Work in Progress
with David C. Chan, Nancy L. Keating, Bruce E. Landon, and Michael L. Barnett
Working Paper · NBER SI Presentation
Abstract
Specialization enhances professional productivity, but its benefits depend on access to the relevant expertise. In oncology, subspecialization—the narrowing of clinical focus within cancer care—has become increasingly common, yet its effects on patient outcomes remain poorly understood. This paper examines the impact of physician subspecialization in medical oncology on patient outcomes, health care spending, and access to innovation. Using detailed US Medicare data on 2.2 million first-time chemotherapy episodes from 2008 to 2020, we exploit quasi-random variation in access to subspecialized oncologists through a differential distance instrument. We find that access to a subspecialist reduces three-year mortality by up to 10 percent relative to the mean, without increasing total Medicare spending. Subspecialist care also increases the use of newer chemotherapy agents and more than doubles enrollment in clinical cancer trials—particularly for trials aligned with the patient’s cancer type. Falsification and selection analyses support the identifying assumptions and suggest that observed gains reflect differences in treatment pathways rather than patient selection. These findings provide new evidence on the productivity effects of specialization in a non-routine, knowledge-intensive profession, and underscore the organizational trade-offs involved in delivering complex care.
Working Paper
Abstract
The establishment of hydroelectric power plants resulted in a rapid structural transformation of Norwegian municipalities around the beginning of the 20th century. Using a novel dataset linking individuals born between 1890 and 1910 to historic death data, I find that experiencing childhood in rapidly transforming local areas leads to an increase of ten months in age at death for men. This effect is entirely driven by individuals born into higher socioeconomic status households. I find that incomes, manufacturing, immigration and economic inequality in local areas in the short/medium-term increase after the introduction of hydropower, while public health deteriorates at the same time. This suggests that, in the long term, economic development through structural transformation outweighs the negative consequences of a deteriorating public health environment and thereby increases the lifespan of individuals.