Research

Waiting Time and Demand for Care in Elective Surgery (JOB MARKET PAPER) — Draft

Waiting times are a key rationing mechanism in health care systems. While they do not impose direct monetary costs, they generate substantial indirect costs—such as pain, deterioration in health status, income loss, and the need for caregiving. This paper examines how waiting times affect individuals' decisions to seek elective surgery and provider choice when there is a faster but more costly private alternative. I use rich administrative data from Chile's public insurer (Fonasa), linking waiting list records, private claims, and public hospital discharges. Exploiting exogenous variation from a policy that caps waiting times for gallstone surgery and hip replacement at specific ages, I find that the shorter waiting times at the prioritization age threshold increase care-seeking by 28.3% for gallstone surgery and 13.5% for hip replacement, with respect to the waiting time level at non-prioritized ages. This response is primarily driven by lower-income patients, who choose to forgo care to a greater extent when waiting times are long, suggesting that waiting time as an allocation mechanism is not absent from equity concerns. For gallstones, the effect is also larger among low-severity individuals, and shorter waits reduce emergency admissions, resulting in a 6% net increase in treatment. These estimates are equivalent to a waiting time elasticity of -0.38, -0.25, and -0.08, respectively. In addition, public sector utilization rises as private care use declines by 27.9% and 5.9% for the two procedures, respectively (equivalent to a cross waiting time elasticity of 0.37 and 0.11).

The Impact of Information Systems on Experts' Decisions: Evidence from Physicians (with Jorge Alé-Chilet, Juan Pablo Atal, and Martín González) — Submitted

Draft available upon request

How do professionals respond to computerized, data-driven guidance in practice? We analyze a workers’ compensation insurance program where physicians make coverage and diagnosis decisions. We study the introduction of an automated system that flagged diagnoses with historically low coverage. We develop a model that yields testable predictions to distinguish between informational and persuasive effects. Consistent with persuasion, physicians granted coverage less often when confronted with alerts, but they also avoided alerts by recoding diagnoses. Data from secondary reviews show that the system aligned physicians’ decisions with management’s preferences. These findings provide lessons for the design of information systems for decision-makers.

Does Hospital Consolidation Promote Quality? Organizational and Strategic Issues (with Robert Burns, Mark Pauly, and Michael Sielski)

Organizational and strategic issues. Health Care Management Review, January/March 2026, Volume 51, Issue 1.

The paper discusses why quality benefits from hospital consolidation are not often observed. The paper documents the ambivalent effects of consolidation on quality, which repeatedly manifest themselves in theory, a conceptual model, and several literature reviews. One explanation for the mixed results are methodological issues that hamper model estimation; another explanation is the two-stage conceptual model. In the first stage, hospitals consolidate to pursue organizational changes and strategic goals, some of which may target quality. In the second stage, such changes can exert quality impacts, but not necessarily. Most research focuses on the second stage rather than the first; research on the first is more indirect.

Hospital Consolidation and Quality: Opening the Behavioral Black Box (with Robert Burns, Mark Pauly, and Michael Sielski)

Social Science & Medicine, 118593.

Compared to its impact on price and cost, much less is known about the impact of hospital consolidation on quality. This is remarkable given that prospective quality improvements are often the main benefit cited by consolidation proponents. This paper develops a two-part conceptual model that explores the circumstances and motivations under which consolidating hospitals would also decide to take actions which increase quality. It briefly reviews more than three decades of research findings that provide little evidence for claims of improved quality from consolidation. It analyzes four sets of circumstances that might predict such quality-improving actions, and finds little evidence that any of them follow mergers. The paper explores firm profit maximization as the hospital’s objective but then considers an alternative model in which any financial surplus generated by consolidation is be invested in quality improvement by a utility-maximizing nonprofit firm.

Hospital Mergers and Quality: Lessons from a Recent Antitrust Case (with Robert Burns, Mark Pauly, and Michael Sielski)

CPI Antitrust Chronicle, October 2024.

The recent rise in hospital mergers across the United States has been accompanied by extensive evidence of higher average costs and unit prices following consolidation. However, the impact of mergers on hospital quality remains less explored, despite acquirers frequently citing quality improvements as a key benefit. This paper examines a 2024 hospital antitrust case in a U.S. District Court to assess the validity of the “quality-enhancing” merger defense. Using data from the Centers for Medicare and Medicaid Services (CMS) Hospital Care Compare database, we evaluate (1) current quality differences between the acquiring hospital system and the rural hospital targeted for acquisition, (2) whether these differences are statistically significant, (3) whether the target hospital’s quality metrics are declining—either absolutely or relative to the acquirer—and (4) whether two prior acquisitions by the same system led to measurable quality improvements. Our findings indicate that the target hospital performed as well as, or better than, the acquiring system on several quality measures, with improving trends over time. In contrast, quality outcomes within the acquirer’s system remained largely unchanged, and prior acquisitions were followed by quality declines. Lower-performing hospitals did not converge toward higher-performing ones within the system but instead diverged further. Overall, the evidence suggests that the rural hospital under review did not require a merger to prevent a decline in quality, undermining the acquirer’s stated defense.

Responses to COVID-19 in five countries of Latin America (with Carolina Velasco, Ana Rita Sequeira, Josefa Henríquez, Flavio Meneses, and Francesco Paolucci)

Published in Health Policy and Technology (2020), 9(4): 525-59

COVID-19 reached Latin-American countries slightly later than European countries, around February/March, allowing some emergency preparedness response in countries characterized by low health system capacities and socioeconomic disparities. This paper focuses on the first months of the pandemic in five Latin American countries: Brazil, Chile, Colombia, Ecuador and Peru. It analyses how the pre-pandemic context, and the government’s responses to contain and mitigate the spread together with economic measures have affected the COVID-19 health outcomes. Extensive qualitative document analysis was conducted focused on publicly-available epidemiological data and federal and state/regional policy documents since the beginning of the pandemic. We find that countries were quick to implement stringent COVID-19 measures and incrementally scaled up their health systems capacity, although tracing and tracking were poor. In addition, pre-pandemic conditions that characterize these countries (high informal employment, and social inequalities) have undermined the effectiveness of the countries’ responses to the pandemic. All five countries have experienced a large number of cases and deaths due to COVID-19. The analysis on the excess deaths also shows that the impact on deaths is far higher than the official numbers reported to date for some countries.

Health inequalities: Gap in access and use between locals and immigrants (with Carolina Velasco; in Spanish)

In Isabel Aninat and Rodrigo Vergara (editors): Immigration in Chile: A multidimensional view (2019); Santiago, Chile: Fondo de Cultura Económica.