Health Policy & Management Theses and Dissertations
Permanent URI for this collectionhttp://hdl.handle.net/1903/7127
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Item DISPARITIES IN ADOLESCENT MENTAL HEALTH SERVICES UTILIZATION AND HELP-SEEKING(2024) Truong, Michelle L; Sehgal, Neil J; Boudreaux, Michel; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Inequities in access to and utilization of mental and behavioral health care for adolescents have persisted for numerous decades. Adolescents from racial and ethnic minority backgrounds, as well as those in underserved geographic regions, are disproportionately impacted. As the youth mental health crisis escalates, it is critical to study the mechanisms driving these disparities to inform effective and targeted interventions and policies. Divided into three studies, this dissertation explored the influence of individual, cultural, and contextual factors on adolescent help-seeking behaviors using data from the 2009 and 2011 to 2019 California Health Interview Survey (CHIS).The first study employed mediation analyses to assess the extent to which having a subjective or perceived need for mental health care, conditional on objective need, contributes to racial and ethnic disparities in mental health services utilization. I found significant racial and ethnic differences in subjective needs for mental health services and that these differences partially explain the racial and ethnic disparities in service utilization. The second study explored differences in mental health service utilization among subgroups of non-Hispanic (NH) Asian and Latino/Hispanic adolescents compared to NH white adolescents. I found that Vietnamese and Mexican adolescents were significantly less likely to utilize mental health services relative to their NH white counterparts. The third study merged the adolescent data with provider data from the National Plan and Provider Enumeration System (NPPES), facility data from the National Substance Use and Mental Health Services Survey (N-SUMHSS), and population data from the US Decennial Census Redistricting Data Summary Files to assess the moderating effects of distance to the nearest pediatric mental health facility and provider-to-population densities on the relationship between subjective mental health care needs and service utilization. I discovered that provider density and subjective needs interact, resulting in a diminished effect of subjective needs on service utilization among adolescents residing in areas with lower primary care provider density. I did not find that distance to the nearest pediatric mental health facility had a significant impact on service utilization. This dissertation examined racial, ethnic, and geographic mental health care disparities among a diverse adolescent population in California. Findings from this work contribute to the understanding of adolescent help-seeking behaviors and provide insights for targeted interventions and policies to advance mental health care equity.Item 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.Item 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.Item 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.Item 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.Item 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.Item 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.Item 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.Item 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.Item 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.