Health Policy & Management Theses and Dissertations

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Distress and Deaths of Despair in the U.S. Healthcare Delivery System: Understanding Patterns in Healthcare among Distressed Americans
(2024) Spencer, Merianne Rose Tiglao; Chen, Jie; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
The United States has experienced rising mortality rates for the past several decades. Drug poisonings have increased nearly five-fold, suicide rates by nearly 40%, and by nearly 30% percent for alcohol-induced deaths between 1999 and 2021. This collection of drug-, alcohol- and suicide deaths are oftentimes referred to as “deaths of despair”, first coined by economists Anne Case and Angus Deaton who cited health and socioeconomic disparities driving Americans into mental distress, depression, and anxiety. The impact on the mental health of Americans was further exacerbated by the COVID-19 pandemic; this exposed vulnerabilities in the mental healthcare system as well as the various stressors that negatively impacted individuals across the globe. Using nationally representative data, this dissertation delves into the deaths of despair phenomenon using a multidisciplinary health services research lens. Access, utilization, and risk from deaths of despair are examined by using psychological distress (which is treated as a proxy for despair in the first two aims). Using the Kessler-6 scale, a well-accepted and clinically valid tool for non-specific mental distress, this dissertation explores patterns of healthcare spending among those with varying severity levels of psychological distress over a two-decade period; delves into patterns of healthcare utilization among young adults aged 18-30 (a population disproportionately impacted by stressors during the COVID-19 pandemic) by psychological distress; and quantifies the risk of death among those with varying severity levels of psychological distress.
CHARACTERISTICS AND HEALTH INSURANCE COVERAGE AMONG ADOPTED CHILDREN IN THE UNITED STATES
(2024) Fleishman, Jamie Lin; Yue, Dahai; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
The practice of adopting a child is a common occurrence within the United States. Research on adoption, birth parents, and adoptive parents has traditionally focused on psychology and social work outcomes. This master’s thesis shifts the focus of adoption outcomes to a public health perspective, examining the demographics, socioeconomic conditions, and health insurance rates of domestic and international adoptees. To help determine the rates of any health insurance, public health insurance, and private health insurance, this thesis examined American Community Survey 2022 5-year data, a nationally representative study of adoptees and their counterparts—non-adoptees who are biologically related to their parents or head of household. It was determined that domestic adoptees and non-adoptees had similar demographic and socioeconomic statuses whereas international adoptees were predominantly non-Hispanic Asians, females, and have wealthier and White heads of households. After controlling for demographic and socioeconomic variables, it was discovered that international adoptees have higher uninsured rates compared to non-adoptees and domestic adoptees, which could be attributed to geographic differences in health insurance coverage. Further research is needed to examine health insurance coverage rates in the United States for adoptees.
LEADERSHIP AS A CATALYST FOR HEALTH EQUITY: AN EXPLORATORY STUDY OF STRATEGIES AND INSIGHTS FOR QUALITY IMPROVEMENT IN HEALTHCARE ORGANIZATIONS
(2024) Howard, Christopher Norman; Thomas, Stephen B; White-Whilby, Kellee W; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
Health equity is a growing field of study and evidence-based practice among healthcare providers. Two essential influencers of this dynamic paradigm are equity-centered leadership and quality improvement strategies. The acclaimed Malcolm Baldrige Framework was selected as the impetus for exploring the conceptual relationship between health equity competence and leader driven quality improvement. Investigating the importance of integrating critical elements of theseinfluencers to achieve equitable outcomes in patient care, workforce diversity, and organizational culture is the focus of this research. A comprehensive review of the literature, supported by a thorough scoping review of eighteen established framework methodologies, developed for health equity aims and primary qualitative data gathered through survey and semi-structured interviews provided useful concepts to guide the process of examining the health equity knowledge base of senior healthcare leaders affiliated with acute care hospitals located in the Washington, D.C. area, and their perceptions of how equity, as a value, is actualized within their healthcare organizations. Study results revealed the lack of systemic integration in the practices of organizational leadership, quality improvement implementations and health equity measures. Also, the study results showed a need for increasing investments in health equity education and training at all levels and classifications of the healthcare professional workforce.
THE POLICY IMPACT OF STATE REINSURANCE PROGRAMS UNDER THE ACA 1332 WAIVER
(2024) Wang, Ren Hao; Yue, Dahai; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
Ten years after the implementation of the ACA, US families have been experiencing a continuing increase in the average premium for health insurance coverage. Although the case differs for the low-income population, providing affordable health insurance remains a significant policy issue. Section 1332 waiver of the ACA allows states to develop innovative strategies to provide affordable health insurance upholding the required high-quality care and basic protections. Seventeen states took the market-oriented approach of state reinsurance programs to stabilize the health insurance market and restrain premium increases. Using RWJF HIX data as well as public and restricted MEPS data, this dissertation investigated the policy impact of state reinsurance programs over premium reduction in the health exchange market, unintended consequence of crowding out Employer-Sponsored Insurance, as well as changes in out-of-pocket premium and insurance coverage on the consumer perspective.
MDPCP Primary Care Practice Capabilities and Care Management Delivery among Maryland Medicare Beneficiaries
(2024) Ector, Kaitlynn Robinson; Sehgal, Neil J.; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
Care management is one of the core components of comprehensive primary care, which represents the future direction of primary care in the United States. Nearly twenty percent of Medicare beneficiaries experience 30-day readmissions. While primary care is uniquely positioned to provide care management services associated with reducing readmissions, only 50 percent of older adults who have experienced 30-day hospital readmissions receive outpatient care. The goal of this dissertation was to identify structural and process components associated with the delivery of care management services to Maryland fee-for-service (FFS) Medicare beneficiaries, to examine geographic variation in the delivery of care management services, and to examine the association between the provision of care management services and patient health outcomes. This dissertation explores the relationship between structural and process components of care delivery and the delivery of care management services with three aims: (1) examine the association between primary care practice structural and process capabilities and the delivery of care management to Medicare beneficiaries and whether this association is altered by primary care practice medically underserved area (MUA) designation, (2) examine the association between Health Equity Advancement Resource and Transformation (HEART) payments and care management comprehensiveness and whether this association is altered by primary care practice care management delivery option, and (3) identify unique trajectories of comprehensive care management performance and examine the association between care management trajectories and readmission rates. Several key findings and implications are identified through the exploration of these aims. Increased primary care practice-level capabilities were associated with increased care management comprehensiveness. There was geographic variation in the provision of care management services among Maryland FFS Medicare beneficiaries. Next, prospective HEART payments were associated with increased care management comprehensiveness, and this association varied according to MUA designation and care management delivery options. Additionally, intensive partnerships between care transformation organizations (CTOs) and primary care practices improved access to comprehensive care management services. Finally, four unique classes of comprehensive care management performance were identified, and these care management performance classes had distinct patient characteristics and geographic locations. Among the low care management performance class, increased comprehensiveness among care management services was associated with decreased unplanned readmissions over time. This dissertation provides evidence that geographic variation in the provision of care management exists and includes guidance on how to assess geographic variation in care management services across the United States. These results also provide valuable evidence about how prospective equity-based payments can transform care delivery in primary care settings. Lastly, this dissertation presents a novel method of program performance evaluation that can be applied to all evaluations of Medicare demonstrations.
THE EFFECTS OF MEDICAID COVERAGE FOR ABORTION
(2024) Kim, Taehyun; Boudreaux, Michel; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
In this dissertation, I examine the causal impact of Medicaid abortion coverage on abortion utilization, births, economic, and maternal health outcomes. I do so by leveraging benefit changes in Illinois, Maine, and West Virginia. Major findings suggest Medicaid abortion coverage increases the abortion rate and decreases birth rates, although the effects differ by state. I also found that Medicaid abortion coverage increases individual wage income and decreases the poverty rate among females of reproductive age. I did not find evidence that introducing Medicaid abortion coverage increased educational attainment or decreased maternal morbidity. The findings have important policy implications for the wellbeing of people capable of pregnancy.
UNDERSTANDING THE IMPACT OF LONG-TERM CARE NEED AMONG MEDICARE-ONLY BENEFICIARIES
(2024) Albaroudi, Asmaa; Chen, Jie; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
The population of adults 65 years of age and older is growing tremendously, and the majority of this population will have some level of long-term services and supports (LTSS) needs. Most older adults will qualify for Medicare insurance, which does not provide coverage for LTSS. The high costs associated with receiving LTSS, which includes supports for activities of daily living, places a financial burden on Medicare-only beneficiaries with limited resources, increasing their likelihood of becoming eligible for Medicaid coverage (i.e., dual-eligible). Given that Medicaid is the primary payer for LTSS, much of the literature on long-term care (LTC) is focused on a Medicaid eligible population. This dissertation explores the experience of Medicare-only beneficiaries with an LTSS need, who are responsible for the costs of their LTSS and may ultimately qualify for Medicaid. The Health and Retirement Study data are used to explore my dissertation objectives. My dissertation examines three areas: (1) the financial burden of Medicare-only beneficiaries with high functional impairment by assessing out-of-pocket costs; (2) spend down to dual-eligible status for Medicare-only beneficiaries with and without a LTC need; and (3) spend down by race and ethnicity with and without a LTC need.
The Role of Personal Integrity in Shaping Healthcare Worker Perceptions of Patient Safety Culture in US Hospitals During the Covid-19 Pandemic
(2024) Edelstein, Lauren Michelle; Franzini, Luisa; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
Abstract Overview: The COVID-19 pandemic strained hospitals in unprecedented ways that required healthcare workers to adapt to and endure challenges, testing their ability to do a good job with the human and technological resources available to them. Using a proxy variable for personal self-integrity (PSI), derived from questions on the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture (HSOPS), this dissertation explores the way workers’ capacity to maintain alignment of their actions and morals shifted during the pandemic. Conceptual Framework: The investigations within this study can be understood through the Healthcare Workforce Integrity Model, an innovation based on the Job Demands and Resources Model that accounts for the deeply moral nature of healthcare work. The model holds that intensity of job demands and the strength of supportive job resources shape workers’ abilities to maintain PSI in their work. Over a sustained period, this impacts worker energy and motivation, and ultimately, organizational resilience. Methods: The study uses descriptive statistics and regression modeling based on data from the AHRQ’s HSOPS and data from the Hospital Cost and Utilization Project (HCUP), from timeframes before and during the COVID-19 pandemic, to analyze shifting perceptions about patient safety culture within the hospital workforce. Results: Workers’ capacity to maintain their PSI worsened steadily over the pandemic. When patient mortality was higher, workers’ PSI worsened, with particularly acute effects experienced in ICU settings. When hospital workers perceived teamwork and leadership support negatively, and when they perceived that staff were blamed for patient safety problems, their perceptions of their own personal integrity diminished by statistically significant margins. No significant associations indicate that hospital workers’ perceptions of teamwork, leadership support, or being blamed for safetyproblems were more closely tied with their ability to maintain positive PSI during the pandemic than they were before the pandemic. Conclusions: Organizational solutions are needed to support healthcare workers’ ability to thrive and maintain integrity in non-crisis moments just as much as they are needed during moments of crisis and uncertainty. Achieving this goal can better ensure that healthcare workers feel they can depend on their institutions and its people to do the right thing.
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.

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