Health Policy & Management Theses and Dissertations

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PERCEPTION OF PATIENT-PROVIDER COMMUNICATION AND ITS ASSOCIATION WITH HEALTH SERVICES UTILIZATION
(2012) Villani, Jennifer; Mortensen, Karoline; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
The Patient Protection and Affordable Care Act of 2010 has generated an unprecedented emphasis on patient satisfaction and patient-centered care. This dissertation is composed of a series of papers on how patients perceive the quality of care delivered by their healthcare providers and its relationship to their usage of health services. The main hypothesis is that higher perceived quality of care is associated with more effective use of health services. The studies use nationally representative data from the Medical Expenditure Panel Survey (MEPS) with the research grounded in Andersen's Behavioral Model of Health Services Use. In the first study, I explore whether differences in satisfaction between English- and Spanish-speaking Hispanics can be explained by acculturation and concordance with their providers with regard to race, ethnicity, gender, and language. I use the econometric Blinder-Oaxaca decomposition method to quantify the contributions of each measured characteristic for explaining disparities in patient satisfaction. In the second study, I examine whether a lack of patient-centeredness and poor access to a regular provider are associated with greater nonemergent emergency department (ED) utilization. I employ a hurdle model to account for the two-part decision making process of whether to use the ED and how often to use the ED for nonemergent purposes. In the third study, I investigate the relationship between patient-centered care and receipt of six recommended clinical preventive services including screening for breast cancer, cervical cancer, colorectal cancer, high cholesterol, hypertension, and vaccination against influenza. I use multivariate logistic regression models to determine the probability of compliance with national prevention guidelines. The results reveal the importance of how patients perceive interpersonal communication with their healthcare providers. In the first study, acculturation is implicated as a major contributor to differences in patient satisfaction with communication. Furthermore, the results from the second study indicate language concordance between patients and providers is related to less nonemergent ED use. Findings from the third study suggest a pattern of greater compliance with clinical preventive service recommendations when patients perceive receiving patient-centered care from their providers. Implications for policy and practice are presented.
RACIAL AND ETHNIC DIFFERENCES IN ACCESSING TIMELY CANCER SCREENING AND TREATMENT SERVICES: A QUANTITATIVE ANALYSIS
(2013) King, Christopher Jerome; Thomas, Stephen B.; Chen, Jie; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
This research is organized into three integrated studies that explored differences in screening and treatment services across the cancer care continuum by race and ethnicity. The Andersen Behavioral Model of Health Services Use and the Five Dimensions of Access were used as conceptual frameworks. In the first study (Chapter 2), data from the Medical Expenditure Panel Survey were used to examine breast and cervical cancer screening rates before and during the Great Recession (2007-2009). The interaction terms of recession and race and ethnicity were controlled to examine whether minorities exhibited different utilization patterns under economic shock compared to Whites. In Chapter 3, data from the National Health Interview Survey (NHIS) from 2006-2010 were used to identify adult cancer survivors and adults without a history of cancer. Multivariate logistic regressions were applied to examine the prevalence of cost, organizational and transportation barriers between survivors and the general population. The likelihood of experiencing barriers was explored by race and ethnicity. In Chapter 4, differences in the likelihood of experiencing access barriers among survivors by race and ethnicity was explored. Data were merged from the 2000-2011 (NHIS) to identify adult cancer survivors who reported cost, organizational and transportation barriers. Logistic regressions were applied to determine the likelihood of reporting each type of barrier, while controlling for demographic and socioeconomic variables. The Fairlie decomposition technique was applied to identify contributing factors that explained differences in accessing care based by race and ethnicity. Overall, results of the investigations demonstrate that: (1) breast and cervical screening rates declined most among White women during the recession period, while rates increased among Hispanic women during the same period; (2) minority cancer survivors were significantly more likely to experience access-to-care barriers than Whites; and (3) insurance, comorbidity, perceived health and nativity were leading factors that contributed to racial and ethnic differences in timely receipt of cancer screening and treatment services. As provisions of the Affordable Care Act take effect, findings provide insight into practices, policies, and future research that will help achieve Healthy People 2020 screening objectives and reduce racial and ethnic disparities in accessing timely cancer care.
EXPANDING THE CONCEPTUAL FRAMEWORK OF HEALTH LITERACY TO IMPROVE LONG-TERM SERVICES AND SUPPORTS
(2013) Ruben, Kathleen Ann; Simon-Rusinowitz, Lori; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
Low health literacy is a significant and growing public health problem. It is estimated that 90 million individuals in the U.S. have low health literacy, which is associated with poor health outcomes. Individuals with low health literacy skills may not be able to obtain health information, communicate with health care providers, or make optimal health care decisions. People from all backgrounds can have low health literacy levels, however, the rates are higher in certain groups such as older adults, Medicaid beneficiaries, and minority populations. Due to our rapidly aging and increasingly diverse U.S. population, the problems associated with low health literacy may increase over the next few decades. Studies have examined the relationship between an individual's health literacy level and their own health outcomes. However, few have focused on how the health literacy level of others, such as caregivers and health care professionals, impacts the health outcomes of care recipients. It is important to understand this relationship in terms of elders who depend on others, such as caregivers and family members, for their care. This series of three studies addresses this critical gap in health literacy research. The first two studies examine the need for a health literacy component of a training program for care teams for individuals with dementia in participant-directed programs. The first is an ethnographic pilot study of caregivers in West Virginia's Personal Options Program, and the second is a mixed- methods study of "Decision-Making Partner" preparedness in Arkansas' IndependentChoices Program. The third study examines the effect of the emergency department referral process on repeated utilization of community health centers by low-income, uninsured adults and Medicaid Beneficiaries, as well as the role of Patient Navigators as mediators within the framework of health literacy. This research provides evidence that the health literacy level of others, including caregivers, decision-making partners, and health care providers significantly impacts the ability of older adults to access health services and supports, communicate with healthcare providers, navigate the healthcare system, and manage chronic diseases. Therefore, addressing health literacy is essential for increasing health-related knowledge, improving health outcomes, and decreasing health disparities in long-term care.
Inpatient Mortality in Emergency Care: Is Competition Always Good?
(2014) Kwok, Veronica; Chen, Jie; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
The objective of this study was to measure the association between regional competition and emergency care outcomes. Competition was measured using the Herfindahl-Hirschman Index for three hospital referral regions in Maryland. Preliminary regression analysis using a logistic binary model showed that higher competition was associated with lower odds of mortality. Further investigation suggested that competition could be endogenous. Further regression analysis using an instrumental variable of hospital system affiliation and two-stage least squares estimation showed that lower competition was associated with lower odds of mortality for sepsis and trauma (OR = 0.7, p-value <0.001, OR = 0.5, p-value <0.001, respectively). Future investigation perhaps on a national level could help identify a stronger, more uniform association between competition and emergency care outcomes including large scale events, and as such provide policy guidance for quality of emergency care.
Preventive Services Use - Disparities and Changes Following Health Care Reform
(2015) Holden, Craig David; Dagher, Rada; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
The federal Patient Protection and Affordable Care Act (ACA), signed into law on March 23, 2010, changes the landscape of U.S. health care through expanded insurance access, enhanced consumer protections, emphasis on wellness and disease prevention, and cost control. This dissertation is composed of three papers that investigate aspects of preventive services. The studies use nationally representative data from the National Survey of Family Growth and the Medical Expenditure Panel Survey and employs Andersen's Behavioral Model of Health Services Use as a theoretical model. The first study explores the relationships between use of various preventive services and being uninsured. The study employs multivariate logistic regression analyses to estimate variation in receipt of eight preventive services by race/ethnicity among adults aged 18 years and older uninsured in the previous year. The second article focuses on expanded access to health insurance in young adults and how this relates to the use of contraception and unintended pregnancy. This study used a difference-in-differences approach in order to identify a causal relationship between the policy and outcome. The third article examines colorectal cancer screening practices in the Medicare population before and after Medicare rules changes stemming from the ACA regarding reimbursement of screening procedures. Multivariate and single difference multivariate logistic regression models were estimated to examine trends and racial/ethnic differences in colorectal cancer screening over the 2007 to 2012 period. The results show how important it is to understand the determinants of preventive service access among a variety of population subgroups. With the introduction of the Affordable Care Act, health systems require strategies to determine what policy, system, and administrative methods are most effective in improving the uptake of preventive services and reducing disparities. This dissertation addressed policy influences on screenings and provided information on the impact of policies on use of preventive services as well as on reducing the disparities among subpopulations. Improved access to health insurance and better coverage of preventive services are necessary mechanisms to increase service utilization in the United States, but these may not be sufficient to actually realize improved utilization.
Determinants of Unintended Pregnancy and Modern Family Planning Use
(2017) Kim, Theresa Youngjoo; Boudreaux, Michel H; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
Unintended pregnancy, defined as a pregnancy that is mistimed or unwanted, is one of the world’s most common negative health outcomes. Furthermore, the United Nations Population Fund has found that 225 million women wish to delay or avoid pregnancy yet do not engage in modern family planning method use. Unintended pregnancy affects both maternal health (by way of nutrient deficiency, reproductive organ deficiency, and mental health) and child health (low birth weight, reduced gestational age, and nursing difficulties). The most life-saving and cost-saving means to prevent unintended pregnancy is to encourage modern family planning use. This dissertation examines family planning and unintended pregnancy in three different national contexts. In these studies, I: 1. Decompose the differences in unintended pregnancy rates for black and Hispanic women compared to white women in the United States; 2. Examine the relationship among indicators of health literacy, health system access, and utilization of modern family planning in Senegal; 3. Evaluate an intervention in Benin designed to increase modern family planning use. My research found that black and Hispanic women had a greater likelihood of unintended pregnancy compared to white women. However, psychosocial and socioeconomic factors contributed to the greater likelihoods of unintended pregnancy among racial and ethnic minorities. Among indicators of health literacy, oral and visual messages were the strongest predictors of health system access and modern family planning use in Senegal. The conclusion of the intervention in Benin found that social diffusion behaviors increased among people in the treatment group, and furthermore, the intervention did reduce unmet need for modern family planning use. These research results, though from different research studies, can imply that increasing access as much as possible to modern family planning use can ultimately prevent unintended pregnancy.
PREVENTIVE CARE UTILIZATION AND ITS IMPACT ON POTENTIALLY PREVENTABLE HOSPITALIZATIONS: IMPLICATIONS OF MEDICAID COST-SHARING, MEDICAID EXPANSION, AND THE AFFORDABLE CARE ACT FOR VULNERABLE POPULATIONS
(2017) Bloodworth, Robin; Chen, Jie; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
About half of Americans have at least one chronic disease, and chronic diseases account for nearly 90% of healthcare expenditures in the US. Primary care can reduce potentially preventable hospitalizations and overall costs of chronic diseases. However, only about 3% of US healthcare spending is on prevention. Racial/ethnic disparities and income disparities have been well documented in the use of primary care. The ACA expanded insurance coverage for millions of Americans and included a mandate that all insurance plans must cover recommended preventive services at no cost to the patient. Literature shows the ACA resulted in an increase in access to care, but results on utilization rates of primary care post-ACA are mixed. Using nationally representative data sets from 2009-2015, I examined the utilization rates of preventive services among vulnerable populations after the full implementation of the ACA, and how Medicaid state policy and expansion under the ACA affected the utilization of preventive services among vulnerable populations. Next, using the Maryland Medical Care Database from 2012-2014, I examined how continuity of primary care affects the odds of having any hospitalization as well as potentially preventable hospitalizations. I found that the ACA was associated with an increase in preventive services recommended yearly, and the ACA was not associated with disparities in preventive service utilization among vulnerable populations. Additionally, I found that state Medicaid policies on preventive services were associated with increased utilization of flu shot, but Medicaid expansion was not associated with increased utilization of preventive services or many changes in disparities in preventive service utilization among vulnerable populations. Finally, I found that primary care, especially ongoing primary care, was strongly associated with a decrease in the odds of having any hospitalization and potentially preventable hospitalizations. Results suggest that increased access alone will not increase utilization rates and reduce health disparities, but rather, a focus on education of what coverage options are available through the ACA, the importance of ongoing primary care, and how to navigate the healthcare system once insured could increase utilization of preventive care, especially in vulnerable populations.
Community Living and Health Services Utilization among the Aging Services Network Population
(2017) Gaeta, Raphael; Simon-Rusinowitz, Lori; Chen, Jie; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
By 2050, the number of older adults will increase from 67 million to 111 million, or roughly 28 percent of the total U.S. population. Age is a principal predictor of physical health status as well as functional and cognitive limitation. As the aging population grows, so too will the demand for long-term services and supports (LTSS) and healthcare services. Despite this intersection, LTSS and healthcare systems are highly disconnected. The Aging Services Network, authorized and partially financed by the Older Americans Act (OAA), may play an important role in an emerging trend toward integrating services. Yet, OAA research is lacking. Existing OAA research faces several obstacles, including handling program variation resulting from a decentralized Aging Services Network, identifying non-user comparison groups for OAA study samples, and limited utility of national datasets. Studies often rely on highly descriptive methods, indirect comparisons to the general population of older adults, or state-restricted analysis. This dissertation addresses several gaps in the research. The first study aims to identify factors associated with community tenure and participation among low-income elderly living in subsidized housing. The research is grounded in conceptual frameworks from the World Health Organization. In-depth interviews and focus groups are used to explore these associations among elderly HUD building residents in Prince George's County, Maryland. The second study aims to identify multilevel predictors of OAA Title III services participation. This study develops a conceptual framework based on the Andersen Behavioral Model of Health Services Use, and uses a merged data set from the nationally representative Health and Retirement Study with geographic data and relevant state policies. The third study further examines the relationship between OAA Title III services participation and patterns of healthcare utilization. This dissertation research provides evidence for the importance of OAA Title III services, including for elderly HUD beneficiaries. Findings from multivariate regression analyses provide evidence for (1) county level targeting criteria used to measure LTSS need and direct OAA Title III funding, (2) substantial influence of Medicaid on access to OAA Title III services, and (3) changes in mix of health care services use among OAA Title III services participants over time.
ADVANCING THE HEALTH OF UNDERSERVED COMMUNITIES ACROSS THE UNITED STATES: OPPORTUNITIES TO IMPROVE HEALTH CENTER QUALITY OF CARE AND PATIENT EXPERIENCE
(2017) Nair, Suma; Chen, Jie; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
1 in 13 people in the United States receives care at a community health center. As health center services become an increasing percentage of all primary care services delivered in the United States, their success is vital to national efforts to advance health and manage costs. This dissertation presents three studies, addressing critical gaps in our understanding of health center quality and quality improvement opportunities. The first study examined the association between ambulatory care accreditation and 14 clinical quality measures in 1,198 health centers. Results demonstrated that accredited centers achieved higher performance on adult weight screening and follow up, tobacco cessation intervention, and use of lipid-lowering therapy. Universal accreditation could lead to an additional 552,087 patients receiving weight screening and follow up, 157,434 receiving tobacco cessation interventions, and 25,289 receiving lipid-lowering therapy. Findings suggest universal accreditation could contribute to quality gains and facilitate health disparity reduction. The second study used the first nationally representative dataset of health center PEC, to investigate the association between five measures of PEC (access to care, provider communication, office staff interactions, follow up on results and overall provider rating) and patient and health center characteristics. Results demonstrated that PEC ratings varied significantly by race/ethnicity, health and mental health status, education and income levels, and language. Findings highlight PEC improvement opportunities as well as the importance of patient-mix adjustment of PEC ratings in value-based payment. The third study evaluated the association between PEC and health center quality of care. Quality of care metrics included receipt of care, health behaviors, patient activation, and clinical outcomes in health center patients. Results showed that PEC ratings were associated with receipt of care, as well as patient adherence and activation. The findings support the importance of measuring PEC as a key determinant of quality, as well improving PEC as a driver for improvement for other aspects of care quality. All three studies were the first to our knowledge to use nationally representative health center data to examine these dimensions of quality and provide significant contributions towards our understanding of health center quality and related quality improvement and policy implications.
EFFECTS OF MEDICAID STATE PLAN DENTAL BENEFITS ON DENTAL VISITS AMONG NON-ELDERLY ADULTS
(2018) Marthey, Daniel Joseph; Franzini, Luisa; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
Using the Behavioral Risk Factor Surveillance Survey and optional Health Care Access module, I analyzed dental visits between insurance types and between three levels of Medicaid dental coverage for non-elderly adults in each state defined as no benefits or emergency-only, offering 1-4 services and offering 5 or more service types. I find Medicaid adults are less likely to experience a dental visit compared with adults covered by private insurance. I also find a statistically significant relationship between the level of benefits offered to beneficiaries and the odds of experiencing a dental visit in the previous year. Understanding factors associated with the use of dental services is necessary to adequately address health needs of the Medicaid population and unnecessary emergency room use for non-emergency dental services.
Socioeconomic Position, Gender, and HPV Vaccine Utilization
(2018) Rogers, Taylor; Boudreaux, Michel; Thomas, Stephen B; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
In 2011-2014, the prevalence of HPV was higher in adult males compared to adult females. HPV and its associated health outcomes can be prevented through the completion of the 3-dose HPV vaccine series. Using the 2010 - 2016 National Immunization Survey - Teen, I examined the association of family income and gender with three HPV vaccine utilization outcomes: (1) receipt of provider recommendation; (2) HPV vaccine initiation; and (3) HPV vaccine completion using logistic regressions. Results suggested that family income was negatively correlated with HPV vaccine outcomes regardless of gender and controlling for other covariates. I also found that males had lower vaccine use compared to females, regardless of income. In the second analysis I investigated if the 2011 ACIP guideline increased vaccine utilization outcomes using a difference-in-differences. This analysis suggested that the new guideline increased recommendations by 24 percentage points for males, relative to females (P<0.01), HPV vaccine initiation improved by 23 percentage points (P<0.01), and vaccine completion improved by 10 percentage points (P<0.01).
THE EXAMINATION OF NATIONAL-NUTRITION POLICIES ON NONCOMMUNICABLE DISEASE MORTALITY AT VARIOUS STAGES OF ECONOMIC DEVELOPMENT: A CROSS-COUNTRY PERSPECTIVE
(2019) Gupta, Manisha; Franzini, Luisa; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
The acceleration of economic growth over the past few decades introduces the need to reorient policy to address the needs and challenges for a healthier population. This paper will review the effectiveness of national nutrition policies targeting overweight, healthy diets during pregnancy, infancy and childhood, and noncommunicable diseases (NCDs) across advanced economies and transitional economies. The level of expansion and industrialization of food systems around the world have had a direct impact on nutritional status and health. Considering the magnitude of nationwide public health responses to shifts in mortality have varied over time, this introduces the need to assess the ability for dietary-related policies to successfully reduce NCDs. Results from this analysis can provide a strong rationale as to when interventions will be most effective as well as ways in which we can carry out a timely response in establishing effective policies for countries at different levels of economic development.
THE EFFECT OF OWN RACE/ETHNICITY DENSITY ON INSURANCE TAKE-UP BY ASIAN AMERICANS
(2019) Choi, Yoon Sun; Roby, Dylan H; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
Asian Americans are the fastest growing minority population in the U.S. (Lopez et al., 2017). Since the implementation of the Patient Protection and Affordable Care Act (ACA), Asian Americans have benefitted from insurance coverage increases but continue to experience disparities at the subgroup level (Park et al., 2018). This study investigates the association of own race subgroup density on the take-up of insurance by examining the effect of Asian subgroup concentration that may provide social and knowledge support linkages to available insurance coverage options.
Adverse Childhood Experiences and Preterm Birth: A Systematic Review
(2019) Wiggan, Morgan Lynn; Franzin, Luisa; Shenassa, Edmond; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
Adverse childhood Experiences (ACEs) elevate one’s risk for poor health outcomes later in life such as psychiatric disorders, cardiovascular disease, depression, anxiety, obesity, diabetes, poor fetal health, and liver disease (Poulton et al., 2002, Anda et al., 2007, Jimenez et al., 2017, Talbot et al., 2009. While the association between ACEs and negative health outcomes is well established in the literature, only ten studies examine the effect of ACEs on one’s risk for preterm birth (Benedict et al. 1999; Bublitz et al., 2014; Cammack et al., 2019; Christiaens et al. 2015; Jacobs 1998; Gillespie et al. 2017; Grimstad et al. 1998; Leeners et al. 2010; Margerison-Zilko et al., 2016; Noll et al. 2007). Preterm birth accounts for 60% of neonatal deaths and elevates an infant’s risk for poor health outcomes later in life ranging from behavioral issues to heart disease (WHO, 2018) and the rate of preterm birth in the United States has steadily risen since 2015, reaching about 10% in 2018 (CDC, 2018). This systematic review seeks to critically assess and synthesize these ten studies and identify proposed mediators and identify gaps in the literature for future research.
The Impact of International Accreditation on The Quality of Health Services at King Fahd University Hospital, Saudi Arabia: A Mixed Methods Approach
(2019) AL Shawan, Deema Saad; Franzini, Luisa; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
The Joint Commission International Accreditation (JCIA) is perceived worldwide as the symbol of exceptional quality of care. Despite the popularity of international accreditation, evidence of its effectiveness on improving health care quality is inconclusive. This dissertation research utilized a Convergent parallel mixed method framework to evaluate the impact of the JCIA process on quality and to identify the factors that influence the effectiveness of this process at King Fahd Hospital of the University in Khobar, Saudi Arabia. An interrupted time series analysis was conducted to assess the changes in a total of 12 quality outcomes pre and post accreditation. Furthermore, a qualitative approach was used to investigate the attitudes and perceptions of 31 health providers towards this process and the factors that influence its success. The quantitative results suggested that the JCIA had a positive impact on 9 out of 12 outcomes. The improved quality outcomes included: the average length of stay, the percentage of hand hygiene compliance, the rate of nosocomial infections, the percentage of radiology reporting outliers, the rate of pressure ulcers, the percentage of the correct identification of patients prior to medication administration, the percentage of critical lab reporting within 30 minutes, and the bed occupancy rate. The outcomes that did not improve were the rate of patients leaving the ER without being seen, the percentage of OR cancelations on the day of the or and the rate of patient falls. The qualitative analysis suggested that the JCIA was perceived positively by all participants. Some of the perceived advantages of international accreditation included the transformation of the organizational culture to a culture that promotes continuous quality improvement, standardization, and the reduced paperwork in some departments. The participants’ responses also indicated that there were many factors that influence the success of the process. Examples of the factors identified in the study include the increased workload and the providers’ resistance to participate in the JCIA process. In conclusion, international accreditation seemed to have a positive impact on quality outcomes and was received positively by providers. Nevertheless, the factors that hindered the JCIA process need to be addressed by the hospital’s leadership to ensure more efficient quality improvement efforts during future accreditation cycles.
Connecting the Dots Across the Care Continuum: Addressing Behavioral Health in ACO Networks
(2019) Anderson, Andrew; Franzini, Luisa; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
Accountable Care Organizations (ACOs) represent a shift from traditional fee-for-service payment systems that reward volume to payment models that reward providers for value (e.g. quality improvement and cost reduction). Hospitals that lead or participate in ACOs have the potential to work with other providers to bridge the gap between traditional medical and behavioral health services. The goal of this dissertation was to examine the structures, processes, and outcomes of care for hospitals that lead or participate in ACO networks. The overarching hypothesis was that ACO-affiliated hospitals provide better behavioral health care due to increased care coordination and increased connections to behavioral health providers. This dissertation had three aims: 1) compare the implementation of care coordination strategies between ACO affiliated hospitals and unaffiliated hospitals and examine whether the implementation of care coordination strategies varies by hospital payment model types; 2) compare the use of care coordination strategies between ACO-affiliated hospitals with and without in-network behavioral health providers; and 3) compare rates of follow-up after a hospitalization for mental illness between ACO-affiliated and unaffiliated hospitals. These aims build on each other to illustrate how hospitals that participate in ACOs are improving care coordination and the provision of behavioral health services. There were several meaningful findings. ACO-affiliated hospitals were more likely to use care coordination strategies compared to unaffiliated hospitals. Participation in global capitation and shared savings models was associated with greater use of care coordination strategies. Nearly two-thirds of ACO-affiliated hospitals did not have in-network behavioral health providers. ACO-affiliated hospitals had a significantly higher average unadjusted rates of follow-up after a hospitalization for mental illness at 7 days and 30 days post-discharge compared to unaffiliated hospitals. Hospitals are important components of the care continuum and will play a critical role in improving outcomes for patients with behavioral health conditions. Policy makers should include behavioral health related performance measures tied to performance-based payment arrangements in ACO programs. ACOs can be used as way to bridge behavioral, clinical, and social services to address the unique needs of individuals with behavioral health conditions.
Health Policy, Care Coordination, and Racial and Ethnic Disparities Among US Adults Aged 18-64 with Serious Psychological Distress
(2019) Novak, Priscilla; Chen, Jie; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
About one in five Americans have a mental health condition, and in any given year, 3-5% of the population experiences serious psychological distress (SPD). The goal of this dissertation is to examine the impact of health policy on racial and ethnic disparities among people experiencing SPD. The literature review in my dissertation details evidence on systemic racial and ethnic differences in access, quality, and care coordination. I develop a causal theory examining the reasons why the problem of SPD and racial and ethnic health disparities exist and specific evidence that illuminates how the problems come into existence. Using National Health Interview Survey data from 2011-2016, access to care among Non-Hispanic (NH) Whites, NH Blacks and Hispanics with SPD is examined. Findings suggest that in comparison to NH Whites, NH Blacks and Hispanics experienced greater gains in health care access following the Affordable Care Act (ACA). Next, using data from the 2015 and 2016 Medical Expenditure Panel Survey, differences in racial and ethnic minorities being served by usual sources of care with care coordination services is examined. Findings suggest that in comparison with NH Whites with SPD, Hispanics with SPD had lower odds of being seen at a Patient Centered Medical Home (OR 0.55, (p <0.05)). Hispanics had higher odds (1.29 (p <0.03)) of being seen at a practice that used case managers; and Non-Hispanic Blacks with SPD had higher odds (3.25 (p< 0.001)) of being seen at a practice that used care managers. Given that people with diabetes experiences mental health conditions occur at about twice the rate of the general population, this dissertation examined the quality of care provided to people with doctor-diagnosed diabetes and SPD using data from the Medical Expenditure Panel Survey. Findings suggest that between 2012 and 2016, racial and ethnic disparities in the receipt of glycated hemoglobin (HbA1c) testing improved but were not eliminated. Results suggest that increased health insurance coverage alone does not eliminate health disparities, and work remains to be done to ensure that all Americans benefit from high-quality, evidence-based care.
THREE ESSAYS ON MARYLAND'S GLOBAL BUDGET REVENUE PROGRAM AND HOSPITAL-BASED NEONATAL CARE
(2020) Xie, Liyang; Boudreaux, Michel; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
Health care spending is a major concern in the United States. State and federal governments have been engaged in a number of health care system reform initiatives designed to contain costs by regulating both price and quantity. Comprehensive evaluations of these initiatives are crucial for policymakers reshaping and expanding reforms. This dissertation evaluates the impact of Maryland's Global Budget Revenue (GBR) program, one of the most innovative statewide hospital payment reforms, on birth-related hospital utilization. The GBR program was designed to provide incentives for hospitals to reduce high-cost services and substitute them for lower-cost population health investments. This is largely accomplished by capitating annual budgets. This dissertation evaluated the effects of GBR on high-cost neonatal services, especially the neonatal intensive care unit (NICU). I examine heterogeneous treatment effects with respect to observable clinical needs and financial incentives. In Chapter One, I provide an overview of Maryland’s GBR program and introduce the conceptual framework. In Chapter Two, I examine the impact of GBR on NICU admissions and infant mortality. I explore the heterogeneity of treatment effects by infant health risk. Chapter Three expands the analysis to broader birth-related hospital services by investigating the impact of GBR on length of stay (LOS), the total cost of care, and utilization of specific high-cost services. Chapter Four departs from GBR and examines NICU utilization related to another critical source of financial incentive – health insurance type. Chapter Five concludes the dissertation. I find that Maryland's GBR program led to a substantial decline in NICU admissions, which was mainly driven by the decrease in admissions of relatively healthy infants, and there are no changes in the infant or neonatal mortality rate. The GBR program is also associated with declines in LOS and high-cost services used for infants. Finally, I observe that infant, maternal, and state characteristics explain the variations in NICU care across insurance type for high-risk infants but not for relatively low-risk infants. My findings provide positive evidence on implementing global hospital budget programs and shed light on the economic incentives affecting NICU care.
SOCIAL AND ENVIRONMENTAL BARRIERS TO HEALTHCARE ACCESS AND UTILIZATION FOR LESBIAN, GAY, AND BISEXUAL PEOPLE IN CALIFORNIA.
(2020) Akre, Ellesse-Roselee; Roby, Dylan H; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
Sexual minorities, lesbian, gay and bisexual people, are exposed to chronic stigmatization and heteronormativity in their daily lives and when they access health care. There are no genetic differences between sexual minorities and their heterosexual counterparts; the literature demonstrates that chronic stress related to being a minority, experiences associated with accessing care in a system that assumes one is heterosexual, exposure to negative attitudes from others, and internalized negative attitudes regarding one’s sexuality impact health outcomes and healthcare access and utilization. While there are known barriers to healthcare access the literature does not examine how multiple social identities influence healthcare access in sexual minorities. Intersectionality posits that the interconnected nature of social identities creates an overlapping and interdependent system of disadvantage. This study had three aims: 1) To examine differences in healthcare access at the intersections of urbanicity, race/ethnicity, and sexual identity; 2) examine differences in healthcare access at the intersections of sexual identity, gender, and income; and 3) determine whether non-identifying sexual minorities have disparate access to healthcare compared to identifying sexual minorities. Using 2014-2017 California Health Interview Survey data combined with the supplemental sexual orientation special use research file, I examined the relationship between healthcare access and utilization outcomes and the intersections between sexual identity, urbanicity, gender, income, and sexual identity disclosures. Using known evidence of barriers to healthcare access as dependent variables I used predictive modeling to estimate odds ratios of experiencing barriers to healthcare access using adjusted logistic regressions. The results of my dissertation produced evidence that for sexual minorities in California, sexual identity is associated with varying levels of healthcare access when examined within the context of other social identities. That is, there are differences in access and utilization amongst sexual minorities based on income and gender, and within subgroups of sexual minorities, especially in female and bisexual subgroups. Urban and rural environment did not determine healthcare access in sexual minorities and there was not enough data to confidently estimate differences in access between urban and rural sexual minorities of color. Study findings demonstrate that the female gender has more disadvantages to healthcare access that advantages regardless of income and sexual identity. They also demonstrated that income does not fully mitigate access barriers in sexual minority women. Lastly, findings from the study demonstrate that the non-identifying sexual minority identity is associated with less access to healthcare, specifically in men. Findings from this dissertation contributes to the knowledge of how disparities in healthcare access and utilization continue to persist in the sexual minority population despite increased access to healthcare coverage. This dissertation suggests that other factors uniquely related to being female and bisexual are salient for accessing healthcare for sexual minorities. It is essential that researchers, policy makers, and healthcare providers and staff provide more data on sexual minorities, create curated policy to support the most vulnerable sexual minorities, and engage in culturally sensitive training to eliminate barriers to healthcare access for sexual minorities to eliminate healthcare access disparities.
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.