective Payment System bundle after an evaluation period. Understanding of utilization patterns of calcimimetics across dialysis facilities may help align financial incentives with clinical objectives. Our study’s purpose was to describe the distribution of cinacalcet prescription across United States hemodialysis facilities and to explore factors that may influence cinacalcet utilization. Design, setting, participants, & measurements We used monthly cross-sectional data from the Dialysis Outcomes and Practice Patterns Study in 2014 to characterize the distribution of cinacalcet prescription across 203 United States hemodialysis facilities (10,521 patients). On the basis of associations with parathyroid hormone levels from patient-level analyses, we used linear mixed-effects regressions to estimate the associations between three facility-level exposures (black race, Results The mean percentage of patients in each facility with cinacalcet prescription was 23% in June 2014 (median, 22%; interquartile range, 13%–30%). Adjusted for facility-level and nonexposure patient-level variables, the difference in prevalence of cinacalcet prescription between facilities with the highest and lowest quartiles of percentage of black patients was 7.8% (95% confidence interval [95% CI], 0.8% to 14.8%; P for trend =0.03). The adjusted prevalence difference was 7.3% for the percentage of patients aged Conclusions Facilities treating more patients who are black, under age 65 years, and having dialysis vintage ≥3 years have higher average levels of cinacalcet prescription. However, these differences were strongly attenuated after accounting for the unbalanced distributions of these patient case-mix variables.

Background The use of social media by students in professional health programs has led to concerns about social networking site (SNS) content, and colleges and universities are deciding whether they should provide guidance for students regarding professional online content. Objective The primary objective was to evaluate the validity of an instrument used to assess student pharmacists’ comfort level and concerns regarding SNS. A secondary objective was to describe students’ perceptions of and concerns about specific SNS behaviors at one college of pharmacy. Methods In 2009, a 24-item questionnaire was distributed to students enrolled at the University of Arizona College of Pharmacy. The first section of the questionnaire (nine questions) asked students to indicate their level of agreement with specific SNS behaviors. The second section (eight questions) requested students to state their level of concern with specific unprofessional SNS behaviors. Rasch analysis was performed to assess reliability and validity. Results A total of 292 students submitted completed questionnaires (74% response rate). Facebook was the primary SNS used. Respondents indicated that they would not send a friend request to or accept a friend request from a faculty member. Students were most concerned about online posting of profanity and least concerned with online posting of unprofessional content affiliated with the pharmacy profession. Conclusions Student pharmacists were uncomfortable networking with faculty or future employers, and their lack of concern with the potential unprofessional online posts could raise some legal and ethical issues for colleges of pharmacy, especially those without a social media policy.

Overactive bladder (OAB) is a common medical condition with significant economic and humanistic burden. Inadequately managed OAB may exacerbate or result in comorbidities such as depression, falls, and urinary tract infections, which can further increase the burden to the health care system. Anticholinergics are often prescribed for management of OAB with urinary incontinence ("wet" OAB). However, research has shown that patient adherence and persistence to anticholinergic therapy is poor, with approximately 80% of patients ultimately failing their first prescribed anticholinergic medication within the first year. While there has been a fair amount of research on the economic burden of OAB, the real-world impact of initiating anticholinergic therapy in patients with wet OAB has not been well studied.To compare falls/fractures, anxiety/depression, health care resource utilization, and health care costs between a cohort of patients with wet OAB who initiated anticholinergic therapy and a matched cohort of patients without OAB.This study was a retrospective medical and pharmacy claims analysis. Cases were members of a primary care-based, multispecialty physician medical group located in California. Cases were eligible for inclusion if they were prescribed anticholinergic therapy between January 2008 and May 2012 based on pharmacy claims, had a diagnosis of OAB, and reported having ≥ 1 urinary incontinence episode per day. Wet OAB cases were matched to non-OAB controls in a 1:3 ratio based on sex, age, and observation time. Medical and pharmacy claims data were used to analyze patient comorbidities, as well as track health care resource utilization (HRU) and direct payer costs.After initiating anticholinergic therapy, wet OAB patients had a 46% higher adjusted risk of experiencing falls/fractures (P0.001) and a 33% higher adjusted risk of experiencing depression/anxiety (P = 0.022) than non-OAB patients. Wet OAB was significantly associated with increased HRU rates of hospital admissions, outpatient visits, prescriptions filled, and diagnostic tests performed. After adjustment for covariates, total health care cost was 33% higher for wet OAB patients than non-OAB patients, resulting in an increased cost of $1,746 per member per year.The findings of this research suggest OAB patients who initiate anticholinergic therapy and still experience incontinence are at a greater risk for comorbidities such as falls/fractures and depression/anxiety, and use significantly more health care resources, than patients without OAB. Programs to improve patient monitoring and referrals, the appropriate use of alternative treatments within guidelines, and adherence to evidence-based practice parameters may improve clinical outcomes and decrease HRU for these patients.This study was sponsored by Allergan, Irvine, California, which reviewed and approved the final manuscript. At the time of the study, Yehoshua had received a fellowship at the University of Arizona, which was funded by Allergan. Yehoshua, Joshi, and Campbell are employees of Allergan. Vasaveda has received consulting fees from Allergan, Medtronic, and Boston Scientific. Chancelor has received consulting fees from Allergan and Medtronic. All authors met the ICMJE authorship criteria. Neither honoraria nor payments were made for authorship. Study design was created by Yehoshua, Pulicharam, Malone, and Armstrong. Pulicharam took the lead in data collection, along with Chancellor and Campbell, and data interpretation was performed by Chancellor, Vasavada, Malone, and Armstrong. The manuscript was written by Yehoshua and revised by Joshi and Yehoshua, with assistance from the other authors.

To describe treatment patterns and outcomes in wet-overactive bladder (OAB) patients treated with anticholinergics.This study was a retrospective claims analysis linked to a one-time patient survey of members of a regional medical group located in California. Participants met the following criteria: received anticholinergic therapy between January 2008 and May 2012, based on pharmacy claims; had a diagnosis of OAB; and reported having ≥1 urinary incontinence (UI) episode per day at the time of the survey. Outcomes included the number of anticholinergics cycled through from treatment initiation until the end of follow-up (May 31, 2013); frequency of UI episodes; and patient requests for additional help for their OAB symptoms.A total of 620 patients were enrolled into the study. During the follow-up period, patients cycled through 1 to 6 unique anticholinergics; 65 % of the study population used only 1 anticholinergic, while 35 % used ≥2 anticholinergics. Patients reported experiencing an average of 3.5 UI episodes per day (3.6, 3.3, and 3.4 episodes for 1, 2, and ≥3 anticholinergics used, respectively), and over 80 % of patients requested additional help for their OAB symptoms, irrespective of how many anticholinergics were attempted.UI symptom burden and adherence to therapy did not change as patients attempted more anticholinergic therapies. These results suggest that for patients who remain incontinent after attempting an anticholinergic, cycling on additional anticholinergics may not provide any additional benefit, resulting in sub-optimal care.