Health Policy & Management Theses and Dissertations

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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.

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