Interviewers: Angela Esi Micah and James Buchanan
The Early Career Researcher Interview Series is a new initiative led by the IHEA Early Career Researcher Special Interest Group (ECR-SIG). The aim of this interview series is to showcase the diversity of people in the ECR subgroup in IHEA. By interviewing a variety of ECRs, we hope to describe the many interesting and emerging career paths available to ECRs in health economics, highlight the choices that individuals have made to help them to reach this point in their career, and reveal how ECRs are navigating the various challenges that they face.
The seventh interview of this series is with Monica Aswani. Monica is an Assistant Professor in the Department of Health Services Administration at the University of Alabama at Birmingham School of Health Professions. Her research employs econometric methods to investigate how national payment reform efforts relate to the quality of and disparities in healthcare delivery. Angela Esi Micah and James Buchanan, two of the conveners of the ECR-SIG, spoke to Monica in September 2019 to discuss her career to date.
Hi Monica, many thanks for talking to us today. We’d like to start by asking you to give us an overview of your career so far.
I graduated in December 2018 from the University of Alabama (UAB) in Birmingham, in the School of Public Health. Although I’ve invested a significant effort to gain a strong quantitative skill set, my ultimate interest is in addressing timely and germane health policy issues. For me, rigorous analyses are a tool to provide evidence to answer those pressing policy questions. I wanted to take a strong set of economics and biostatistics courses, but a lot of programmes didn’t provide the flexibility for me to triangulate health policy, economics and biostatistics to the degree that I wanted. As I had already completed my Masters at UAB, I knew that they were going to be accommodating in that respect.
In terms of funding, I was really fortunate because for my first three years I was on an institutional T32 grant from the Agency for Healthcare Research and Quality. During that time I then wrote an individual grant to the National Institute on Aging, which funded the rest of my dissertation.
So was your degree a three year process, or did it take a little longer?
My Doctor of Public Health (DrPH) degree took a little longer; all in all it took around six and a half years. And I didn’t start my degree straight after completing my Masters; I did a Fellowship in between at Johns Hopkins University.
So compared to people who spent 3-4 years as an undergraduate, then went straight onto a Master’s programme then straight onto a doctoral programme you had a bit more time to breathe during your journey. How did that slightly extended timeframe work for you?
I think it was very valuable, and in large part, allowed me to transition straight to a tenure track position after graduation. I was also able to pursue valuable opportunities, such as writing a grant to fund my dissertation, presenting my work at national meetings, and spending a summer at the World Health Organization (WHO) in Geneva.
Could you tell us a bit about the topic of your dissertation?
My dissertation explored a pay-for-performance programme in the US: the Hospital Re-admissions Reduction programme. This programme penalizes hospitals for potentially excessive unplanned 30-day readmissions for select conditions. I was really interested in exploring two areas. First, the potential for the risk-adjustment methodology to disproportionally penalize hospitals that were serving vulnerable populations; the risk adjustment only accounted for illness severity, gender and age, not characteristics such as race or socioeconomic status. Second, with any pay-for-performance programme, a key worry is often that the incentives offered might have unintended consequences.
So what did you find?
The first paper that came out of this work was the paper that won the iHEA Student Paper Prize in 2019. The title of this paper was “The Differential Impact of Hospital and Community Factors on Medicare Readmission Penalties”, and it was published in Health Services Research. The paper used a two-level hierarchical model with correlated random effects, also known as the Mundlak correction, to account for hospitals nested within counties. I was interested in the role of both social risk factors and also where hospitals were located. Hospitals tend to share geographic commonalities – like health attitudes or market characteristics or disease patterns – that could be associated with readmission risk but that are difficult to capture empirically. The conventional approach is to account for hierarchical data such as hospitals nested within counties using either fixed effects – by including a dummy variable for each county – or random effects using a random intercept model. It is seldom the case that both approaches are applied simultaneously. This study was interesting to me because it explored the role of regional heterogeneity in readmission penalties through both fixed and random effects to better illustrate the role of geography in readmission penalties.
How did a paper that presented both approaches come about? How did you select a journal?
I actually went back and forth between fixed effects and random effects, getting different results for the two approaches. Given this, I refused to consign one of these approaches to the paper appendix. In terms of selecting a journal, I was addressing a policy-relevant question but the methods were imperative to answering that question. It was important to find a journal with enough space to elaborate on the differences between fixed effects and random effects in the methods section. Health Service Research was therefore a good home for the paper because it had a larger word limit than the average journal.
Was this work published before you graduated?
Congratulations! How many papers do you hope to publish based on your dissertation work?
I honestly don’t know at the moment. I love academia, but the metrics in academia such as author order or impact factor are not the incentives that align with my passion. These are the metrics that academia cares about but what drives me is my ability to fire up Stata and indulge my intellectual curiosity by answering questions that I find both policy-relevant and thought-provoking.
If academia was just a question of firing up Stata I think we would all be a lot happier!
I concur! I’m grateful that I had mentors that allowed me to fail without feeling like a failure so I really got to appreciate the joy of learning. Research is truly an iterative process, none of us knock it out of the park on the very first try, and if we encourage the process of learning, rather than focusing on academic metrics, it would be better for the field.
Were there any particular challenges that you faced during your doctoral work? How did you overcome these challenges?
I had to confront a number of personal challenges. During my doctoral degree, my Dad passed away, my dissertation chair passed away the month before I defended, my Mum was diagnosed with a brain tumour, and I suffered a concussion that landed me in hospital. Those are just the personal, not professional, challenges. Given this, I’m grateful that I started graduate school with healthy coping mechanisms in place before I needed them! It also helped that I loved my dissertation topic; indulging my intellectual curiosity was a great outlet for solace and comfort. In addition, I’m thankful that I had a supportive mentor who forced me to prioritize work-life balance and who helped to create an environment where I could thrive.
I’m mindful to pay these things forward now. For example, I maintain a failure CV; when my students are discouraged I share it with them to demonstrate that my real CV just represents survivorship bias. I also impress upon them that graduate school isn’t a zero-sum game. I would not have gotten through my degree without my cohort of peers; we always supported each other. Everyone’s success was genuinely celebrated, not begrudged. No matter what stage you are in your career, it’s crucial to find your tribe and have that peer network.
As well as these challenges, I also experienced several ‘highs’ during my graduate studies, such as when my NIH grant received a perfect score on the first submission. That said, I try not to measure my success by the lines on my CV but by how well my actions and my work align with my moral compass.
Tell us about your job market search. Why did you decide to stay on at UAB?
My job market experience wasn’t your typical one. My dissertation chair unfortunately passed away a month before I defended. He was also the department chair so it was a chaotic time with a lot of unknowns. I was fortunate in that I had put the application in for my current position four to five months beforehand. More importantly, when I read the job description it was something that merged my topical interests in health care quality with my methods expertise in economics. I was not expecting to find the perfect intersection of everything I wanted in a position, let alone find that one building over.
So we get the timing right, when did you graduate? You said 2018?
Yes, I graduated in December 2018, and I started my position in January 2019.
Yes, I barely had any turnaround between graduation and my start date. I was also asked to be the speaker at my Commencement ceremony, which was such an honor, so I was writing my speech while preparing for my defense and navigating the job market. I look back and I am somewhat amazed that I was even semi-functional the last few months of 2018.
The relationship between a doctoral student and their advisor is such a critical determinant of success in the program. Can you share how you managed to organize and get through all this with the passing of your advisor? I’m sure your experiences will be useful to other graduate students.
My mentor, Meredith Kilgore, and I were very close and had complementary personalities. There were a lot of unknowns when he became ill, and my main priority was for him to focus on recovering and spend quality time with his family. While Dr. Kilgore was undoubtedly my primary and closest mentor, like most students, I had more than one mentor and was confident others would also help me navigate the job market. Something else I really appreciate about academia is how many members of the community are willing to help out people they have never met before. I attended the Annual Health Econometrics Workshop and the Society for Medical Decision Making meetings in the weeks before he passed. At those conferences, a number of people offered to review my job market materials, introduce me to people, and said to reach out to them if I had any questions.
In short, I recommend students have a diverse team of mentors, cultivate a network, and ultimately, recognize that the job market time is fraught with a lot of uncertainty (although my situation was clearly a bit more unusual).
Finally, I also think that by the time you get to the job market, you cannot easily augment the lines on your CV. It often takes months to get a paper published or to get a grant score back from a study section – not to mention all of the time required beforehand to prepare the submission. I am incredibly fortunate that my mentor invested time in helping me cultivate skill sets like grant writing long before I was on the market.
That is remarkable! He sounds like an amazing mentor. Sorry for your loss.
May we now talk more about your current position and some of your future plans?
Sure, I am now an Assistant Professor at the UAB School of Health Professions in the Department of Health Services and Administration. I am currently teaching two sections of Health Economics – a residential for Masters students and a hybrid session for Executive students.
It has been really rewarding to teach; our MSHA program is ranked number one in the nation, and UAB has a diverse and growing student population. As someone without a PhD in Economics but who has developed that skill set over time, I think one of my strengths is that I am able to make economic concepts relatable and accessible. I enjoy the challenge of making these concepts more relevant for students, particularly if they are math- or econ-phobic.
With respect to service, as a student, I served on the School of Public Health’s Diversity and Inclusion committee. In my current school I serve on a committee doing similar type of service. There are a lot of senior people that have paved the way for all of us so I am grateful for that and believe in being an invested citizen of the academic community.
Then there is my research, which I always love!
So are you extending the work that you did for your DrPH or you branching out into new research areas?
I am doing a mix of both. My dissertation explored whether hospitals can be appropriately benchmarked in the Hospital Readmissions Reduction Program, and I am expanding on that line of work. The program recently changed its methodology to incorporate hospital percent of Medicare/Medicaid-eligible patients so I am researching how that affects hospital performance in the program.
Additionally, I am starting to expand my risk adjustment research into other value-based programs beyond readmissions. I am also branching out into different research areas. As I mentioned earlier, between my Masters and DrPH degrees I undertook a patient safety fellowship at Johns Hopkins University. One of my areas of interest then was diagnostic errors and I am now exploring that further. Back then it was a very nascent field since diagnostic errors are difficult to analyze and measure. There are some errors where the effects do not materialize for several years, while for others, the impact can be seen very quickly. I am interested in how we can empirically capture them.
What one thing would you do differently if you were beginning your career now?
One thing I would do differently is to get formal training in learning how to teach. In graduate school, I served as a teaching assistant in many courses and lectured in them, but there is a big learning curve when transitioning to faculty. Designing your own course from start to finish differs considerably from grading and giving lectures. If I could go back in time, I would have sought out more pedagogical training and solicited more feedback on my own teaching.
That’s really interesting because many people respond to that question by saying “not really”!
Really? I find it valuable to reflect on lessons learned, but it doesn’t mean they resonate as regrets with me either. For example, I also wish I had leveraged social media and recognized its value sooner. Through the iHEA mentoring program I have been paired with John Cawley from Cornell and one of the things he has encouraged me to do is to be more active on Twitter (@Monica_Aswani). I am learning that it is a great medium to find out about opportunities, get advice, and meet other folks with similar interests.
What are your long-term goals? Five or ten years from now?
One of my goals is to produce research that substantively influences policy rather than just collecting online dust in a journal. The health care system in the United States feels like it is at an inflection point. It is clear that without some substantial reform it is unsustainable.
I think what makes my work – and I would argue all of our work in health economics – meaningful and exciting is that it has the potential to impact policy. As attempts to bend the cost curve intensify, I hope my research helps to ensure costs are reduced without sacrificing accessible and high quality care, especially in vulnerable populations.
Another aspiration is to collaborate with government agencies in order to gain frontline insights into policymaking. I think being able to understand the nuances of how policy and research overlap and how I can position my research to provide relevant and meaningful evidence to policymakers is critical.
Many thanks to Monica for talking to us today. Interested readers can learn more about Monica’s work by visiting her profile page. The next interview in the Early Career Researcher Interview Series will be published in November 2019.