Health Policy & Management Theses and Dissertations

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THE LONG TAIL OF HISTORY: COMBINING THE 1940 CENSUS, REDLINING MAPS, AND HRS: METHODS FOR ANALYZING THE IMPACT OF REDLINING ON HEALTH, ECONOMIC, AND HEALTHCARE OUTCOMES IN OLDER ADULTS TODAY
(2023) Huang, Shuo Jim; Sehgal, Neil J; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
ABSTRACTTitle of Dissertation: THE LONG TAIL OF HISTORY: COMBINING THE 1940 CENSUS, REDLINING MAPS, AND HRS: METHODS FOR ANALYZING THE IMPACT OF REDLINING ON HEALTH, ECONOMIC, AND HEALTHCARE OUTCOMES IN OLDER ADULTS TODAY Shuo Huang, Doctor of Philosophy, 2023 Dissertation directed by: Neil Jay Sehgal, PhD, MPH Department of Health Policy Management BackgroundAs part of the New Deal in the 1930s, the Federal government used the Home Owners’ Loan Corporation (HOLC) to draw real estate security maps that were color coded or redlined to discourage lending in majority Black neighborhoods. Redlined areas still have worse health and economic outcomes in the present day. Current literature is focused on present-day residents of redlined areas. Tracking exposures to redlining and conditions of redlining close to the 1930s with present-day health is an unexplored area. Methods We utilize geo-referenced 1930s HOLC maps to locate individuals and map demographic considerations. We use novel algorithmic solutions to geolocate unknown 1940 enumeration districts. Using a 1940 census-linked sample of the Health and Retirement Study to locate individuals in HOLC areas at the time, we conduct survival analysis on HOLC categories’ effect on age at death as well as other analysis on health, economic, and healthcare utilization in the near present. We test for a potential mediator. Results Population density is not associated with either HOLC category or present day life expectancy, and is unlikely to be a mediator. In uncontrolled models, for HRS individuals in the 1940 census HOLC category is associated with greater hazards, worse odds of self-rated health, and worse economic outcomes. With controls, HOLC category is only associated with worse odds of self-rated health. HOLC category is not associated with health insurance or healthcare utilization in this sample. Conclusion Redlining is associated with health and economic outcomes which are attenuated when controlling for likely pathways between redlining and health. Future research should focus on whether individuals stay in redlined areas, and on identifying policy and initial state matrix that can describe what redlining may be a proxy for.
ASSESSING THE IMPACT OF POLYPHARMACY ON THE ELDERLY USING NATIONALLY REPRESENTATIVE SURVEY DATA
(2023) Eschenlauer, Adam; Franzini, Luisa; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
Background: Polypharmacy is a growing issue that affects individuals of all ages yet is most prevalent among patients aged 65 and older with chronic comorbidities. Although integral to most treatment plans, pharmaceutical intervention may negatively impact one’s health when five or more medications are taken daily. Given the concurrent rise in elderly population and polypharmacy prevalence, it is vital that we better understand the impact that concomitant medication use has on this vulnerable segment of population.Purpose: This research examines the factors leading to polypharmacy among the elderly population and explores its various impacts on healthcare utilization. Data and Methods: This study uses Medical Expenditure Panel Survey (MEPS) Data. Fixed-Effects regression analyses examine relationships between predictive factors and polypharmacy, polypharmacy and expenditures, and polypharmacy and utilization. Classification models assess the ability of machine learning to correctly predict utilization within the sample population. Key Results: Aside from clinical indicators, demographic and socio-economic factors play a role in determining polypharmacy status. Polypharmacy risk is higher for women (1.088, p < 0.001), high income individuals (1.107, p < 0.01), and those covered by Medicaid (1.110, p < 0.001). Conversely, married individuals (0.930, p < 0.001) and non-Hispanic Blacks (0.864, p < 0.001) have reduced risks of polypharmacy. We find polypharmacy to be associated with higher total (p < 0.001), inpatient (p < 0.01), outpatient (p < 0.01), and prescription medical expenditures (p < 0.001) when holding other predictors constant. We find the risk of hospitalization to be higher for polypharmacy patients (RR: 1.592, p < 0.001) than nonpolypharmacy patients after controlling for multimorbidity and medication class. Lastly, machine learning algorithms classify admissions with an overall accuracy of 84.9%; however, a low true positive rate (TPR) of 41.7% and high true negative rate (TNR) of 96.5% indicate best performance is achieved in predicting non-admissions. Conclusion: Polypharmacy is associated with several non-clinical factors and has a statistically significant impact on medical expenditures and admissions. Though imperfect, predictive analysis methods improve our ability to identify patients at risk for admissions and present a potential opportunity for future applications aimed at reducing utilization and costs.
Home Hemodialysis Utilization and Health Outcomes among Racial and Ethnic Minority Populations
(2023) Zhu, Ying; Franzini, Luisa; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
Background: Home hemodialysis (HHD) offers end-stage renal disease (ESRD) patients greater flexibility and advantages in terms of health outcomes over in-center hemodialysis. There is limited research on the differences between home and center hemodialysis (CHD) and preferences among racial/ethnic minorities, despite ESRD disproportionately affecting these groups. Methods: This project aims to explore the usage and health outcomes of HHD vs. CHD with a focus on racial/ethnic differences using a systematic review of the global main academic database from 2004 to 2022 (study 1), logistic regression and negative binomial analysis of the U.S. Renal Disease System (USRDS) cumulative core data since 2010 merged with 2016-2019 Medicare clinical claims (study 2), and qualitative research using semi-structured interviews with 18 nephrologists and 5 other hemodialysis providers in 8 states of the U.S. (study 3). Results: Study 1: from 3,114 unique studies, six studies met the inclusion criteria and all of them were comparative cohort studies; five out of six studies with a total of 3,172 White patients (68%) and 1,477 minority patients (32%) reported the utilization of HHD; in four of the six studies, the adjusted odds ratio for HHD treatment was shown to be significantly lower for patients of racial or ethnic minorities than for White patients; three out of six studies examined racial/ethnic differences in mortality and other outcomes indicating a lower risk of death for minorities in home hemodialysis. Study 2: minorities were significantly less likely to use HHD than Whites; most minority patients were younger and had fewer comorbidities than Whites, and all minority groups displayed significantly lower mortality and hospitalization incidences than the White group with adjustment on multiple covariates; in the overall and main racial/ethnic cohorts, HHD showed a significantly lower risk of death than CHD after confounding for major risk factors. Study 3: the majority of the interviewees felt that HHD was a viable, safe, and most cost-effective treatment for those with kidney failure, it offered many advantages over traditional CHD but there is a need for additional training and support for the patient, family, provider; minorities and White patients differed in their attitude toward dialysis care, social norms on HHD, and perceived control of personal health. Conclusion: There were major obstacles and considerable racial/ethnic variations in HHD utilization and health outcomes in the US. This study showed that the promotion of HHD will probably require a systematic overhaul in kidney disease management and education.
ASSESSING IMPACT OF CANCER AND DEPRESSION ON THE FINANCIAL HEALTH OF MIDDLE AGED AND OLDER AMERICANS
(2023) Omeaku, Nina; Boudreaux, Michel; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
This dissertation examines the impact of cancer on financial outcomes for individuals aged 50 and older and documents how this relationship varies by sex and race/ethnicity. I then turn to the impact of depression on out-of-pocket medical spending among those with a history of cancer. Findings suggest cancer can have a deleterious effect on the financial outcomes of those who are diagnosed with cancer. Out-of-pocket spending rises in the year of diagnosis, reduced earnings persist beyond diagnosis, and depression increases out-of-pocket spending. I fail to find evidence that the relationship between cancer and financial outcomes is moderated by sex or race-ethnicity.
PATTERNS OF HEALTH CARE UTILIZATION AMONG PATIENTS WITH ALZHEIMER'S DISEASE AND RELATED DEMENTIAS BEFORE AND DURING COVID-19
(2023) Wang, Nianyang; Chen, Jie; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
There are currently over 6.2 million people with Alzheimer’s Disease and Related Dementias (ADRD) in the US and this population will grow to over 13 million by 2060. Patients with ADRD have high rates of health care utilization due to their complex health needs, which may have been impacted by the COVID-19 pandemic.This dissertation examined the patterns of health care utilization during COVID-19 for the ADRD population. I used 2019-2020 claims data from Inovalon MORE2 to identify emergency department (ED) visits, preventable ED visits, hospitalizations, potentially preventable hospitalizations (PPH), office/clinic visits, and telehealth visits and the Fall 2020 and Winter 2021 Medicare Current Beneficiary Survey COVID-19 Supplements to study telehealth access before and during COVID-19 and telehealth use during COVID-19. The first aim examined patterns in health care utilization before and during COVID-19 using an interrupted time series analysis. The results showed that the total number of ED visits decreased while the percent of preventable ED visits stayed the same, the total number of hospitalizations and the percent of PPH decreased, and office/clinic visits decreased while the percent of telehealth visits increased during COVID-19 for patients with ADRD. The second aim examined the impact of COVID-19 on the rate of monthly PPH for Managed Medicaid enrollees with ADRD and Medicaid expansion status using a difference-in-differences design. The results showed that COVID-19 did not affect the rate of PPH for patients with ADRD by state Medicaid expansion status. The third aim evaluated telehealth access and use for Medicare enrollees with a focus on enrollees with ADRD and Medicare Advantage within the context of COVID-19. Medicare enrollees with ADRD did not have different rates of telehealth access before or during COVID-19 or telehealth use during COVID-19 compared to their non-ADRD counterparts. The interaction of Medicare Advantage and ADRD was not significant in rates of telehealth access or use. Findings from this dissertation provide policymakers with evidence on how to predict and prepare for the health care needs of future pandemics for vulnerable populations such as patients with ADRD.
EXAMINING NEIGHBORHOOD SOCIOECONOMIC CHARACTERISTICS AND ACCESS TO THE NATIONAL DIABETES PREVENTION PROGRAM: A MARYLAND PERSPECTIVE
(2023) Buchongo, Portia; Franzini, Luisa; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
Despite substantial federal and state investments made to promote the National Diabetes Prevention Program (NDPP) as a population health strategy for diabetes prevention it remains underutilized. Research has pointed to a variety of factors that have contributed to low uptake of this evidence-based lifestyle change program. However, the role neighborhood socioeconomic disadvantage plays in NDPP access and use has been underexplored. The state of Maryland is an ideal setting to investigate how neighborhood socioeconomic disadvantage impacts various dimensions of NDPP access due to the significant investments in primary care transformation and NDPP. This dissertation examines: (1) the relationship between neighborhood socioeconomic disadvantage and potential access to the NDPP using primary care providers geographic proximity to the NDPP sites in Maryland, (2) the relationship between neighborhood socioeconomic disadvantage and potential access to the NDPP based on geographic proximity of individuals with prediabetes to the nearest NDPP site in Maryland, and (3) the relationship between neighborhood socioeconomic disadvantage and utilization of diabetes prevention intervention such as NDPP, metformin, or both among individuals with prediabetes in Maryland. Findings from this work underscore how targeted statewide public health and health care initiatives can enhance NDPP access and utilization in neighborhoods with higher levels of socioeconomic disadvantage.
PHYSICIAN PEER NETWORKS AND PATTERNS OF OPIOID-RELATED BEHAVIOR
(2023) Pope, Elle; Sehgal, Neil J; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
Physicians are known to learn prescribing behavior from peers, although the extent and magnitude of peer influence on opioid prescribing is not well understood. Identifying the role peer networks play on influencing opioid prescribing, or opioid-related behavior, could elicit new understandings on how information in healthcare is spread and, in turn, lead to policy solutions and interventions to modify physician behavior in the direction of evidence-based medicine. The goal of this dissertation was to evaluate physicians prescribing opioids to patients in Medicare, or physicians receiving opioid industry payments, in order to determine if network-level characteristics are associated with patterns in opioid prescribing. This dissertation has three aims: (1) to determine whether patterns in opioid prescribing exist across physician networks and association with specialties, (2) to empirically demonstrate influence industry can have on clinical decision-making via targeted marketing within provider networks, and (3) to attempt to parse whether certain physicians with greater peer influence result in similar opioid prescribing among network peers. There are several findings and important implications related to this work. First, I find that primary care physicians who have more peer connections and more peers within a pain management specialty or surgery are more likely to have a higher median opioid prescribing rate across patient-sharing, hospital, and shared group clinic networks. Second, I find physicians who have any opioid payments are associated with three times the likelihood of at least one peer also having an opioid payment compared to physicians who did not have a similar payment. These physicians are more likely to belong to smaller and more interconnected patient-sharing networks. Finally, I perform a novel identification analysis of potential peer influencers to find certain provider-level characteristics that may shape peer prescribing behavior. The implications of this dissertation reveal that peer influence may serve as a potential mechanism for altering prescribing behavior and may be a lower-cost and efficacious way to increase adherence to evidence-based medicine.
HOSPITAL CROSS-SECTOR PARTNERSHIPS TO PROMOTE POPULATION HEALTH
(2022) Barath, Deanna; Chen, Jie; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
Health reform efforts continue to hold hospitals accountable for the care they provide by connecting hospital payments to hospital quality. With an understanding that there is no one size fits all solution and a long history of operating within the silo of the medical sector, hospitals have slowly begun to look beyond health care and invest in population health strategies. These upstream strategies usually promote health and wellbeing by addressing the social needs of patients and the social determinants of health: the conditions in which we live, work, and play. The central research question asks if hospital investments in population health strategies improve hospital quality of care. As cross-sector partnerships have long been at the center of solving large population health concerns, this dissertation seeks to assess how hospitals are engaging partners across-sectors, establish a taxonomy of hospital partnership engagement, and examine variation in hospital and community characteristics across the taxonomy in Chapter Two. This taxonomy will then be used to assess the provision of community-oriented health services in Chapter Three and readmission rates in Chapter Four. Data sources include the 2018 American Hospital Association Annual Survey Database, Area Health Resource Files, Minority Health Social Vulnerability Index, Care Compare data for unplanned readmission rates, and the Centers for Medicare and Medicaid Services’ Impact File. The analysis resulted in a four-cluster taxonomy of hospital partnership engagement (HPE) that ranged from little to no partnerships to many partnerships and often at formal levels of engagement. In general, partnership engagement increased with hospital size, teaching status, nonprofit ownership, multihospital systems, greater proportions of Medicaid discharges, urbanicity, hospital competition, median home value, household income, educational attainment, and non-white population. Partnership engagement declined with the proportion of Medicare discharges, critical access hospitals, and sole community providers shortage area designation, poverty, and elderly populations. HPE was also found to be a significant predictor of the total sum of community health services provided by hospitals, as well as each of those services, even after accounting for state-level effects. Lastly, high levels of HPE were associated with lower 30-day unplanned readmission rates. Results demonstrate an association between HPE and hospital quality, indicating that hospital investments in population health strategies can improve hospital quality.
EXAMINING THE IMPACTS OF PUBLIC POLICY CHANGES ON IMMIGRANT CHILDREN’S INSURANCE COVERAGE, ACCESS TO CARE, AND HEALTH OUTCOMES
(2022) Chu, Jun; Boudreaux, Michel H; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
A large body of evidence shows that public policies that expanding public insurance eligibility to children would lead to improvements in health care access and health outcomes during childhood. Growing up in the US, immigrant children face multifaceted barriers related to “not from here”, including economic constrains, acculturation pressure, immigration status of self and family members. It is unclear if immigrant children may respond to a public policy that expand public insurance eligibility to them. Prior research showed that immigrants would adjust their participation in public programs and health care utilization based on their perceived immigration climate. However, less is known about the impact of a national immigration enforcement program on immigrant children’s health care access and health outcomes. In this study, I examined two public policies: Children’s Health Insurance Program Reauthorization Act of 2009, the public policy that expanded public insurance eligibility to immigrant children under the five-year bar; and Secure Communities, a national immigration enforcement program that linked federal immigration enforcement activities to local authorities. I found that immigrant children in states that adopted CHIPRA’s option experienced a 6.35 percentage points decrease in uninsurance, and 8.1 percentage points increase in public insurance coverage, while estimated changes on private coverage were not statistically significant. I did not observe any statistically significant effects of CHIPRA on immigrant children’s access to care and health outcomes. My estimates suggested that activation of SC significantly decreased immigrant children’s public insurance coverage by 8.2 percentage points, while the estimates on other outcomes were not statistically significant.
RACIAL AND ETHNIC DISPARITIES IN ADL LIMITATIONS AMONG MEDICARE BENEFICIARIES AND THE EXPERIENCE OF TRANSPORTATION BARRIERS IN THE ADL POPULATION
(2022) Saint Dic , Venchele; Boudreaux, Dr. Michel; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
The study’s aims were to first determine if racial/ethnic disparities in ADL limitations for low-income Medicare beneficiaries. The logistic regression results suggested there is a variance in ADL limitation among Medicare Beneficiaries across race. Then, it tested if low-income elderly Medicare enrollees aged 65 years and older were at a higher risk of experiencing transportation barriers to care. On account of covariates, persons with ADL limitations (OR: 2.47 p<0.001) had higher odds of having transportation barriers compared to those without ADL limitations. Non-Hispanic African Americans had a higher chance of experiencing transportation delays than non-Hispanic Whites (OR 1.76 p<0.001). Finally, the effect size for transportation access barriers did not have a dose-relationship with increasing ADL limitation severity. Though the point estimates suggested that barriers were greatest for those with moderate severity (3-4 ADLs), it failed to find evidence of a statistically significant dose-response relationship between ADL severity and transportation.
THE EFFECT OF COMMUNITY HEALTH CENTERS ON HEALTH CARE ACCESS, CRIME, AND INTERACTIONS WITH THE MEDICAID PROGRAM
(2022) Marthey, Daniel J; Boudreaux, Michel; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
Health centers are community-based clinics that provide services to medically underserved populations. They serve nearly 30 million adults nationwide and more than 90% of patients come from households earning below 200% of the federal poverty level. To date, we know very little about the impact of health centers on measures of social wellbeing.This dissertation estimates the causal impact of the health centers using the staggered expansion of health centers between 2006 and 2020 and advancements in causal inference methods that allow for unbiased identification of treatment effects in the presence of variation in treatment timing and treatment effect heterogeneity. I use the Centers for Medicare and Medicaid Services Provider of Services file to identify the introduction of health centers over time. Measures of primary care access come from the Dartmouth Atlas and the FBI’s UCR Offenses Known and Clearances by Arrest (2005-2016) files are used to measure agency and county level crime rates. Area-by-year covariates are compiled from several sources. The empirical approach uses staggered difference-in-differences where treatment is defined as the year the first health center receives certification in a county-year. Major findings suggest health centers increase annual visits with a primary care clinician by 4.5% within 7 years after certification among Medicare fee-for-service beneficiaries. I find health centers reduce the total crime rate by 7% over the period. Results are robust to several alternative specifications. While results on Medicaid interactions are inconclusive, they suggest declines in crime are largest in counties that experienced a health center opening and Medicaid expansion. My dissertation adds to the literature on the impacts of the Health Center Program’s main objective—increasing access to care. In addition, my findings broaden the literature related to health access programs and crime. The Health Center Program has grown considerably in size and scope since inception, and it is a centerpiece of many policy approaches to reform the US health care system. Findings from my dissertation have important policy implications for health, criminal justice, and social justice reforms.
Examining the State-Level, and Racial and Ethnic Impact of Cigarette Taxes on Youth Smoking and Cessation
(2022) Shinaba, Muftau; Boudreaux, Michel; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
The objective of this study is to examine the relationship between per-pack cigarette taxes at the state level and smoking behavior among youth in the United States, based on race and ethnicity. State-level Youth Behavioral Risk Surveys (YRBS) from 2017 and 2019, as well as Tax Burden on Tobacco (TBOT) data, were used to analyze current (past 30-day) cigarette use and quit attempts among high school students, stratified by race/ethnicity and adjusting for age and sex. The findings found that overall odds of cigarette use were lower with higher cigarette taxes across states. The findings look to further evaluate a key tobacco control policy from both an economic and public health perspective.
Wraparound Services in Primary Care Settings: Evaluating the Health Center Model for Patients with Cardiometabolic Risk Factors
(2021) Martinez, Gilda Sofia; White, Kellee; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
Background: Community health centers provide a wide range of services beyond standard primary care, including social and enabling services, dental services, and behavioral health care. These wraparound services may be particularly important for individuals with cardiometabolic risk factors who are at increased risk for cardiovascular disease, the number one cause of death in the United States, but little is known about this relationship.Purpose: The purpose of this study is to assess the relationship between wraparound service use and health and healthcare outcomes for individuals with cardiometabolic risk factors. Data and Methods: We used data from the 2014 Health Center Patient Survey to measure associations between enabling service use and health care access and utilization using doubly robust propensity score matching and generalized linear models. To assess associations with wraparound service use and cardiometabolic risk factor presence, we used Poisson regressions to analyze 2015-2016 electronic health records data from the federally qualified health center, Mary’s Center. Key Results: We did not find wraparound service use to be associated with changes in cardiometabolic risk factor presence from one year to the next. We did find that nationally, enabling service use is associated with a 16.1 percentage point (pp) decrease in delayed/foregone care and a 29.4 pp increase in routine check-ups among individuals with cardiometabolic risk factors. However, among those with 3+ cardiometabolic risk factors, enabling service use is associated with a 41.3 pp increase in emergency room visits and a 7.6 pp decrease in check-ups. Among Mary’s Center clients, social service use is associated with a decreased rate of cardiometabolic multimorbidity (0.73). However, interactions between social service use and age find an increased rate of cardiometabolic multimorbidity among individuals 45 to 64 (1.42) and those 65 and over (1.64). Dental service use is also associated with an increased rate of cardiometabolic multimorbidity (1.09). Conclusion: Cardiometabolic risk factors remain highly prevalent in the U.S. and contribute to serious negative health outcomes. We found some positive associations between wraparound service use and cardiometabolic health and healthcare outcomes, highlighting the need for further longitudinal research and funding of these services.
Mental health and mental health services during the COVID-19 pandemic
(2021) Benjenk, Ivy; Chen, Jie; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
The COVID-19 pandemic significantly impacted mental health and mental health services in the United States. During February 2021, 42% of Americans experienced symptoms of depression or anxiety. During the pandemic, the largest and most sustained growth in telemedicine occurred in mental health services. The goal of this dissertation is to explore strategies for maintaining mental health services and promoting mental health during the COVID-19 pandemic. In this work, I review the literature on what is currently known about the impact of the COVID-19 pandemic on mental health and mental health services. I provide conceptual frameworks that posit how vulnerable populations are at highest risk for losing access to healthcare during the pandemic and how population-level strategies are needed to promote mental health recovery. In my first research paper, I use qualitative data collected from semi-structured interviews with twenty adults with serious mental illness (SMI) during the pandemic. I found that most study participants did not experience increases in unmet mental health or social service needs. However, several participants who lacked identification documents, housing, and/or a personal device reported significant increases in unmet needs, including inability to access mental health care and public benefits. As many participants in the qualitative study reported receiving audio-only telemental health services versus video telemedicine during the pandemic, I used data from the Medicare Current Beneficiary Survey COVID-19 Supplements to explore the use of audio-only telemedicine during the pandemic. Findings suggest that the high rate of audio-only telemedicine is not exclusively related to the digital divide or patient preferences, but also to provider behavior. Lastly, as the COVID-19 pandemic impacted the mental health of the entire population, I used data from the Census Bureau’s Household Pulse Survey to explore whether availability and receipt of an effective COVID-19 vaccine could promote mental health. Results suggest a reduction in the predicted probability of mental health symptoms after approval of the vaccine and a lower predicted probability of mental health symptoms among those who have been vaccinated, however these rates remain higher than what was seen prior to the pandemic. Overall findings suggest that the mental health care system has adapted fairly well to meet the needs of persons with SMI during the pandemic and mental health has improved since the approval of the vaccine, but additional work will be needed to reengage those who were disconnected from mental health services during the pandemic and to achieve pre-pandemic levels of mental health.
Psychological Distress and Need for Mental Healthcare: Examining and Modeling Prevalence & Need Using Multiple Datasets
(2021) Toussaint, Ebony Allen; Roby, Dylan; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
The Patient Protection and Affordable Care Act (ACA) expanded Medicaid eligibility to include non-elderly adults with incomes up to 138 percent of the federal poverty level. As a result, Medicaid enrollment by individuals with severe psychological distress increased (Gonzales et al, 2017). The goal of this dissertation is to use patient-reported outcome measures to examine whether disparities in access to mental healthcare exist in California, a state that expanded health insurance coverage dramatically through the ACA. The literature review in this dissertation discusses the use of patient-reported outcomes, specifically psychological distress, to determine need for mental healthcare. Established theory on behavioral health services utilization is used to examine mental health disparities with specific evidence on race/ethnic group affiliation, health insurance status, and geographic access. California Health Interview Survey data and Medical Expenditure Panel Survey data from 2014-2018, is used to model both the prevalence of and need for mental healthcare among non-elderly adults. Findings suggest the need to examine moderate levels of distress, as this population demonstrates the need for prevention and early intervention. Those most at risk for high levels of distress include non-elderly adults with low socioeconomic status, as socioeconomic status was a better predictor of psychological distress than racial/ ethnic group affiliation. Taken together, the results of this dissertation research suggest that health insurance coverage alone is an insufficient predictor of adequate mental healthcare access.
Perceived Neighborhood Cohesion, Homeownership, and Race/Ethnicity: Implications for Adult Mental Health
(2021) Brown, Melanie; Boudreaux , Michel; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
This study utilized 2013-2017 data from the National Health Interview Survey to evaluate the association between perceived neighborhood cohesion and mental health outcomes (serious psychological distress, anxiety, and depression) and how this association varies by race/ethnicity. This study also evaluated perceived neighborhood cohesion as a mediator of the relationship between homeownership and mental health. Results indicated that residing in a cohesive neighborhood is associated with reductions in risk (p<.01) for adverse mental health outcomes. Individuals living in cohesive neighborhoods had a reduced risk of 1.30 percentage points of serious psychological distress, a 4.10 percentage point reduced risk of anxiety symptoms, and a 3.80 percentage point reduced risk of depression symptoms. This study found a statistically significant reduction in risk of adverse mental health outcomes for those that own vs. rent their home and this relationship is partially mediated by neighborhood cohesion. These findings suggest that neighborhood cohesion provides a protective benefit against adverse mental health outcomes.
Food Insecurity in the District of Columbia: Do Community Gardens Help?
(2021) Sodergren, Cassandra; Roby, Dylan; Wilson, Sacoby; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
More than 10% of the District of Columbia’s residents have difficulty accessing affordable and healthy food, a number that is now projected to be over 16% because of COVID-19 (Sustainable DC, 2019; Food Security Report, 2020). Wards 7 and 8 experience the highest levels of food insecurity, with one grocery store per 60,000 residents versus other wards with one grocery store per 10,000 residents (Sustainable DC, 2019). Community gardens are sometimes referred to as part of the solution to food insecurity. This study explored if there was an intersection between community gardens and food security in Washington, DC. Through qualitative interviews and an inductive thematic analysis this study concludes that community gardens have a role in food security for those who experience food insecurity. The three core themes that emerged from studying community gardens were food security, relationships, and quality of life.
Novel Immunotherapy Agents in Oncology: Generalizability of Trial Results and Drivers of Clinical Utilization
(2021) Mishkin, Grace; Franzini, Luisa; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
Cancer is the second most common cause of death in the United States after heart disease. Novel immunotherapy agents such as nivolumab and pembrolizumab have become an essential, albeit extremely expensive, component of oncology care since their first approvals in melanoma in 2014 and lung cancer in 2015. However, little is known about differences between immunotherapy clinical trial participants and the real-world patient population, or about the drivers of provider utilization of these agents. The first objective of this dissertation used the SEER-Medicare linked database with claims data from 2014-2016 to conduct two aims analyzing potential disparities between Medicare beneficiaries on active treatment for melanoma and lung cancer and Medicare clinical trial participants. Aim one compared the characteristics of Medicare patients on active cancer treatment to Medicare patients on active cancer treatment clinical trials. Aim two compared Medicare patients receiving the novel immunotherapy agents nivolumab or pembrolizumab to Medicare patients participating in trials of these two immunotherapy agents. Because of the demographic differences in the melanoma and lung cancer patient populations, these aims were analyzed separately in melanoma and lung cancer. As hypothesized, patients in clinical trials were significantly younger and had fewer comorbid conditions than patients undergoing active cancer treatment not in clinical trials. Underrepresentation of non-White and female patients in clinical trials was hypothesized, but these results were less consistent. The second objective used Medicare Open Payments data from 2016 and Medicare provider utilization data from 2017 to analyze 1) if industry payments promoting nivolumab or pembrolizumab were positively associated with whether a provider was a high utilizer of the agent, and 2) among these high utilizers, if industry payments were positively associated with greater utilization amounts. The hypothesized results, that industry payments were associated with greater likelihood of high utilization and more utilization among high utilizers, were seen in some of the analyses but not consistently throughout the study. Through unique analyses of recent datasets, this dissertation advances our understanding of potential disparities in clinical trial representativeness and the generally positive relationship between promotional payments and provider utilization of immunotherapy agents in the Medicare cancer patient population.
Competition and Consolidation in Medicare Advantage
(2020) Chao, Sandra; DuGoff, Eva H.; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
Background: Medicare Advantage (MA) serves roughly one in three (24 out of 68 million) Medicare beneficiaries and this number is expected to grow to about half (40 out of 80 million) of Medicare beneficiaries by 2030. Given this expected increase in demand for MA health plans, it is important to assess the relationship between market structure and benefit generosity to ensure that beneficiaries have equal access to high quality plans at low prices.Purpose: The purpose of this research is to assess how policy changes and market structures influence Medicare Advantage plan benefit designs. Data and Methods: This study uses publicly available MA data from the Centers for Medicare & Medicaid Services and the Area Health Resources File. Retrospective cross-sectional analyses examine contract consolidation and reconsolidation from 2012–2020, market competition and supplemental benefits in 2013, and market competition and maximum out-of-pocket limits in 2018. Key Results: Contract consolidations have declined in recent years, likely as a result of a policy that changed the calculation method of the star ratings among consolidated contracts. During the years that contract consolidations peaked, market concentration also increased. We find that the odds of a plan in a nonconcentrated market offering a transportation supplemental benefit is 2.8 times higher than a plan operating in a highly concentrated market, when holding all other predictors constant (p < 0.001). Similarly, plans in nonconcentrated service areas are 2.4 times more likely to offer a hearing benefit (p < 0.001) and 2.3 times more likely to offer a dental benefit (p < 0.001) than plans in highly concentrated markets. Regarding maximum out-of-pocket limits, we find that the odds of a plan in a highly concentrated market having a higher maximum limit is 1.6 times higher than a plan with a nonconcentrated market, when holding all other predictors constant (p = 0.049). Conclusion: MA contract consolidations have declined since 2016 but market concentration continues to increase. Market structure is important because we find that MA market concentration is associated with the offering of supplemental benefits and the level of maximum out-of-pocket limits.
Perceived Discrimination and Multimorbidity Among Middle-Aged and Older Adults
(2020) Howard, Jianna; White, Kellee; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
Multimorbidity, the presence of multiple chronic conditions, is increasingly recognized by researchers as a major health priority. Relative to younger adults, the burden is much higher among middle-aged and older adults with prevalence estimates ranging from 25-98%. Variations in the burden of multimorbidity within the aging population exist with a growing body of research showing racial/ethnic differences in the incidence, prevalence, and severity of multimorbidity. This study analyzed the association between perceived racial discrimination and multimorbidity among middle-aged and older adults and whether or not existing associations vary by race/ethnicity. Findings show that individuals reporting perceived discrimination are more likely to have multimorbidity. While racial/ethnic differences in the association between perceived discrimination and multimorbidity were not observed, Black respondents displayed the greatest risk for multimorbidity. Perceived discrimination may provide insight into why multimorbidity varies by race/ethnicity through the mechanisms of stress responses and health behaviors.

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