: Ellen P Green - Home

Ellen P. Green

health and behavioral economist

Contact Information:


Where:
College of Health Solutions
Arizona State University

Email:
Ellen.Green [at] asu [dot] edu

Office Phone:
(602) 496-2879

Fax:
(602) 496-0544

JEBO Special Issue - Experimental and Behavioral Economics of Healthcare

The Journal of Economic Behavior and Organization on experimental studies in health economics. This issue will be edited by James C. Cox, Ellen P. Green, and Heike Hennig-Schmidt. The deadline for submissions is October 31, 2014. When submitting, please select “Health Experiments” as the article type. Submission fees are waived for this special issue.

For more information follow this link: JEBO Special Issue - Experimental and Behavioral Economics of Healthcare

Short CV:

Academic Positions:
Assistant Professor
College of Health Solutions
Arizona State University

Past:
Visiting Assistant Professor
Department of Economics
University of Delaware

Education:
Virginia Polytechnic Institute and State University, Ph.D. December 2011
Dissertation: A Study of Human Decision-Making in Economic Games

Research Interests:
Health Economics, Behavioral Economics, Experimental Economics

Select Fellowships, Honors, and Awards [for complete list see full CV] :
Distinguished Scholar, University of Delaware Honors Program

Lee B. Lusted Award [awarded to the top abstract in behavioral economics], Society for Medical Decision Making

Graduate Instructor of the Year, Department of Economics, Virginia Tech

Publications:
“Payment Systems in the Healthcare Industry: An Experimental Study of Physician Incentives.” Journal of Economic Behavior and Organization [2014]

“Lessons Learned from Implementing the Patient-Centered Medical Home.” joint with John Wendland, Colette Carver, Hughes Cortney, and Sun Ki Mun, International Journal of Telemedicine and Applications [2012] [First Author]

Working Papers:

“Counterfactual Simulations in Experimental Economics: A Study of Blended Physician Payment Systems.”

“Should I stay or Should I Go? An Experimental Study of Decision Support Devices and Hospital Discharge,” joint with Sheryl Ball and Landis Atkinson. [First Author]

Works In Progress:

“Physician Payment Structures in Burkina Faso: An Experimental Study” joint with Sheheryar Banuri

“Adverse Selection in the Healthcare Industry” joint with Hernán Bejarano

Invited Talks:
2015: University of Tennessee

2014: Franklin and Marshall, Rochester Institute of Technology, Creighton University, Bryn Mawr College, University of South Carolina (Arnold School of Public Health), Auburn University, UT Dallas

2013: AEA/ASSA Annual Meetings, Virginia Tech

2012: University of Delaware

2011: University of Pennsylvania (Leonard Davis Institute of Health Economics)

About:

I am a health economist with interests in behavioral economics and experimental design. The goal of my research is to contribute to the understanding of how incentive schemes and other variables impact the efficacy and efficiency of the healthcare industry.

My research focuses on the role of payment structures and other non-monetary motivators in healthcare delivery, a relevant yet poorly understood aspect of the US healthcare system. Through a series of laboratory experiments, I evaluate the quantity and quality of healthcare services induced by physician incentive structures. This research has pertinent policy implications among both developed and developing economies and contributes to several literatures including healthcare incentive structures, real-effort experimental design, and intrinsic motivations in contract design.

My paper, “Payment Systems in the Healthcare Industry: An Experimental Study of Physician Incentives,” explores alternative physician payment mechanisms. This paper demonstrates that the most commonly employed payment mechanisms in the healthcare industry provide poor incentive structures, resulting in undesirable contractual outcomes. For instance, under retrospective payment systems, the experiments suggest that healthcare is overprovided and mistake prone. This paper was honored with the 2011 Lee B. Lusted award in behavioral economics from the Society of Medical Decision Making. Only one paper receives this honor each year in recognition of outstanding and innovative healthcare research. In response to that research, I was invited to present my work at one of the Economic Science Association’s sessions at the 2013 ASSA meetings in San Diego. Additionally, the results of this research has caught the attention of many researchers at academic conferences and in the healthcare industry including Professor Rachel Croson from the University Texas-Dallas who noted the research in her plenary talk at the 2013 ESA meetings.


Past Research:

“Payment Systems in the Healthcare Industry: An Experimental Study of Physician Incentives.” The Journal of Economic Behavior and Organization

Policy makers and the healthcare industry have proposed changes to physician payment structures as a way to improve the quality of health care and reduce costs. Several of these proposals require healthcare providers to employ a value-based purchasing program (also known as pay-for-performance [P4P]). However, the way in which existing payment structures impact physician behavior is unclear and therefore, predicting how well P4P will perform is difficult. To understand the impact physician payment structures have on physician behavior, I approximate the physician-patient relationship in a real-effort laboratory experiment. I study several prominent physician payment structures including fee-for-service, capitation, salary, and P4P. I find that physicians are intrinsically motivated to provide high-quality care and that relying exclusively on extrinsic incentives to motivate physicians is detrimental to the quality of care and costly for the healthcare industry.

“Counterfactual Simulations in Experimental Economics: A Study of Blended Physician Payment Systems.”

In this study, I used counterfactual simulations to predict the impact of blended payment structures on agent behavior. The blended payment structures analyzed included combination of capitation, fee-for-service, salary, and pay-for-performance. I utilized the behavioral responses collected in my laboratory experiment to simulate the response to the blended payment structures. Within the simulation model, I maximize the healthcare provider’s payoff with other-regarding behavior toward the patient to find the optimal payment structure. The simulations indicate that the optimal blend of these payment structures is a combination of the capitation and fee-for-service payment structures, rather than a single incentive scheme.

“Should I stay or Should I Go? An Experimental Study of Decision Support Devices and Hospital Discharge,” [First Author]

joint with Sheryl Ball and Landis Atkinson.

Efforts to reduce frank medical errors and promote evidence-based clinical practice in the U.S. health system have reduced clinical judgment in discretionary decisions. With a specific application to hospital discharge, our experiment expands on Falk, Fehr, and Fischbacher (2008) by exploring how the dissemination of responsibility in clinical decision-making impacts patient outcomes. Our results suggest that when Clinical Decision Support devices are used in place of physician discretion, patients are less likely to penalize their physician for negative outcomes if the patient selects the use of a CDS. This suggests that there is less utility lost for bad outcomes when decisions are made by CDS devices, ceteris paribus.

“Lessons Learned from Implementing the Patient-Centered Medical Home” [First Author]

joint with John Wendland, Colette Carver, Hughes Cortney, and Sun Ki Mun, International Journal of Telemedicine and Applications.2012

The Patient-Centered Medical Home (PCMH) is a primary care model that provides coordinated and comprehensive care to patients to improve health outcomes. This paper addresses practical issues that arise when transitioning a traditional primary care practice into a PCMH recognized by the National Committee for Quality Assurance (NCQA). Individual organizations' experiences with this transition were gathered at a PCMH workshop in Alexandria, Virginia, in June 2010. An analysis of their experiences has been used along with a literature review to reveal common challenges that must be addressed in ways that are responsive to the practice and patients’ needs. These are: NCQA guidance, promoting provider buy-in, leveraging electronic medical records, changing office culture, and realigning workspace in the practice to accommodate services needed to carry out the intent of PCMH. The NCQA provides a set of standards for implementing the PCMH model, but these standards lack many specifics that will be relied on in location situations. While many researchers and providers have made critiques, we see this vagueness as allowing for greater flexibility in how a practice implements PCMH.

Present Research:

Burkina Faso:

My current work expands on the results of my laboratory experiments by further exploring the efficacy of classical physician payment structures in comparison with (1) the novel payment structures developed in my counterfactual simulations and (2) the current proposed policy changes to Burkina Faso’s healthcare system. I am currently collaborating on this research project with Sheheryar Banuri from the World Bank.

Burkina Faso is a low-income country in western Sub-Saharan Africa, which has a low health care utilization rate among their impoverished population. In an attempt to correct their low utilization rate, the Ministry of Health in Burkina Faso has proposed a change to physician payment structures that would reward physicians with a bonus for treating patients below the poverty line. To study the proposal’s effect on physicians’ treatment strategies, we will run a real-effort laboratory experiment with nursing students in Burkina Faso starting this winter.

Nursing students from Burkina Faso’s capital, Ouagadougou, and the surrounding region will be asked to prescribe treatments to patients depicted in 20 distinct medical cases. Each of the medical cases provides the details of a characteristic ailment of citizens in Burkina Faso. The nurses will be reimbursed for their services based on one of several different payment structures including fee-for-service, pay-for-performance, salary, capitation, impoverished-patient bonus, and a blend of these. The patients will be represented by charity organizations, and the nurses’ behavior will directly affect the size of a donation made to the charity organization. The size of the donation will be determined by the quality of the treatment provided by the nurse, that is, the more appropriate a treatment is for the medical case, the higher the donation. The measure of quality (appropriateness) has been calibrated by a preliminary group of nursing subjects. These nurses were asked to rank the potential treatments from best prescription to worst prescription for the ailments described in each of the 20 medical cases.

To distinguish between patients above and below the poverty line, donations will be made to one of two charity organizations on a per case basis. The first charity organization’s mission is to assist underprivileged populations in Burkina Faso. This charity organization acts as the patients below the poverty line. The second charity organization’s mission is to promote the arts and other activities associated with the more privileged members in a society. This charity acts as patients above the poverty line. To capture the change in behavior due to the proposed impoverished-patient bonus for treating citizens below the poverty line, nurses will earn the impoverished-patient bonus for each patient represented by the former charity treated.

Overall, we anticipate a change in behavior based on the treatment group and the charity benefited from the quality of prescription. Specifically, we hypothesize that the bonus payment linked with the impoverished patients will induce the nurses to provide more services to the impoverished patients, while providing fewer than desired services to patients above the poverty line.

The results from the Burkina Faso experiments will contribute to literatures on physician payment structures, specifically performance-based incentives, and healthcare utilization policies in Sub-Saharan Africa. These results will aid in the strategic development of payment structures that are specifically effective in developing countries. We further expect that these findings can translate to developed countries and yield hybrid payment mechanisms that optimize physician performance and patient outcome.

Chapman University: Adverse Selection

On a joint project with Hernan Bejarano at Chapman University, we employ the same experimental design as in Green(2014) to explore the impact of adverse selection on physician behavior. Experiments are in progress.

Future Research:

I plan to continue examining the key variables of physician decision making induced by intrinsic and extrinsic motivations. My approach to exploring these influences is multifaceted. I plan to continue using my real-effort experiments as a foundation for my research and then expand on the experimental design so that I can collect telling data regarding the impact of new variables on agent decision making in a series of laboratory experiments (e.g., repeated games, patient selection, physician selection, etc.). Each new variable introduced to the experimental design will bring the approximation of the healthcare industry closer to reality, while allowing a direct measure of the impact of each variable.

Based on the results of this series of experiments on physician payment structures, I will be able to provide insight into the optimal physician payment structure. The optimal payment structure balances quality of care with the cost of care. With this information in hand, I will team up with medical schools or local healthcare providers to test the efficacy and efficiency of the novel payment structures in the field. During my time at both the University of Delaware and Virginia Tech I have developed relationships with health care providers and local medical schools in the interest of this project. I will use these valuable network connections and the networking experience gained as a springboard for establishing new contacts in the healthcare industry. The benefits of these relationships are twofold: they provide invaluable feedback on incentive structures and implementation, and they offer new venues to test payment scheme efficacy. Through collaborations with the healthcare industry, we can design and implement new, efficient payment mechanisms that optimize patient outcomes.


Teaching:

Teaching Awards:

Graduate Instructor of the Year, 2011

Department of Economics, Virginia Tech

Press Coverage of Teaching:

“Interactive Classroom” UDailyonline edition, October 26, 2012

Teaching Interest:

Micro and Macro Principles of Economics, Microeconomic Theory, Experimental Economics, Health Economics, Money and Banking, Economics of Health Policy

Courses Taught:

University of Delaware

Fall 2012, Spring 2013: Honors Principles of Microeconomics

Spring 2012: Principles of Macroeconomics

Summer 2012–Spring 2013: Money and Banking

Fall 2013: Intermediate Microeconomic Theory

Spring 2014: Honors Colloquium: Behavioral Economics Honors Money and Banking

Virginia Tech

Summer 2009, Fall 2009 and 2011, Spring 2011: Principles of Microeconomics

University of Delaware Student Comments
[selected from end of the year teaching evaluations]:

• [Dr. Green] challenged the class with questions and demonstrations on the board that required the students to really think about and apply the concepts discussed in class.

• [Dr. Green] regularly interjects personal stores / examples of economics in action.

• [Dr. Green] gets the class thinking beyond just the concepts presented in the textbook.

• Her use of technology through research days reinforced the material and showed her willingness for progression in teaching methods.

• I thought Dr. Green did a good job of engaging the class by balancing lecture and discussion. The research days were also particularly helpful.

• Dr. Green is so excited and positive and she really made class fun. She also draws excellent graphs. I really liked that we had a small class and she was able to engage us all and make an economics class bearable.

• Dr. Green's use of the iPad to display notes was really helpful. Notes were easy to read and well organized. It is obvious she knows a lot about her field and tries very hard to apply it to our lives.

• Dr. Green clearly knows the material.

• [Dr. Green] Used real world examples effectively and made the material understandable

• Dr. Green is by far one of the best teachers I have had so far at UDel. She is organized and explains the material thoroughly and in a way that is easy to understand.

• The instructor helped us learn the concepts by showing us graphs and real world examples of economics, which I thought was very helpful. The graphs that the instructor drew made me see the demand and supply for markets. The instructor was very passionate about the subject and she was always willing to answer questions in class.

• Favorite class of the semester, mostly because of Dr. Green's teaching.

• I loved how organized this class was, and it really helped me to understand the information better.

• [Dr. Green was] passionate about the subject; entertaining - I enjoyed coming to class.

• She was always excited to start class and explained things further and effectively if someone asked.

• She was always very enthusiastic about the material and made herself readily available with answering any questions we may have had. Although a short period, I learned a lot from her. By coming to class and filling out her power points and by reading the textbook, I was able to fully absorb the material at hand. I also thought her research days were a great choice because it gave the students a time to actively apply the concepts. In her lectures she also accompanied the terms or concepts with examples, which definitely helped reinforce the material. She did a great job!

• Great. She's nice, fair, and really clear with the way she teaches. Notes are clear and easy to study from. Enthusiastic about econ.

• Dr. Green was a great professor. She made the topics very clear. The research days really helped as hands on examples for the material.

• Dr. Green was an awesome teacher and really nice person. I enjoyed this class and Econ is not one of my strong subjects.

• She's very dedicated and wants students to understand the course not just to pass her exams.

• Professor Green is an outstanding teacher. She makes Econ an informative yet enjoyable class.

• Professor Green was very nice and was always open to questions and discussions. She knew the subject well and provided good examples.


Extra Curricular Activities:

As with any academic, I strive to for a healthy balance between my research, teaching, and extra curricular activities.

While in graduate school, I started running as a form of “motion therapy”. I ran my first 10k in my second year of my PhD program and have since completed several other races including my first half marathon in the fall of 2012 [the hilly Runner’s World Half in Bethlehem, PA].

My passion for running eventually spilled over to swimming and cycling. I have completed 3 Sprint and 2 Olympic Triathlons. Perhaps one of the most gratifying of my accomplishments was beating my older brother in an Olympic Triathlon this past summer. My personal goal is to complete a marathon and a century ride (my longest bike ride to date is 92 miles).

I also enjoy hiking and have trekked several mountains up and down the east coast. My most recent victory was climbing Mount Washington via Huntington’s Ravine. Huntington’s Ravine is noted as the most difficult trail in the White Mountains and it lives up to its name.

Of course one must balance exercise with a healthy amount of culinary experimentation. Over the past couple of years I have sought to find the optimal recipe for several baked goods.

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