2025
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Bernice Hua Ma, Samia Badji, Dennis Petrie, and Gang Chen
2025-19
This study examines the impact of enhanced social care provided through the Australian National Disability Insurance Scheme (NDIS) on subsided healthcare utilisation for people with disability. Using linked administrative datasets from 2011 to 2020, we employed a Difference in Difference model and the staggered rollout of the NDIS to assess its effects on healthcare services, focusing on visits to general practitioners (GP), mental healthcare providers, allied health professionals, specialists, and mental health prescriptions. The results show that the NDIS reduced subsidised mental health services and allied health services in the six quarters after enrolment. However, it did not significantly affect visits to GP, specialists, or mental health prescriptions. These effects were most pronounced among individuals aged 0-24 years, males, and those living in major cities. The findings suggest that services available from NDIS may substitute for subsided healthcare services by providing non-clinical care through social care channels. Further research is needed to investigate the long-term effects and health outcomes of the NDIS.
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Adam Irving, Dennis Petrie, Anthony Harris, Laura Fanning, Erica M. Wood, Elizabeth Moore, Cameron Wellard, Neil Waters, Bradley Augustson, Gordon Cook, Francesca Gay, Georgia McCaughan, Peter Mollee, Andrew Spencer, Zoe K. McQuilten
2025-18
Background
Health technology assessments traditionally rely on cohort modelling using clinical trial data, leaving uncertainties about real-world cost-effectiveness. This post-market economic evaluation used individual-level modelling with a discrete-event simulation (DES) framework and registry data to estimate the real-world cost-effectiveness of bortezomib, lenalidomide and dexamethasone (VRd) in Australia which was listed for newly diagnosed multiple myeloma in 2019.
Methods
We conducted an economic evaluation of VRd versus No VRd using the EpiMAP Myeloma model, a DES model powered by risk equations from the Australia & New Zealand Myeloma and Related Diseases Registry. This approach captured individual patient heterogeneity and complex treatment pathways through up to nine lines of therapy. We assessed differences in quality-adjusted life-years (QALYs) and costs over a lifetime horizon, with bootstrapping to quantify uncertainty.
Results
VRd was associated with positive incremental QALYs (0.16; 95% CI: 0.10, 0.21) and incremental cost (A$10K; 95% CI: A$8K, A$11K). Improved response to first-line therapy with VRd was predicted to marginally increase receipt of autologous stem cell transplantation by 1.1% (95% CI: 0.6, 1.7%), significantly increase receipt of maintenance therapy by 13.8% (95% CI: 10.4%, 17.3%) and marginally offset further lines of therapy. VRd was the most cost-effective option in 95% of the bootstrap iterations at a willingness-to-pay threshold of $60K/QALY.
Conclusion
The 2019 decision to list VRd for newly diagnosed multiple myeloma has resulted in a somewhat cost-effective allocation of healthcare resources when judged against the traditional A$50K/QALY willingness-to-pay threshold. This analysis demonstrates how using individual-level modelling with registry data to perform economic evaluation can capture the interplay between patient characteristics, treatment decisions, and outcomes. Our findings provide nuanced insights into the real-world cost-effectiveness of VRd, highlighting how post-market evaluations can inform refinement of funding decisions for complex therapeutic interventions.
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Adrianna Bella, Nicole Black, Teguh Dartanto, Danusha Jayawardana, and Dennis Petrie
2025-17
Child marriage remains a significant global issue, violating human rights and limiting development outcomes, particularly for girls. This study examines the impact of Indonesia’s first minimum marriage age (MMA) law, which in 1975 set the minimum age of marriage for girls at 16 years. The analysis relies on a regression discontinuity design to estimate the effects of the policy on child marriage and girls’ education, with specific adjustments to address non-random heaping in reported years of birth. Using data from the 2018–2021 Indonesia National Socio-economic Survey (SUSE-NAS), we find that the MMA law reduced marriages under the age of 16 by 18% and increased the age at first marriage by about five months. It also had a broader effect by delaying marriages beyond the legal threshold. The effects were stronger in regions with entrenched child-marriage norms and in urban settings. We also find evidence that the MMA policy had positive effects on educational attainment, particularly in obtaining a tertiary degree.
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Jessica Arnup, Nicole Black, and David Johnston
2025-16
Attention Deficit Hyperactivity Disorder (ADHD) is the most common mental health condition among children and adolescents, with diagnosis rates rising sharply over the past two decades. We examine the impact of adolescent ADHD on early adulthood outcomes using whole-of-population administrative data from Australia and two complementary identification strategies: sibling fixed effects and neighbour fixed effects. ADHD is identified through prescription records, capturing moderate-to-severe cases, and models account for a range of comorbid health conditions. Adolescents with ADHD are 12-16 percentage points less likely to be enrolled in tertiary education and 5-6 percentage points more likely to receive unemployment payments at age 20 compared to similar peers. These economic penalties are larger than those for other common conditions, including anxiety/mood and psychotic disorders. Relative reductions in tertiary enrolment are similar for males and females. Additional analyses show that comorbid mental health conditions do not meaningfully exacerbate the disadvantage associated with ADHD. Our findings highlight the substantial and enduring costs of ADHD for young people, even among those receiving treatment, and underscore the need for greater investment in school-based supports and transitional services. -
Ashani Abayasekara, Sonja de New, and David Johnston
2025-15
As economies decarbonise and automate, entire industries within countries will disappear, raising questions about how displaced workers will fare and how policy can best support them. To provide evidence on this issue, this paper examines the economic and mental health consequences of the complete shutdown of Australia’s automotive manufacturing industry. Using linked administrative data, we estimate the medium-term effects of this large-scale closure relative to comparable workers in unaffected manufacturing and construction sectors. We find substantial and persistent declines in employment and salary income among displaced workers, with limited recovery over five years. These effects are concentrated among older and lower-skilled workers, who experience higher rates of joblessness, occupational downgrading, and transition into self-employment. In contrast, younger and higher-skilled workers recover more quickly. Despite substantial disruption, we find no increase in mental healthcare use, potentially reflecting the unusually comprehensive support programs provided before and after closure. -
Anthony Scott, Susan Méndez, Jongsay Yong
2025-14
This paper examines the impact of a fall in demand for voluntary private health insurance on physician behaviour. We find that dual practice physicians who earned more revenue from working in private hospitals before the fall in demand for PHI were more likely to experience a fall in the volume of private hospital care and a less complex mix of in-hospital services provided. Risk-averse doctors drove this reduction in complexity. There was weak evidence suggesting that doctors compensated for the fall in volume by increasing their working hours in public hospitals and reducing fees for in-hospital services. We found no evidence of higher volumes of care in out-of-hospital visits to compensate for the lower in-hospital volumes, but some weak evidence of claiming for more complex and costly out-of-hospital services, which we interpret as upcoding. Compensatory behaviours were small and primarily observed among risk-averse male doctors with low conscientiousness, from non-surgical specialties, and located in areas with lower doctor density.
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Nicole Black, Danusha Jayawardana, David W. Johnston and Trong-Anh Trinh
2025-13
Rising out-of-pocket costs for psychotherapy in Australia have heightened concerns about financial barriers to mental healthcare, particularly for lower-income households, who disproportionately experience psychological distress. Using nation-wide linked administrative records of income and healthcare use, we estimate the magnitude of income-related inequity in psychotherapy use among 5.4 million individuals diagnosed with a mental health condition, and examine how such inequity has evolved over the decade from 2014 to 2023. Our findings show that income-related inequity is substantial, consistently higher among children than among adults, and has nearly doubled over the decade. By 2023, only 32% of low-income children and 40% of low-income adults accessed psychotherapy within three months of receiving a mental health treatment plan, compared with 55% among both high-income children and adults. We rule out changes in complexity of mental health disorders and the introduction of telehealth services as key drivers. We find no discernible difference by gender or age subgroups. Examination of antidepressant use reveals a growing gap in the opposite direction, with lower-income individuals increasingly reliant on medication without psychotherapy, relative to higher-income individuals. This suggests a shift towards lower-cost treatment pathways among disadvantaged groups. Our findings highlight the need for policies to address the increasing costs and other barriers to accessing psychotherapy, especially for lower-income households.
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Nicole Black, Danusha Jayawardana, and Gawain Heckley
2025-12
Recent research shows that birth order affects human capital outcomes, yet there is limited empirical evidence on the underlying mechanisms. This study examines the effect of birth order on children’s time use across activities that are important for human capital development. Using detailed time-use diaries of Australian children aged 2-15, we find that within families with two or three children, later-born children spend less time on enrichment activities and more on digital media, compared to first-born children. We obtain the same findings when we repeat the analysis using detailed time-use diaries of US children. Further investigation reveals that part of the birth order effect is driven by parents spending less time with later-born children compared to first-borns. However, later-borns also independently devote less of their own time to enrichment activities, suggesting that personal time use may be an important mechanism behind the well-documented impact of birth order on human capital development. We find evidence that later-born children experience more lenient parenting, which may help explain this pattern of own time use.
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Karinna Saxby, Thomas Buchmueller, Sonja C. de New, Dennis Petrie
2025-11
Poor mental health is a major global health issue, with many countries documenting high levels of unmet need and regional disparities in mental healthcare utilization. To determine how best to address these disparities, it is important to understand what drives regional variation. Using Census-linked microdata from Australia, we exploit cross-region migration to identify the extent to which patient and place factors drive regional variation in utilization of mental healthcare services and mental health prescriptions (antidepressants, anxiolytics, antipsychotics). We find that place factors account for approximately 72% and 19% of the regional variation in utilization of mental healthcare services and mental health prescriptions, respectively, with the rest reflecting patient-related demand. We also find suggestive evidence that larger place effects predict fewer mental health related ED presentations, self-harm hospitalizations, and suicides. Altogether, our findings suggest there is inadequate and inequitable supply in regions with low utilization, rather than inefficiently high utilization in high utilization regions.
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Daniel Avdic, Bo Lagerqvist, Nils Gutacker, Giovanni van Empel, Johan Vikström‖
2025-10
We study how multi-technology hospitals respond to market entry of single-technology competitors using a rescindment of regulations for heart attack treatments that prompted a rapid expansion of catheterization laboratories (cath labs) in Sweden. We isolate supply-side effects by exploiting that patients cannot choose their hospital and compare outcomes of cardiac patients residing in areas affected and unaffected by provider market entry, respectively. We show that patients with indications for cardiac surgery were more likely to receive catheter-based treatment after a cath lab opened in their hospital, and document increases in adverse health outcomes for inframarginal patients. Incumbent hospitals responded to this demand reallocation by augmenting their own demand for surgery, but to a lesser extent and without patient health consequences.
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Jing Jing Li, Anthony Harris
2025-09
Public funding decisions for pharmaceuticals are the outcomes of a dynamic bilateral bargaining process between the funding agency and a company and can involve considerable delay. Using an empirical duration model of negotiation in Australia from 2005 to 2018, we test if agreement patterns on national public subsidy of pharmaceuticals are consistent with the predictions of dynamic bargaining theory. It took a median of 16 months for the Australian government and companies to reach an agreement, averaging 1.51 rounds of negotiations, with 71% of the rounds failing to reach an agreement. Overall, the results of a process of one-sided offers from companies are consistent with theories of bargaining with incomplete information and delay strategies, where evidence of quality develops over negotiation rounds. Lower value and more risk for the payer delayed agreements and increased the probability of no agreement, while public awareness and interest in a drug reduced the agency’s bargaining power and increased agreement rates. Enhanced knowledge about the drug’s attributes benefits the government and its constituencies, but pharmaceutical companies have a strong incentive to invest in political alliances to raise awareness of potential benefits to patients and hasten public funding of a drug.
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Hai-Anh H. Dang, Stephane Hallegatte, Minh Cong Nguyen, Trong-Anh Trinh
2025-08
Despite a vast body of literature documenting the harmful effects of climate change on various socio-economic outcomes, little cross-country analysis exists on the global impacts of higher temperatures on poverty and inequality. Analyzing a new global panel dataset of subnational poverty in 137 countries covering the past decade, we find that a one-degree Celsius increase in temperature leads to a 17.1% increase in poverty, employing the US$2.15 daily poverty threshold, and a 1.1% increase in the Gini inequality index. We also find negative effects of colder temperature on poverty and inequality. Yet, while poorer countries—particularly those in Sub-Saharan Africa—are more affected by climate change, household adaptation could have mitigated some adverse effects in the long run. The findings provide relevant and timely inputs for the global fight against climate change as well as the current policy debate on cost-sharing between richer and poorer countries.
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Preety Srivastava, Trong-Anh Trinh, Xiaohui Zhang
2025-07
This paper contributes to the growing body of research examining the impact of temperature on educational outcomes. Utilising national-level administrative data on nearly one million Australian students, it investigates whether temperature fluctuations, and prolonged heatwaves influence test performance. The analysis reveals that both heat and cold affect student test scores, with some evidence of the effects intensifying during heatwaves. Australia’s vast geographical diversity and climate variability provides a unique opportunity to explore spatial heterogeneity in these effects. Findings suggest that in regions with hot weather conditions, the most thermally comfortable temperature is likely to be higher, whereas students in the coldest parts of the country appear to be less sensitive to cold weather conditions, consistent with the adaptation hypothesis. In contrast, in regions with moderate and temperate weather conditions, student scores are affected by both hot and cold weather.
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Sefa Awaworyi Churchill, Simon Chang, Russell Smyth, Trong-Anh Trinh
2025-06
This paper extends prior theory linking present-day sex ratios to present-day propensity for entrepreneurship among men backward in time to explore the long-run gender origins of entrepreneurship. We argue that present-day propensity for entrepreneurship among men will be higher in neighbourhoods which had historically high sex ratios. We propose that high sex ratios generate attitudes and behaviours that imprint into cultural norms about gender roles and that vertical transmission within families create hysteresis in the evolution of these gender norms. To empirically test the theory, we employ the transport of convicts to the British colonies of New South Wales and Van Diemen’s Land in the eighteenth and nineteenth centuries as a natural experiment to examine the long-run effect of gender norms on entrepreneurship in present-day Australia. We use a representative longitudinal dataset for the Australian population that provides information on the neighbourhood in which the participant lives, which we merge with data on the sex ratio in historical counties from the mid-nineteenth century. We find that men who live in neighbourhoods which had high historical sex ratios have a higher propensity for entrepreneurship. We present evidence consistent with the vertical transmission of gender norms within families being the likely mechanism. Arguments for policies to promote female entrepreneurship are typically couched in terms of gender norms representing a barrier to more women starting their own business. We present evidence consistent with gender norms contributing to gender differences in rates of entrepreneurship by being a spur for higher male entrepreneurship rather than a barrier to female entrepreneurship.
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Sander de Vries, Nadine Ketel, Maarten Lindeboom
2025-05
There is a clear consensus that childhood experiences shape adult success, yet there is limited understanding of their impact on future generations. We proxy parental investments during childhood with birth order and study whether disadvantages due to lower investments are transmitted to future generations. Birth order effects on the first generation are large, apply to 80% of the population, and can be identified with relatively mild assumptions. Using cousin comparisons in Dutch administrative data, we find that around 20 percent of the income disadvantages are transmitted. Additionally, we find sizeable decreases in children’s education and increases in boys’ criminal behaviour.