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 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 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 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.Item 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.Item 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.Item 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.Item 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.