End-of-life expenditures account for 25% of all Medicare spending. Over the past few decades, hospice care, which provides palliative rather than curative care at the end of life, has increased in prominence, being used by 47% of Medicare decedents in 2021. The simultaneous increase in per-patient hospice expenditures during this period has resulted in several policy attempts to rein in spending, though evidence on the impacts of these policies is limited. In this paper, I study hospice responses to a 2016 reform which decreased the profitability of long stays relative to short stays. Using variation in exposure to the policy and a difference-in-differences strategy, I find that this policy resulted in a 9% reduction in the share of long stays for more exposed hospices, with nonprofit hospices exhibiting larger responses through patient selection and for-profit hospices exhibiting larger responses through live discharges. At the patient level, in a sample of Medicare beneficiaries diagnosed with Alzheimer’s/dementia, I document a 7% reduction in hospice admission for those made less profitable by the policy, suggesting meaningful impacts on access to hospice care.

We examine the relationship between physician preferences and both the intensity and cost of care delivered to commercially insured heart attack patients. We match survey data on physician preferences, collected by Cutler, Skinner, Stern, and Wennberg (2019) (CSSW), to medical claims data from the Health Care Cost Institute, which spans over 50 million insurance beneficiaries. In contrast to CSSW, who find strong correlations between aggressive practice preferences and both expenditure and utilization for the Medicare population, we find relationships that are both economically and statistically smaller in magnitude within the commercially insured population. Variations in commercial insurers’ prices appear to play an important mediating role.

We add to the understanding of DEI within the field of environmental economics by examining gender differences in a ubiquitous task in academia that has a large public goods component and where private rewards are uncertain: refereeing. We use the entire universe of submissions to JAERE from 2014-2021 in our analysis, assigning gender based on names of editors and referees. Using manuscript fixed effects and controlling for referee experience, we find that male and female referees in JAERE are similar on several dimensions. An important difference is when referees are late submitting a report, female referees are late by fewer days, and this effect is more pronounced when the handling editor is more senior. Since nearly all other dimensions of the report are the same, we interpret this as female referees putting in more effort conditional on being late. Because perceived reputational consequences are likely most salient along the dimension of lateness rather than other aspects of refereeing which are more subjective (e.g., rejection decisions, word count, etc.), this behavior is consistent with a model in which female referees perceive greater reputational costs for submitting late referee reports.