Keith M. Marzilli Ericson

Time Discounting for Primary Rewards

Previous research, involving monetary rewards, found that limbic reward-related areas show greater activity when an intertemporal choice includes an immediate reward than when the options include only delayed rewards. In contrast, the lateral prefrontal and parietal cortex (areas commonly associated with deliberative cognitive processes, including future planning) respond to intertemporal choices in general but do not exhibit sensitivity to immediacy (McClure et al., 2004). The current experiments extend these findings to primary rewards (fruit juice or water) and time delays of minutes instead of weeks. Thirsty subjects choose between small volumes of drinks delivered at precise times during the experiment (e.g., 2 ml now vs 3 ml in 5 min). Consistent with previous findings, limbic activation was greater for choices between an immediate reward and a delayed reward than for choices between two delayed rewards, whereas the lateral prefrontal cortex and posterior parietal cortex responded similarly whether choices were between an immediate and a delayed reward or between two delayed rewards. Moreover, relative activation of the two sets of brain regions predicts actual choice behavior. A second experiment finds that when the delivery of all rewards is offset by 10 min (so that the earliest available juice reward in any choice is 10 min), no differential activity is observed in limbic reward-related areas for choices involving the earliest versus only more delayed rewards. We discuss implications of this finding for differences between primary and secondary rewards.

Money Earlier or Later? Simple Heuristics Explain Intertemporal Choices Better Than Delay Discounting Does

Heuristic models have been proposed for many domains involving choice. We conducted an out-of-sample, cross-validated comparison of heuristic models of intertemporal choice (which can account for many of the known intertemporal choice anomalies) and discounting models. Heuristic models outperformed traditional utility-discounting models, including models of exponential and hyperbolic discounting. The best-performing models predicted choices by using a weighted average of absolute differences and relative percentage differences of the attributes of the goods in a choice set. We concluded that heuristic models explain time-money trade-off choices in experiments better than do utility-discounting models.

Forgetting We Forget: Overconfidence and Memory

Do individuals have unbiased beliefs, or are they over- or underconfident? Overconfident individuals may fail to prepare optimally for the future, and economists who infer preferences from behavior under the assumption of unbiased beliefs will make mistaken inferences. This paper documents overconfidence in a new domain, prospective memory, using an experimental design that is more robust to potential confounds than previous research. Subjects chose between smaller automatic payments and larger payments they had to remember to claim at a six-month delay. In a large sample of college and MBA students at two different universities, subjects make choices that imply a forecast of a 76% claim rate, but only 53% of subjects actually claimed the payment.

Designing and Regulating Health Insurance Exchanges: Lessons from Massachusetts

The Massachusetts health care reform provides preliminary evidence on the function of health insurance exchanges and individual insurance markets. This paper describes the type of products consumers choose and the dynamics of consumer choice. Evidence shows that choice architecture, including product standardization and the use of heuristics (rules of thumb), affects choice. In addition, while consumers often choose less generous plans in the exchange than in traditional employer-sponsored insurance, there is considerable heterogeneity in consumer demand, as well as some evidence of adverse selection. We examine the role of imperfect competition between insurers, and document the impact of pricing and product regulation on the level and distribution of premiums. Given our extensive choice data, we synthesize the evidence of the Massachusetts exchange to inform the design and regulation on other exchanges.

The articulation of government policy: Health insurance mandates versus taxes

Can the articulation of government policy affect behavior? Participants in our experiment report their probability of purchasing health insurance under one of two financially equivalent policies: a government mandate to purchase insurance or a tax on the uninsured. During our one-year study frame, controversy arose over the Affordable Care Acts individual mandate. Pre-controversy, the mandate articulation increased purchase by 10.2 percentage points relative to the tax articulation (equivalent to a

Cost-Effectiveness Analysis in Markets with High Fixed Costs

1000 decrease in premiums). Post-controversy, the mandate was no more effective than the tax. We show that articulation affects behavior and should be considered when evaluating the efficacy of policy.

A behavioral blueprint for improving health care policy

We consider how to conduct cost-effectiveness analysis when the social cost of a resource differs from the posted price. From the social perspective, the true cost of a medical intervention is the marginal cost of delivering another unit of a treatment, plus the social cost (deadweight loss) of raising the revenue to fund the treatment. We focus on pharmaceutical prices, which have high markups over marginal cost due to the monopoly power granted to pharmaceutical companies when drugs are under patent. We find that the social cost of a branded drug is approximately one-half the market price when the treatment is paid for by a public insurance plan and one-third the market price for mandated coverage by private insurance. We illustrate the importance of correctly accounting for social costs using two examples: coverage for statin drugs and approval for a drug to treat kidney cancer (sorafenib). In each case, we show that the correct social perspective for cost-effectiveness analysis would be more lenient than researcher recommendations.

The Role of Organizational Affiliations in Physician Patient-Sharing Relationships:

Behavioral policy to improve health and health care often relies on interventions, such as nudges, which target individual behaviors. But the most promising applications of behavioral insights in this area involve more far-reaching and systemic interventions. In this article, we propose a series of policies inspired by behavioral research that we believe offer the greatest potential for success. These include interventions to improve health-related behaviors, health insurance access, decisions about insurance plans, end-of-life care, and rates of medical (for example, organ and blood) donation. We conclude with a discussion of new technologies, such as electronic medical records and web- or mobile-based decision apps, which can enhance doctor and patient adherence to best medical practices. These technologies, however, also pose new challenges that can undermine the effectiveness of medical care delivery.

The Impact of Partial-Year Enrollment on the Accuracy of Risk Adjustment Systems: A Framework and Evidence

Provider consolidation may enable improved care coordination, but raises concerns about lack of competition. Physician patient-sharing relationships play a key role in constructing patient care teams, but it is unknown how organization affiliations affect these. We use the Massachusetts All Payer Claims Database to examine whether patient-sharing relationships are associated with sharing a practice site, medical group, and/or physician contracting network. Physicians were 17 percentage points more likely to have a patient-sharing relationship if they shared a practice site and 4 percentage points more likely if they shared a medical group, as compared with sharing no affiliation. However, there was no detectable increased probability of a patient-sharing relationship within the same physician contracting network. Our finding that physician patient-sharing relationships are concentrated within organizational boundaries at practice site and medical group levels helps illuminate referral incentives and provide insight into the role of organizational affiliations in patient care team construction.

Expectations as Endowments: Evidence on Reference-Dependent Preferences from Exchange and Valuation Experiments

Accurate risk adjustment facilitates health-care market competition. Risk adjustment typically aims to predict annual costs of individuals enrolled in an insurance plan for a full year. However, partial-year enrollment is common and poses a challenge to risk adjustment, since diagnoses are observed with lower probability when an individual is observed for a shorter time. Because of missed diagnoses, risk-adjustment systems will underpay for partial-year enrollees, as compared with full-year enrollees with similar underlying health status and usage patterns. We derive a new adjustment for partial-year enrollment in which payments are scaled up for partial-year enrollees’ observed diagnoses, which improves upon existing methods. We simulate the role of missed diagnoses using a sample of commercially insured individuals and the 2014 Marketplace risk-adjustment algorithm and find the expected spending of six-month enrollees is underpredicted by 19 percent. We then examine whether there are systematically different care usage patterns for partial-year enrollees in this data, which can offset or amplify underprediction due to missed diagnoses. Accounting for differential spending patterns of partial-year enrollees does not substantially change the underprediction for six-month enrollees. However, one-month enrollees use systematically less than one-twelfth the care of full-year enrollees, partially offsetting the missed-diagnosis effect.