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Background: Recent Alzheimer’s disease (AD) genetics findings from genome-wide association studies (GWAS) span progressively larger and more diverse populations and outcomes. Currently, there is no up-to-date resource providing harmonized and searchable information on all AD genetic associations found by GWAS, nor linking the reported genetic variants and genes with functional and genomic annotations. Objective: Create an integrated/harmonized, and literature-derived collection of population-specific AD genetic associations. Methods: We developed the Alzheimer’s Disease Variant Portal (ADVP), an extensive collection of associations curated from >200 GWAS publications from Alzheimer’s Disease Genetics Consortium and other consortia. Genetic associations were systematically extracted, harmonized, and annotated from both the genome-wide significant and suggestive loci reported in these publications. To ensure consistent representation of AD genetic findings, all the extracted genetic association information was harmonized across specifically designed publication, variant, and association categories. Results: ADVP V1.0 (February 2021) catalogs 6,990 associations related to disease-risk, expression quantitative traits, endophenotypes, or neuropathology. This extensive harmonization effort led to a catalog containing >900 loci, >1,800 variants, >80 cohorts, and 8 populations. Besides, ADVP provides investigators with a seamless integration of genomic and publicly available functional annotations across multiple databases per harmonized variant and gene records, thus facilitating further understanding and analyses of these genetics findings. Conclusion: ADVP is a valuable resource for investigators to quickly and systematically explore high-confidence AD genetic findings and provides insights into population-specific AD genetic architecture. ADVP is continually maintained and enhanced by NIAGADS and is freely accessible at https://advp.niagads.org.

There exists extensive literature analyzing the effect of sibship size and a child’s educational attainment, termed the quantity-quality (QQ) trade-off. Studies using data from developed countries tend to find limited or nonexistent effects, while studies that use data from developing countries find a wide range of relationships. We study a possible explanation for these seemingly contradictory findings that the existence or non-existence of a QQ trade-off is correlated with the socioeconomic context within which the family resides. We use the census files comprised of the entire Taiwan population in the years 1980, 1990, and 2000, reflecting different levels of economic growth across time, coupled with an instrumental variable approach and more than 7000 village fixed effects. Our results indicate that sibship size has large and significant effects on educational outcomes, measured in terms of high school and college enrollments, for early birth cohorts, and the effects diminish for more recent birth cohorts. In addition, we find that areas in different developmental stages face different QQ trade-offs: areas with higher levels of development only have trade-offs among higher measures of quality.

BACKGROUND Patients may use two information sources about a health care provider’s quality: online physician reviews, which are written by patients to reflect their subjective experience, and report cards, which are based on objective health outcomes. OBJECTIVE The aim of this study was to examine the impact of online ratings on patient choice of cardiac surgeon compared to that of report cards. METHODS We obtained ratings from a leading physician review platform, Vitals; report card scores from Pennsylvania Cardiac Surgery Reports; and information about patients’ choices of surgeons from inpatient records on coronary artery bypass graft (CABG) surgeries done in Pennsylvania from 2008 to 2017. We scraped all reviews posted on Vitals for surgeons who performed CABG surgeries in Pennsylvania during our study period. We linked the average overall rating and the most recent report card score at the time of a patient’s surgery to the patient’s record based on the surgeon’s name, focusing on fee-for-service patients to avoid impacts of insurance networks on patient choices. We used random coefficient logit models with surgeon fixed effects to examine the impact of receiving a high online rating and a high report card score on patient choice of surgeon for CABG surgeries. RESULTS We found that a high online rating had positive and significant effects on patient utility, with limited variation in preferences across individuals, while the impact of a high report card score on patient choice was trivial and insignificant. About 70.13% of patients considered no information on Vitals better than a low rating; the corresponding figure was 26.66% for report card scores. The findings were robust to alternative choice set definitions and were not explained by surgeon attrition, referral effect, or admission status. Our results also show that the interaction effect of rating information and a time trend was positive and significant for online ratings, but small and insignificant for report cards. CONCLUSIONS A patient’s choice of surgeon is affected by both types of rating information; however, over the past decade, online ratings have become more influential, while the effect of report cards has remained trivial. Our findings call for information provision strategies that incorporate the advantages of both online ratings and report cards.

Alzheimer’s Disease (AD) genetics has made substantial progress through genome-wide association studies (GWASs). An up-to-date resource providing harmonized, searchable information on AD genetic variants with linking to genes and supporting functional evidence is needed.We developed the Alzheimer’s Disease Variant Portal (ADVP), an extensive collection of associations curated from >200 GWAS publications from Alzheimer’s Disease Genetics Consortium (ADGC) and other researchers. Publications are reviewed systematically to extract top associations for harmonization and genomic annotation.ADVP V1.0 catalogs 6,990 associations with disease-risk, expression quantitative traits, endophenotypes and neuropathology across >900 loci, >1,800 variants, >80 cohorts, and 8 populations. ADVP integrates with NIAGADS Alzheimer’s GenomicsDB where investigators can cross-reference other functional evidence.ADVP is a valuable resource for investigators to quickly and systematically explore high-confidence AD genetic findings and provides insights into population- and tissue-specific AD genetic architecture. ADVP is continually maintained and enhanced by NIAGADS and is freely accessible (https://advp.niagads.org).

Our study examines a case where cross-border air pollution had not been effectively dealt with by a decentralized, state level policymaking, letting a coal-fired power plant located on the border between two states pollute the downwind state for years without being controlled. We find that the shutdown of the power plant, thanks to a landmark ruling by the federal government, reduces the likelihoods of having a low birth weight baby and having a preterm birth by 15 percent and 28 percent, respectively, in areas downwind of the power plant. The ruling marks the first-ever federal level regulation under the Clean Air Act that overrides state-level regulations and is directly imposed upon a single pollution source. Our empirical setting emphasizes the importance of such regulation in curbing environmental free riding induced by jurisdictional borders, where pollution cost-shifting can be aided by natural forces such as prevailing winds.

To examine the infant health impact of prenatal exposure to power plant emissions, we draw scientific evidence on the impacted region downwind of a large polluter, a coal-fired power plant located on the border of two states and proven to be the sole contributor to the violation of air quality standards of the impacted region. Our results show that among all live singleton births that occurred during 1990 through 2006, those born to mothers living as far as 20 to 30 miles away downwind from the power plant (which is also an affluent region) during pregnancy are at greater risks of low birth weight (LBW) and very low birth weight (VLBW): the likelihoods of LBW and VLBW could increase approximately by 6.50 and 17.12 percent, respectively. In light of the continual efforts of The U.S. Environmental Protection Agency in reducing cross-state air pollution caused by transboundary power plant emissions, our study is aimed at broadening the scope of cross-border pollution impact analysis by taking into account adverse infant health effects of upwind polluters, which can impose disproportionate burdens of health risks on downwind states due to air pollutants transported by wind.

Since Wakefield et al. (1998), the public was exposed to mixed information surrounding the claim that measles-mumps-rubella vaccine causes autism. A persistent trend to delay the vaccination during 1998-2011 in the US was driven by children of college-educated mothers, suggesting that these mothers held biases against the vaccine influenced by the early unfounded claim. Consistent with confirmatory bias, exposures to negative information about the vaccine strengthened their biases more than exposures to positive information attenuated them. Positive online information, however, had strong impacts on vaccination decisions, suggesting that online dissemination of vaccine-safety information may help tackle the sticky misinformation.

This paper studies the effect of family size on parents' labor supply and occupational prestige, using the censuses of both Taiwan and Mainland China. We rely on the exogenous increase in child quantity that results from having twins at the first birth. Our results indicate that an increase in family size has negative effects on the labor supply of mothers but not of fathers, in both Taiwan and Mainland China. In addition, we find that in Taiwan fathers tend to switch to occupations with lower prestige scores in response to an increase in family size. However, the negative effect of family size on occupational prestige is not observed in Mainland China, where the occupational mobility is low.

In this paper, we assemble five large administrative data sets in Taiwan to investigate the short-run and long-run effects of birth weight. Comparing with previous studies, our results are more precisely estimated due to the large sample size. Using administrative data sets, the problems arising from self-reported samples are also mitigated. Moreover, we are able to examine both singletons by controlling sibling fixed effects and twins by controlling twin fixed effects. Our results show that an infant's birth weight has positive influence on health and education. Our twin fixed-effects estimates confirm the finding of a long-lasting, but diminishing in the longer run, effects of birth weight. Copyright © 2016 John Wiley & Sons, Ltd.

INTRODUCTION: Although Pay-for-Performance (P4P) programs are being increasingly used by state Medicaid programs to provide incentives for managed care plans to provide high quality care, no national study has examined the effects of these plans on commonly targeted outcomes such as the use of particular preventive care services. METHODS: We use information on state Medicaid P4P programs from the Centers for Medicare and Medicaid Services combined with information from the National Immunization Survey 1999–2011 to study the effect of Medicaid P4P programs on children’s immunization status. We use difference-in-difference models that compare the effect of P4P programs on children’s immunization status for children estimated to be Medicaid-eligible before and after introduction of a P4P program relative to the “pre-post” change for other children in the same group of states. We also estimate difference-in-difference-in-difference models that compare these changes to those for children in states that do not implement P4P. RESULTS: We find that Medicaid P4P increases the probability that a Hispanic or non-Hispanic white child is up-to-date on several vaccinations. For example, we find that the chance that these children are up-to-date on the measures, mumps, and rubella series increased by about 2.7–2.9 percentage points. However, we do not find statistically significant effects on all vaccines, and no statistically significant effects for non-Hispanic black children. CONCLUSIONS: This study provides some evidence that Medicaid P4P programs may be helpful in improving childhood vaccination rates. Further study of the effects on other targeted outcomes as well as the effects of different P4P program designs may further increase our understanding of the potential role of these programs.

The authors use a mixed-methods approach to investigate how the integration of electronic health records between ambulatory and hospital practices affected physician productivity and birth outcomes at a large health network. Physicians and staff were interviewed during a five-year staged integration of electronic health records, and a direct measure of physician productivity, relative value units, was analyzed concurrently with several measures of birth outcomes. The regression analyses show an 11% reduction in total productivity following the installation of the new system at primary-care sites. The qualitative findings indicate the reduction is attributable to the additional time physicians and staff needed to learn new processes, adopt work practice changes, and develop coordination. Nevertheless, users value the additional integration, especially as information flows back to the ambulatory practices from the hospital. This is supported by increases in treatment intensity over time and a 37% reduction in the severity of adverse birth events.

In July 2002, a global budgeting system was imposed on hospitals in Taiwan. This system set a fixed budget for all hospitals within a region but included special provisions that sheltered reimbursements for drug expenditures. We study the size and nature of changes in hospital physicians' use of drugs for outpatient care following this budgetary change and find that drug expenditures for outpatient care increased by 11.7%. Our results suggest that physicians began prescribing more expensive drugs, more drugs, and drugs for longer periods but that these different responses did not all occur at the same time. The overall response was strongest in for-profit hospitals, but drug-related decisions changed in all hospital types.

We utilize the variations in home appliance adoption generated by China’s Home Appliances Going to the Countryside policy to isolate the actual effects of household technology on weight and health outcomes. Using difference-in-differences and instrumental variable approaches, we find that the policy-induced technological change has increased the probability of being obese and the incidence of being sick or injured for rural women but has had no impact on rural men. Our results also indicate that household technology has increased female labor force participation but has decreased women’s overall levels of energy expenditure.

A number of states have adopted mandatory managed care to provide health services to Medicaid patients, raising concerns that the care provided may be of lower quality than care provided under traditional fee-for-service arrangements. In this article, we study the effect of Pennsylvania's mandatory managed care program, HealthChoices, on health outcomes and the cost of care for pregnant Medicaid patients. Using difference-in-differences, we find evidence that the adoption of managed care resulted in fewer preventable complications, particularly for more severely ill mothers, but no general reduction in costs except in the highest decile of the cost distribution.

The prevalence of obesity has doubled over the last 25 years. We estimate the effects of multiple socio-environmental factors (e.g., physical demands at work, restaurants, food prices, cigarette smoking, food stamps, and urban sprawl) on obesity using NLSY data. Then we use the Oaxaca–Blinder decomposition technique to approximate the contribution of each socio-environmental factor to the increase during this time. Many socio-environmental factors significantly affect weight, but none are able to explain a large portion of the obesity increase. Decreases in cigarette smoking consistently explains about 2–4 % of the increase in obesity and BMI. Food stamp receipt also consistently affects the measures of weight, but the small decrease in food stamp program participation during the period we examine actually dampened the increases in obesity and BMI. Collectively, the socio-environmental factors we examine never explain more than about 6.5 % of the weight increases.

Using data of twin students graduating from junior high schools between 2002 and 2004 in Taiwan, we estimate the effects of peers on high school joint entrance examination performance. To alleviate the potential endogeneity of peer educational achievement, linear models with twin fixed effect and instrumental variables are estimated. Quantile, quantile with twin fixed effect and quantile with instrument variables regressions are also implemented to determine whether estimated peer effects differ at various locations of the testing scores’ conditional distributions. Positive and statistically significant peer effects are found to exist at the mean and at different quantile levels.

We estimate a gender differential in the intergenerational transmission of adverse birth outcomes. We link Taiwan birth certificates from 1978 to 2006 to create a sample of children born in the period 1999-2006 that includes information about their parents and their maternal grandmothers. We use maternal-sibling fixed effects to control for unobserved family-linked factors that may be correlated with birth outcomes across generations, and define adverse birth outcomes as small for gestational age. We find that when a mother is in the 5th percentile of birth weight for her gestational age, then her female children are 49-53% more likely to experience the same adverse birth outcome compared to other female children, while her male children are 27-32% more likely to experience this relative to other male children. We then investigate whether long-run improvements in local socio-economic conditions experienced by the child's family, as measured by intergenerational changes in town-level maternal education, affect the gender differential. We find no evidence that intergenerational improvements in socioeconomic conditions reduce the gender differential.

To examine the infant health impact of prenatal exposure to power plant emissions, we draw scientific evidence on the impacted region downwind of a large polluter, a coal-fired power plant located on the border of two states and proven to be the sole contributor to the violation of air quality standards of the impacted region. Our results show that among all live singleton births that occurred during 1990 through 2006, those born to mothers living as far as 20 to 30 miles away downwind from the power plant (which is also an affluent region) during pregnancy are at greater risks of low birth weight (LBW) and very low birth weight (VLBW): the likelihoods of LBW and VLBW could increase approximately by 6.50 and 17.12 percent, respectively. In light of the continual efforts of The U.S. Environmental Protection Agency in reducing cross-state air pollution caused by transboundary power plant emissions, our study is aimed at broadening the scope of cross-border pollution impact analysis by taking into account adverse infant health effects of upwind polluters, which can impose disproportionate burdens of health risks on downwind states due to air pollutants transported by wind.

This paper attempts to identify the causal effect of parental education on the male ratio at birth. To deal with the endogeneity of parental education, we exploit Taiwan's educational reform in 1968 making education compulsory up to the ninth grade. Based on a uniquely large and detailed administrative data set from Taiwan, our results show that the average education level of mothers is positively related to the male ratio at birth, both in the case of high-parity births and when mothers are at least 30 years old.

We estimate the impacts of the introduction of National Health Insurance in Taiwan in March 1995 on infant survival. Prior to NHI, government workers (the control group) possessed health insurance policies with comprehensive coverage for births and infant medical care services. Private sector industrial workers and farmers (the treatment groups) lacked this coverage. All households received coverage in 1995. Since stringent requirements for reporting births introduced in 1994 produced artificial upward trends in early infant deaths, we focus on postneonatal mortality. The introduction of NHI led to reductions in this rate for infants born in farm households but not for infants born in private sector households. For the former group, the rate fell by between 0.3 and 0.6 deaths per thousand survivors or by between 8 and 16%. A large decline of between 3.4 and 6.8 deaths occurred for pre-term infants—a drop of between 20 and 41%.

Background: Changes in the location and availability of surgical services change the distances that patients must travel for surgery. Identifying health effects related to travel distance is therefore crucial to evaluating policies that affect the geographic distribution of these services. We examine the health outcomes of coronary artery bypass graft (CABG) patients in Pennsylvania for evidence that traveling further to a hospital for a one-time, scheduled surgical procedure causes harm. Methods: We perform instrumental-variable regressions to test for the effect of distance to the admitting hospital on the in-hospital mortality and readmission rates of 102,858 CABG patients in Pennsylvania during 1995–2005, where the instrumental variables are constructed based on the quality of and distance to nearby CABG hospitals. Results: We found that patients living near a CABG hospital with acceptable quality traveled significantly less and if they were highrisk, had lower in-hospital mortality rates. Readmission rates in general are not affected by patients’ travel distance. Discussion: The positive correlation between travel distance and health outcomes observed by previous studies may reflect the confounding effects of behavioral factors and patient health risks. We found instead that living further from the admitting hospital increases in-hospital mortality for high-risk CABG patients. More research on the possible causes of these effects is necessary to identify optimal policy responses.

We investigate whether and how physicians' prescriptions of a new drug are influenced by their colleagues in the same hospital during shared working time. We use longitudinal data of physicians who prescribed antipsychotic drugs for schizophrenia patients in Taiwan between 1997 and 2010. We find that peer effects are small, but stronger among physicians of similar age and among those sharing a longer, larger, or more stable group. Peer effects are also stronger when drugs are newly introduced. We also find that peer effects are more likely to be overestimated using fixed-effect models than using first-difference models. (JEL D01, D83, I10)

Objectives Our research provides evidence on the intergenerational fetal programming effect by examining associations in the low birth weight (LBW, birth weight

We investigate the health impacts of unconventional natural gas development of Marcellus shale in Pennsylvania between 2001 and 2013 by merging well permit data from the Pennsylvania Department of Environmental Protection with a database of all inpatient hospital admissions. After comparing changes in hospitalization rates over time for air pollution-sensitive diseases in counties with unconventional gas wells to changes in hospitalization rates in nonwell counties, we find a significant association between shale gas development and hospitalizations for pneumonia among the elderly, which is consistent with higher levels of air pollution resulting from unconventional natural gas development. We note that the lack of any detectable impact of shale gas development on younger populations may be due to unobserved factors contemporaneous with drilling, such as migration.

There is a long-standing interest in the relationship between surgical procedural volume and patient outcomes dating back to early work by Luft, Bunker, and Enthoven (1979) and Luft (1980). Meta-analysis of earlier studies suggests there is a positive association between volume and outcomes in a variety of surgical and treatment settings (Halm, Lee, and Chassin 2002). As a result of this literature, there is a push to use surgical volume as a measure of provider quality, particularly for prevalent or high-risk procedures, including coronary artery bypass grafting surgery (CABG) (Peterson et al. 2004). Researchers, policy makers, hospital managers, physicians, and patients have continued interest in whether volume should be used as a quality indicator for major surgery, including CABG (Birkmeyer 2000; Birkmeyer, Finlayson, and Birkmeyer 2001; Birkmeyer et al. 2002; Epstein 2002; Shahian and Normand 2003; Birkmeyer and Dimick 2004; Shahian 2004;). Given that this procedure is still performed more than 100,000 times each year in the United States and an estimated 800,000 times per year globally and is invasive and expensive, this interest and efforts to address the extent to which volume continues to impact the outcomes of CABG surgery in different settings are warranted. Over time, a variety of methodological and empirical concerns have been raised in the volume–outcomes literature (Sfekas 2009). Some have suggested that further probing the mechanisms through which volume affects mortality would be of additional value (Huesch and Sakakibara 2009). Previously stated and investigated concerns about the observed relationship between volume and outcomes range from issues of patient selection and the causality of the observed relationship (Luft, Hunt, and Maerki 1987) to whether administrative data are detailed enough to account for differences in patient severity of illness (Hannan et al. 1992, 1997; Ho 2005; Tsai et al. 2006) to which modeling methods are appropriate in estimating this relationship (Austin, Tu, and Alter 2003; Hannan et al. 2005; Sfekas 2009;) and whether superior processes of care, which are generally unmeasured by researchers, may be correlated with volume and are at the root of the volume–outcome relationship (Shahian 2004). In spite of these concerns, studies using modern statistical analysis has found a relationship between both hospital (Sfekas 2009) and surgeon volume and outcomes (Hannan et al. 2003), though there is evidence these associations may have grown weaker over time in the United States (Peterson et al. 2004; Marcin et al. 2008; Ricciardi et al. 2008; Boudourakis et al. 2009;). In this study we reiterate the original question, “Does provider volume impact patient health outcomes?” We address this question by first clarifying what it means for volume to impact outcomes. Better technology and strategic efforts to improve immediate postoperative care reduce the likelihood of short-term mortality following CABG, meaning that measurable differences in mortality outcomes may not occur within 30 days, but at a later time point. Rather than simply estimate the impact of volume on a binary mortality outcome of whether a patient survives to a particular time point shortly after surgery, we consider what the impact of volume is on the postoperative hazard of mortality. We show that only looking at binary short-term mortality outcomes may not provide a complete picture of the volume–outcome relationship for CABG, particularly as it applies to Taiwan. We also address an important methodological issue with our choice of models; we consider whether unobserved heterogeneity of the patients or providers could be impacting the estimated relationship between volume and outcomes. We use a model rarely applied in this literature to address the issue of unobserved heterogeneity. While this estimation technique does not allow us to separate the impacts of the unobserved characteristics from one another (i.e., we cannot separate referral effects from organizational process effects, for example), it yields estimates of the impact of provider (hospital and surgeon) volume net of this unobserved heterogeneity on the hazard of mortality. We obtain estimates of the impact of surgeon and hospital volume on the hazard to mortality that are more statistically robust than those that would be derived from standard hazard estimation using administrative claims data in a study such as this.

Between 1968 and 1973 the Taiwanese government undertook the most extensive expansion on record of the public junior high school system in Taiwan. This study analyzes the effects of the 1968 education reform and subsequent high school expansion on gender disparities in employment generally, as well in different sectors and classes of employment. Our results show that the education expansion exerted a major influence on the reallocation of female workers across various sectors and types of employment, thereby contributing to the efficient reallocation of females in the Taiwan economy.

We use the matched mother-child data from the 2000 wave of the US National Longitudinal Survey of Youth 79 (NLSY79) to assess the impact of full-time working mothers on children’s body mass index (BMI) and the likelihood of becoming overweight. Parametric, semi-parametric and non-parametric methods are employed to correct the bias of selection on observables and unobservables. Pros and cons of various methods are discussed and specification tests are conducted. In general, we find that a mother’s full-time employment does have some impact on her children’s BMI and likelihood of becoming overweight across models and inference procedures.

Childhood obesity is an escalating problem around the world that is especially detrimental as its effects carry on into adulthood. To estimate the effects of television fast-food restaurant advertising on children and adolescents with respect to being overweight, this paper employs the 1979 ChildﾖYoung Adult National Longitudinal Survey of Youth and the 1997 National Longitudinal Survey of Youth to estimate the effects of television fast-food restaurant advertising on children and adolescents with respect to being overweight. A ban on these advertisements would reduce the number of overweight children ages 3ﾖ11 in a fixed population by 18 percent and would reduce the number of overweight adolescents ages 12ﾖ18 by 14 percent. The elimination of the tax deductibility of this type of advertising would produce smaller declines of between 5 and 7 percent in these outcomes but would impose lower costs on children and adults who consume fast food in moderation because positive information about restaurants that supply this type of food would not be completely banned from television.

This paper compares program expenditure and treatment quality of stroke and cardiac patients between 1997 and 2000 across hospitals of various ownership types in Taiwan. Because Taiwan implemented national health insurance in 1995, the analysis is immune from problems arising from the complex setting of the U.S. health care market, such as segmentation of insurance status or multiple payers. Because patients may select admitted hospitals based on their observed and unobserved characteristics, we employ instrument variable (IV) estimation to account for the endogeneity of ownership status. Results of IV estimation find that patients admitted to non-profit hospitals receive better quality care, either measured by 1- or 12-month mortality rates. In terms of treatment expenditure, our results indicate no difference between non-profits and for-profits index admission expenditures, and at most 10% higher long-term expenditure for patients admitted to non-profits than to for-profits.

The productivity of firms has been shown to decline after breaks in production. The literature suggests that one cause of this decline is the depreciation of human capital of individual workers. We examine the productivity of cardiac surgeons and hospitals to determine whether the length of or level of task repetition prior to breaks in production affects the productivity of individuals. We find decreases in surgeon productivity that are directly attributable to the length of the break between surgeries, with little evidence that this effect is mitigated by the level of task repetition prior to the break.

We test the effect of the introduction of Medicare Part D on physician prescribing behavior by using data on physician visits from the National Ambulatory Medical Care Survey (NAMCS) 2002-2004 and 2006-2009 for patients aged 60-69. We use a combined DD-RD specification that is an improvement over either the difference-in-difference (DD) or regression discontinuity (RD) designs. Comparing the discrete jump in outcomes at age 65 before and after 2006, we find a 35% increase in the number of prescription drugs prescribed or continued per visit and a 55% increase in the number of generic drugs prescribed or continued, providing evidence of physician response to changes in patient out-of-pocket costs.