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Abstract

The topic of this defense is the extent policy studies can be used to address current problems in healthcare policy. As the subtitle states, the dissertation will present three essays on the topic of the subjective made objective. The first and second papers investigate the ramifications of two present policies, which attempted to reshape payments to fairly reflect two subjective quantities: patient need for inpatient psychiatric care and physician work, respectively. In both cases, unintended consequences can impact our interpretation of these policies and their repercussions, though these unintended consequences require some canniness to measure. The third paper is a departure from this tact. It will critique a commonplace measure for subjective mental health and give my suggested improvements. ,In the first paper, I examine the assertion that there is substitutability in the populations of psychiatric hospitals, medical hospitals, and jails. I suggest that abrupt changes in psychiatric bed supply in local-area time series can supply a source of exogenous variation to examine the effects of psychiatric beds on hospitalizations and jail populations in the short-run. I present some evidence in favor of a previous claim that psychiatric bed reductions result in patient spillovers across settings, however, I also present some caveats. Some patients are much more likely to spill between settings than others and the effect of bed additions is not simply the inverse effect of bed reductions. ,In the second paper, I investigate the extent to which medical specialty representation on a committee may have affected medical payments. The committee, the Resource-Based Relative Value Scale Update Committee, is charged with assigning a price for subjective physician work in Medicare. I examine whether rotating specialty representation correlates with specialty-specific payments, potentially exacerbating a generalist-specialist income gap. I find that rotating representation and specialist payments are indeed correlated, and in such a way that specialties prefer to raise the reimbursements most sharply on the procedures that are most unique to them.,In the third paper, I describe some limitations of the current measures of mental health. I perform some tests to reveal properties of mental health metrics that could be useful for investigators. Most importantly, I recommend more adaptable metrics be used for policy studies with methods of analysis borrowed from the psychometrics or clinical psychiatry literature rather than the wholesale borrowing of instruments. In other words, I wade into the perils of subjective measurement myself.

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