Browsing by Author "Sloan, Frank A"
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Item Open Access Adherence to diabetes guidelines for screening, physical activity and medication and onset of complications and death.(J Diabetes Complications, 2015-11) Chen, Yiqun; Sloan, Frank A; Yashkin, Arseniy PAIMS: Analyze relationships between adherence to guidelines for diabetes care - regular screening; physical activity; and medication - and diabetes complications and mortality. METHODS: Outcomes were onset of congestive heart failure (CHF), stroke, renal failure, moderate complications of lower extremities, lower-limb amputation, proliferative diabetic retinopathy (PDR), and mortality during follow-up. Participants were persons aged 65+ in the Health and Retirement Study (HRS) 2003 Diabetes Study and had Medicare claims in follow-up period (2004-8). RESULTS: Adherence to screening recommendations decreased risks of developing CHF (odds ratio (OR)=0.83; 95% confidence interval (CI): 0.72-0.96), stroke (OR=0.80; 95% CI: 0.68-0.94); renal failure (OR=0. 82; 95% CI: 0.71-0.95); and death (OR=0.86; 95% CI: 0.74-0.99). Adherence to physical activity recommendation reduced risks of stroke (OR=0.64; 95% CI: 0.45-0.90), renal failure (OR=0.71; 95% CI: 0.52-0.97), moderate lower-extremity complications (OR=0.71; 95% CI: 0.51-0.99), having a lower limb amputation (OR=0.31, 95% CI: 0.11-0.85), and death (OR=0.56, 95% CI: 0.41-0.77). Medication adherence was associated with lower risks of PDR (OR=0.35, 95% CI: 0.13-0.93). CONCLUSIONS: Adherence to screening, physical activity and medication guidelines was associated with lower risks of diabetes complications and death. Relative importance of adherence differed among outcome measures.Item Open Access Competition between Generic and Branded Drugs(Pharmaceutical innovation: incentives, competition, and cost-benefit analysis in international perspective, 2007-04-30) Grabowski, HGThe pharmaceutical industry worldwide is a rapidly burgeoning industry contributing to growth of gross domestic product and employment. Technological change in this field has been very rapid, with many new products being introduced. For this reason in part, health care budgets throughout the world have increased dramatically, eliciting growing pressures for cost containment. This book explores four important issues in pharmaceutical innovations: (1) the industry structure of pharmaceutical innovation; (2) incentives for correcting market failures in allocating resources for research and development; (3) competition and marketing; and (4) public evaluation of the benefits and costs of innovation. The lessons are applicable to countries all over the world, at all levels of economic development. By discussing existing evidence this book proposes incentive arrangements to accomplish social objectives.Item Open Access Do specialty courts achieve better outcomes for children in foster care than general courts?(Eval Rev, 2013-02) Sloan, Frank A; Gifford, Elizabeth J; Eldred, Lindsey M; Acquah, Kofi F; Blevins, Claire EOBJECTIVE: This study assessed the effects of unified family and drug treatment courts (DTCs) on the resolution of cases involving foster care children and the resulting effects on school performance. METHOD: The first analytic step was to assess the impacts of presence of unified and DTCs in North Carolina counties on time children spent in foster care and the type of placement at exit from foster care. In the second step, the same data on foster care placements were merged with school records for youth in Grades 3-8 in public schools. The effect of children's time in foster care and placement outcomes on school performance as measured by math and reading tests, grade retention, and attendance was assessed using child fixed-effects regression. RESULTS: Children in counties with unified family courts experienced shorter foster care spells and higher rates of reunification with parents or primary caregivers. Shorter foster care spells translated into improved school performance measured by end-of-grade reading and math test scores. Adult DTCs were associated with lower probability of reunification with parents/primary caregivers. CONCLUSION: The shortened time in foster care implies an efficiency gain attributable to unified family courts, which translate into savings for the court system through the use of fewer resources. Children also benefit through shortened stays in temporary placements, which are related to some improved educational outcomes.Item Open Access Effect of diabetes mellitus on giant cell arteritis.(J Neuroophthalmol, 2015-06) Abel, Anne S; Yashkin, Arseniy P; Sloan, Frank A; Lee, Michael SBACKGROUND: To determine if Type 2 diabetes mellitus (DM) is protective against giant cell arteritis (GCA) and to estimate the incidence of GCA diagnosis from Medicare claims. METHODS: Medicare 5% claims files from 1991 to 2011 were used to identify beneficiaries diagnosed with DM, but not GCA, within a 3-year ascertainment period. Propensity score matching was used to define a control group of nondiabetics with comparable demographic covariates. Competing risk regression was then used to assess the impact of DM diagnosis on GCA diagnosis. To allow for a 3-year ascertainment period, the analysis sample was limited to beneficiaries older than 68 years at baseline. RESULTS: A total of 151,041 beneficiaries diagnosed with DM were matched to an equal number of controls. Mean study follow-up was 67.75 months. GCA was diagnosed among 1116 beneficiaries with DM (0.73%) vs 465 (0.30%) controls. The risk of receiving a GCA diagnosis among patients with DM was increased by 100% (subhazard ratio, 2.00; 95% confidence interval, 1.78-2.25). The annual incidence of GCA diagnosis among claims for US Medicare beneficiaries older than 68 years old was 93 in 100,000. CONCLUSIONS: A DM diagnosis is not protective against a GCA diagnosis in the Medicare population. Our data suggest that a DM diagnosis increases the risk of GCA diagnosis within 5.7 years for Medicare beneficiaries older than 68 years.Item Open Access Effect of Prior Anti-VEGF Injections on the Risk of Retained Lens Fragments and Endophthalmitis after Cataract Surgery in the Elderly.(Ophthalmology, 2016-02) Hahn, Paul; Yashkin, Arseniy P; Sloan, Frank APURPOSE: To investigate the effect of prior intravitreal anti-vascular endothelial growth factor (VEGF) injections on surgical and postoperative complication rates associated with cataract surgery in a nationally representative longitudinal sample of elderly persons. DESIGN: Retrospective, longitudinal cohort analysis. PARTICIPANTS: A total of 203 643 Medicare beneficiaries who underwent cataract surgery from January 1, 2009, to December 31, 2013. METHODS: By using the 5% sample of Medicare claims data, the study assessed risks of 3 adverse outcomes after receipt of cataract surgery for beneficiaries with a history of intravitreal injections. Risks of these outcomes in beneficiaries with a history of intravitreal injections relative to those without were calculated using the Cox proportional hazard model. MAIN OUTCOME MEASURES: The primary outcome was the risk of subsequent removal of retained lens fragments (RLFs) within 28 days after cataract surgery. Secondary outcomes were a new diagnosis of acute (<40 days) or delayed-onset (40+ days) endophthalmitis and risk of a new primary open-angle glaucoma (POAG) diagnosis within 365 days after cataract surgery. RESULTS: Prior intravitreal anti-VEGF injections were associated with a significantly increased risk of subsequent RLF removal within 28 days after cataract surgery (hazard ratio [HR], 2.26; 95% confidence interval [CI], 1.19-4.30). Prior injections were also associated with increased risk of both acute (HR, 2.29; 95% CI, 1.001-5.22) and delayed-onset endophthalmitis (HR, 3.65; 95% CI, 1.65-8.05). Prior injections were not a significant indicator of increased risk of a new POAG diagnosis. CONCLUSIONS: A history of intravitreal injections may be a risk factor for cataract surgery-related intraoperative complications and endophthalmitis. Given the frequency of intravitreal injections and cataract surgery, increased preoperative assessment, additional intraoperative caution, and postoperative vigilance are recommended in patients with a history of intravitreal injections undergoing cataract extraction.Item Open Access Effects of Tort Liability and Insurance on Heavy Drinking and Driving(Journal of Law and Economics, 1995-04) Sloan, Frank A; Reilly, Bridget A; Schenzler, ChristophItem Open Access Essays on Health Economics(2009) Wang, YangIn this dissertation, I discuss two important factors in individuals' decision-making processes: subjective expectation bias and time-inconsistent preferences. In Chapter I, I look at how individuals' own subjective expectations about certain future events are different from what actually happens in the future, even after controlling for individuals' private information. This difference, which is defined as the expectation bias in this paper, is found to have important influence on individuals' choices. Specifically, I look into the relationship between US elderly's subjective longevity expectation biases and their smoking choices. I find that US elderly tend to over-emphasize the importance of their genetic makeup but underestimate the influence of their health-related choices, such as smoking, on their longevity. This finding can partially explain why even though US elderly are found to be more concerned with their health and more forward-looking than we would have concluded using a model which does not allow for subjective expectation bias, we still observe many smokers. The policy simulation further confirms that if certain public policies can be designed to correct individuals' expectation biases about the effects of their genes and health-related choices on their longevity, then the average smoking rate for the age group analyzed in this paper will go down by about 4%.
In Chapter II, my co-author, Hanming Fang, and I look at one possible explanation to the under-utilization of preventive health care in the United States: procrastination. Procrastination, the phenomenon that individuals postpone certain decisions which incur instantaneous costs but bring long-term benefits, is captured in economics by hyperbolic discount factors and the corresponding time-inconsistent preferences. This chapter extends the semi-parametric identification and estimation method for dynamic discrete choice models using Hotz and Miller's (1993) conditional choice probability approach to the setting where individuals may have hyperbolic discounting time preferences and may be naive about their time inconsistency. We implement the proposed estimation method to US adult women's decisions of undertaking mammography tests to evaluate the importance of present bias and naivety in the under-utilization of mammography, controlling for other potentially important explanatory factors such as age, race, household income, and marital status. Preliminary results show evidence for both present bias and naivety in adult women's decisions of undertaking mammography tests. Using the parameters estimated, we further conduct some policy simulations to quantify the effects of the present bias and naivety on the utilization of preventive health care in the US.
Item Open Access Essays on the Economics of Insurance and Healthcare Markets(2017) Robinson, Patricia AlexanderThis dissertation contains three chapters that investigate the role of asymmetric information in determining market outcomes in insurance and healthcare markets. The first two chapters focus on the U.S. automobile insurance market and how asymmetric information about consumer characteristics affect consumer and insurer behavior. The third chapter focuses on the U.S. healthcare market and studies how the financial incentives that arise due to price variation in the multi-payer system affect physician behavior when the physician has more information and the discretion to choose a treatment for the patient.
The first chapter, co-authored with Frank Sloan and Lindsey Eldred, quantifies the role of private information in automobile insurance policy choice using data on individuals' subjective beliefs, risk preference, reckless driving, insurer, and insurance policy characteristics merged with insurer-specific quality ratings distributed by independent organizations. We find a zero correlation between ex post accident risk and insurance coverage, reflecting advantageous selection in policy choice offset by moral hazard. Advantageous selection is partly attributable to insurer sorting on consumer attributes known and used by insurers. Our analysis of insurer sorting reveals that lower-risk drivers on attributes observed by insurers obtain coverage from insurers with higher-quality ratings.
The second chapter extends the work of the first chapter to quantifying the welfare impact of private information in an insurance market and evaluating potential policy interventions. Many studies show that asymmetric information exists in insurance markets, yet there is little consensus on the effectiveness of interventions in these markets. This chapter provides empirical evidence that improving information about risk is not always welfare-improving. I show how the theoretical effect of risk-rating can depend on whether the market is adversely- or advantageously-selected. I then estimate a structural model of insurance choice and reckless behavior to show that in the advantageously-selected U.S. automobile insurance market, risk-rating induces high-risk drivers to drop coverage, creating a negative externality and social welfare loss. Community rating improves welfare despite increasing asymmetric information.
The third chapter considers the impact of cross-payer price variation on physician behavior in the U.S., specifically for the case of births. A key innovation of the paper is to use data from multiple private payers---the Massachusetts All-Payer Claims Database. With these data, I ask how the change in reimbursement from one payer affects the probability that a physician performs a C-section on patients insured by that payer and by other payers. I use a difference-in-differences strategy that takes advantage of variation in contract change dates across the three largest private payers in Massachusetts. The results show that physicians are less likely to perform a C-section on a patient when the relative price the doctor receives from her insurer for a C-section decreases. This effect is concentrated among patients classified as medium-risk based on factors observed before the delivery, specifically women who reportedly experience long labor. These findings suggests that prices can be used as an incentive to change physician behavior, at least in the case of births. Whether this is welfare-improving depends on health impacts and patient preferences. Nevertheless, any policy that will affect prices paid to physicians---such as unilateral price changes by government payers and mergers of insurance companies or provider groups that affect bargaining power---should consider the downstream effects on utilization.
Item Open Access Gaps in receipt of regular eye examinations among medicare beneficiaries diagnosed with diabetes or chronic eye diseases.(Ophthalmology, 2014-12) Sloan, Frank A; Yashkin, Arseniy P; Chen, YiqunOBJECTIVE: To examine a wide range of factors associated with regular eye examination receipt among elderly individuals diagnosed with glaucoma, age-related macular degeneration, or diabetes mellitus (DM). DESIGN: Retrospective analysis of Medicare claims linked to survey data from the Health and Retirement Study (HRS). PARTICIPANTS: The sample consisted of 2151 Medicare beneficiaries who responded to the HRS. METHODS: Medicare beneficiaries with ≥ 1 of the 3 study diagnoses were identified by diagnosis codes and merged with survey information. The same individuals were followed for 5 years divided into four 15-month periods. Predictors of the number of periods with an eye examination evaluated were beneficiary demographic characteristics, income, health, cognitive and physical function, health behaviors, subjective beliefs about longevity, the length of the individual's financial planning horizon, supplemental health insurance coverage, eye disease diagnoses, and low vision/blindness at baseline. We performed logit analysis of the number of 15-month periods in which beneficiaries received an eye examination. MAIN OUTCOME MEASURES: The primary outcome measure was the number of 15-month periods with an eye examination. RESULTS: One third of beneficiaries with the study's chronic diseases saw an eye care provider in all 4 follow-up periods despite having Medicare. One quarter only obtained an eye examination at most during 1 of the four 15-month follow-up periods. Among the 3 groups of patients studied, utilization was particularly low for persons with diagnosed DM and no eye complications. Age, marriage, education, and a higher score on the Charlson index were associated with more periods with an eye examination. Male gender, being limited in instrumental activities of daily living at baseline, distance to the nearest ophthalmologist, and low cognitive function were associated with a reduction in frequency of eye examinations. CONCLUSIONS: Rates of eye examinations for elderly persons with DM or frequently occurring eye diseases, especially for DM, remain far below recommended levels in a nationally representative sample of persons with health insurance coverage. Several factors, including limited physical and cognitive function and greater distance to an ophthalmologist, but not health insurance coverage, account for variation in regular use.Item Open Access Intergenerational effects of parental substance-related convictions and adult drug treatment court participation on children's school performance.(Am J Orthopsychiatry, 2015-09) Gifford, Elizabeth J; Sloan, Frank A; Eldred, Lindsey M; Evans, Kelly EThis study examined the intergenerational effects of parental conviction of a substance-related charge on children's academic performance and, conditional on a conviction, whether completion of an adult drug treatment court (DTC) program was associated with improved school performance. State administrative data from North Carolina courts, birth records, and school records were linked for 2005-2012. Math and reading end-of-grade test scores and absenteeism were examined for 5 groups of children, those with parents who: were not convicted on any criminal charge, were convicted on a substance-related charge and not referred by a court to a DTC, were referred to a DTC but did not enroll, enrolled in a DTC but did not complete, and completed a DTC program. Accounting for demographic and socioeconomic factors, the school performance of children whose parents were convicted of a substance-related offense was worse than that of children whose parents were not convicted on any charge. These differences were statistically significant but substantially reduced after controlling for socioeconomic characteristics; for example, mother's educational attainment. We found no evidence that parent participation in an adult DTC program led to improved school performance of their children. While the children of convicted parents fared worse on average, much--but not all--of this difference was attributed to socioeconomic factors, with the result that parental conviction remained a risk factor for poorer school performance. Even though adult DTCs have been shown to have other benefits, we could detect no intergenerational benefit in improved school performance of their children.Item Open Access Introducing Anti-Vascular Endothelial Growth Factor Therapies for AMD Did Not Raise Risk of Myocardial Infarction, Stroke, and Death.(Ophthalmology, 2016-10) Yashkin, Arseniy P; Hahn, Paul; Sloan, Frank APURPOSE: To assess the effect of availability of anti-vascular endothelial growth factor (VEGF) therapy on mortality and hospitalizations for acute myocardial infarction (AMI) and stroke over a 5-year follow-up period in United States Medicare beneficiaries newly diagnosed with exudative age-related macular degeneration (AMD) in 2006 compared with control groups consisting of beneficiaries (1) newly diagnosed with exudative AMD at a time when anti-VEGF therapy was not possible and (2) newly diagnosed with nonexudative AMD. DESIGN: Retrospective cohort study. PARTICIPANTS: Beneficiaries newly diagnosed with exudative and nonexudative AMD in 2000 and 2006 selected from a random longitudinal sample of Medicare 5% claims and enrollment files. METHODS: Beneficiaries with a first diagnosis of exudative AMD in 2006 were the treatment group; beneficiaries newly diagnosed with exudative AMD in 2000 or nonexudative AMD in 2000 or 2006 were control groups. To deal with potential selection bias, we designed an intent-to-treat study, which controlled for nonadherence to prescribed regimens. The treatment group consisted of patients with clinically appropriate characteristics to receive anti-VEGF injections given that the therapy is available, bypassing the need to monitor whether treatment was actually received. Control groups consisted of patients with clinically appropriate characteristics but first diagnosed at a time when the therapy was unavailable (2000) and similar patients but for whom the therapy was not clinically indicated (2000, 2006). We used a Cox proportional hazard model. MAIN OUTCOME MEASURES: All-cause mortality and hospitalization for AMI and stroke during follow-up. RESULTS: No statistically significant changes in probabilities of death and hospitalizations for AMI and stroke within a 5-year follow-up period were identified in exudative AMD beneficiaries newly diagnosed in 2006, the beginning of widespread anti-VEGF use, compared with 2000. As an alternative to our main analysis, which excluded beneficiaries from nonexudative AMD group who received anti-VEGF therapies during follow-up, we performed a sensitivity analysis with this group of individuals reincluded (11% of beneficiaries newly diagnosed with nonexudative AMD in 2006). Results were similar. CONCLUSIONS: Introduction of anti-VEGF agents in 2006 for treating exudative AMD has not posed a threat of increased risk of AMI, stroke, or all-cause mortality.Item Open Access Longitudinal patterns of cost and utilization of medicare beneficiaries with bladder cancer.(Urologic oncology, 2020-02) Sloan, Frank A; Yashkin, Arseniy P; Akushevich, Igor; Inman, Brant ABackground
Bladder cancer (BC) is highly prevalent and costly. This study documented cost and use of services for BC care and for other (non-BC) care received over a 15-year follow-up period by a cohort of Medicare beneficiaries diagnosed with BC in 1998.Methods
Data came from the Surveillance, Epidemiology and End Results Program linked to Medicare claims. Medicare claims provided data on diagnoses, services provided, and Medicare Parts A and B payments. Cost was actual Medicare payments to providers inflated to 2018 US$. Cost and utilization were BC-related if the claim contained a BC diagnosis code. Otherwise, costs were for "other care." For utilization, we grouped Part B-covered services into 6 mutually-exclusive categories. Utilization rates were ratios of the count of claims in a particular category during a follow-up year divided by the number of beneficiaries with BC surviving to year-end.Results
Cumulatively over 15-years, for all stages combined, total BC-related cost per BC beneficiary was $42,011 (95% Confidence Interval (CI): $42,405-$43,417); other care cost was about twice this number. Cumulative total BC-related cost of 15-year BC survivors for all stages was $43,770 (CI: $39,068-$48,522), intensity of BC-related care was highest during the first year following BC diagnosis, falling substantially thereafter. After follow-up year 5, there were few statistically significant changes in BC-related utilization. Utilization of other care remained constant during follow-up or increased.Conclusions
Substantial costs were incurred for non-BC care. While increasing BC survivorship is an important objective, non-BC care would remain a burden to Medicare.Item Open Access Medicaid Managed Care Programs and Healthcare Markets(2017) Chehal, Puneet KaurMy dissertation research offers insights about the effects of Medicaid managed care (MMC) programs from Kentucky’s statewide market-based program. Kentucky’s significant reforms to introduce a comprehensive MMC program just one year after the passage of the ACA can provide valuable lessons for other rural states with substantial poor populations.
In the first study, I explore Kentucky’s 2011 introduction of MMC and the quality of hospitals used by Medicaid recipients. Kentucky’s MMC program is a post-Affordable Care Act (ACA) market-based program that uses a small set of competing managed-care organizations (MCOs) to administer Medicaid benefits. Using a quasi-experimental research design, I explore whether the introduction of MMC changes the hospitals used by pregnant Medicaid-insured mothers for their deliveries and whether the quality of these hospitals is different compared to the hospitals used before the policy change. I also test whether the changes in hospitals used by pregnant Medicaid-insured mothers for their deliveries differ in smaller counties with fewer hospitals and Medicaid recipients compared to those in larger counties with more hospitals and Medicaid recipients. My analysis uses hospital quality measures designed by the Agency for Healthcare Research and Quality to measure hospital quality. I find that Medicaid-insured pregnant women from nonmetropolitan counties have an increased probability of delivering in the highest quality local hospitals as opposed to the lowest quality local hospitals. In contrast, I find that Medicaid-insured pregnant women from metropolitan counties have a decreased probability of delivering in the highest quality local hospitals and increased probability of delivering in lower quality local hospitals. Since Kentucky’s metropolitan counties have high quality hospitals and its nonmetropolitan counties have some of the poorest quality hospitals in the state, these findings may be positive for patient outcomes and program costs. Additional research evaluating patient outcomes and identifying the causal mechanisms responsible for changes in the hospitals used by Medicaid recipients is needed.
Motivated by my findings in the first chapter, in my second chapter I exploit Kentucky’s reforms to explore potential mechanisms that link MMC to changes in the hospitals used by Medicaid-insured pregnant women for their deliveries. I focus on hospital network status and physician-hospital arrangements, which are the terms by which physicians practice in hospitals. These arrangements can affect the hospital ultimately used by physicians’ patients and may be designed specifically for the purposes of joint contracting with insurers. After using reduced form hospital choice models to estimate the change in the hospitals used by pregnant women in Kentucky in response to the introduction of MMC, I introduce measures of hospital network status and physician-hospital arrangements to my analysis. The primary policy effects on the hospitals used by Medicaid-insured women for deliveries remain unchanged, including the two covariates that suggest that other mechanisms with opposing effects to hospital-network status and physician-hospital arrangements are responsible for the changes in hospitals used by Medicaid-insured women. Future research should consider the role of information in provider choice after the introduction of MMC.
In the third chapter, I shift my focus to considering how well Kentucky’s MMC program navigated expanding Medicaid eligibility. Specifically, I explore the impact of the ACA on disparities in access to medical providers in MMC programs. In states expanding Medicaid eligibility, low-income communities with pre-existing elevated numbers of uninsured people experienced larger gains in coverage from the ACA than other communities. While researchers have reported that there is increased physician participation in states that expanded Medicaid, researchers have yet to explore whether increases in physician participation coincided with areas experiencing the greatest increases in Medicaid coverage or inadequate access to medical services. In these programs, Medicaid recipients access care from provider networks created by the health maintenance organizations (HMOs) selected by states to administer Medicaid benefits. Using an original dataset on Kentucky’s Medicaid HMO networks, I use a difference-in-differences framework to compare provider network participation before and after the implementation of the ACA across counties. Specifically, I compare counties with differing levels of pre-ACA uninsured rates, medically underserved populations and poverty. I find provider network participation is greater in counties experiencing smaller increases in Medicaid coverage but subtly larger participation in counties with medically underserved areas or high poverty.
Item Open Access Parental Criminal Justice Involvement and Children's Involvement With Child Protective Services: Do Adult Drug Treatment Courts Prevent Child Maltreatment?(Subst Use Misuse, 2016) Gifford, Elizabeth J; Eldred, Lindsey M; Sloan, Frank A; Evans, Kelly EBACKGROUND: In light of evidence showing reduced criminal recidivism and cost savings, adult drug treatment courts have grown in popularity. However, the potential spillover benefits to family members are understudied. OBJECTIVES: To examine: (1) the overlap between parents who were convicted of a substance-related offense and their children's involvement with child protective services (CPS); and (2) whether parental participation in an adult drug treatment court program reduces children's risk for CPS involvement. METHODS: Administrative data from North Carolina courts, birth records, and social services were linked at the child level. First, children of parents convicted of a substance-related offense were matched to (a) children of parents convicted of a nonsubstance-related offense and (b) those not convicted of any offense. Second, we compared children of parents who completed a DTC program with children of parents who were referred but did not enroll, who enrolled for <90 days but did not complete, and who enrolled for 90+ days but did not complete. Multivariate logistic regression was used to model group differences in the odds of being reported to CPS in the 1 to 3 years following parental criminal conviction or, alternatively, being referred to a DTC program. RESULTS: Children of parents convicted of a substance-related offense were at greater risk of CPS involvement than children whose parents were not convicted of any charge, but DTC participation did not mitigate this risk. Conclusion/Importance: The role of specialty courts as a strategy for reducing children's risk of maltreatment should be further explored.Item Open Access Preventive Health Behaviors among the Elderly(2008-07-07) Ayyagari, PadmajaThis dissertation consists of three essays that study preventive health behaviors among the elderly U.S. population.
The first essay studies the effect of Medicare coverage on demand for the influenza vaccine. I use a propensity score matching estimator to look at the effect of the 1993 Medicare part B coverage of the flu shot on demand. Using data from the Medicare Current Beneficiary survey, I find that the coverage increases demand by 12.4%. I also find that this effect varies by smoking status and by the presence chronic respiratory illnesses such as COPD, Asthma or Emphysema.
The second essay examines the effect of disease specific health shocks on risk perceptions and demand for the pneumonia vaccine. I find strong evidence of learning - individuals who experience a health shock are less likely to believe that they are not at risk of infection, conditional on prior beliefs. This change in beliefs is accompanied by a corresponding change in demand. Individuals who contract pneumonia or influenza are 60% more likely to vaccinate by the end of next year as compared to those who are not infected.
The third essay studies the relationship between education and health for a sample of elderly diabetics. We identify various mechanisms through which more education leads to improved health. We find that part of the strong positive correlation between educational attainment and health can be explained through differences in cognitive status, self-control and parental characteristics. However, some part of this relationship still remains unexplained.
Item Open Access Should Minnesota Reinstate a Certificate of Need Program for Health Care Capital Expenditures?(2015-05-04) Moran, PatrickThe Minnesota Department of Health regulates capital investments made by hospitals, ambulatory surgery centers, diagnostic imaging centers, and physician clinics. The primary purpose of these regulations is to reduce health care spending by preventing the development of excess health care supply capacity. Most states regulate health care investments using a certificate-of-need (CON) law. CON programs require “prospective” review of expenditures, meaning that health care providers must obtain permission from the state before making major capital investments. Minnesota has not maintained a formal CON program since 1984. Instead, Minnesota mainly uses a “retrospective” review process in which the state reviews capital investments only after the provider has already made an investment. Analyses by the state have determined that current capital expenditure regulations are not providing significant cost control for Minnesota’s health care system. This report examines whether reinstating a CON program would improve the law’s effectiveness in controlling health care costs, and examines the impact that CON would have on other dimensions of Minnesota's health care system, such as quality and access to care. Based on existing empirical literature, this report concludes that there is insufficient evidence to justify the adoption of a CON program in Minnesota.Item Open Access The Cost to Medicare of Bladder Cancer Care.(European urology oncology, 2020-08) Sloan, Frank A; Yashkin, Arseniy P; Akushevich, Igor; Inman, Brant ABackground
Bladder cancer care is costly, including cost to Medicare, but the medical cost associated with bladder cancer patients relative to identical persons without bladder cancer is unknown.Objective
To determine incremental bladder cancer cost to Medicare and the impact of diagnosis stage and bladder cancer survival on cost.Design, setting, and participants
A case-control study was conducted using 1998-2013 Surveillance, Epidemiology and End Results-Medicare data. Controls were propensity score matched for diagnosis year, age, gender, race, and 31 Elixhauser Comorbidity Index values. Three incident cohorts, 1998 (n=3136), 2003 (n=7000), and 2008 (n=7002), were compared.Outcome measurements and statistical analysis
Survival following diagnosis and Medicare payments (in 2018 dollars) were tabulated, and compared between cases and controls.Results and limitations
From 1998 to 2008, bladder cancer patients became older and had more comorbidities at diagnosis, although no stage migration or change in survival occurred. Incremental costs (above those associated with controls) were highest during the 1st year after diagnosis and were higher for distant ($47533) than for regional ($42403) or localized ($14304) cancer. Bladder cancer survival was highly stage dependent. After an initial spike in costs lasting 1-2yrs, monthly costs dropped in survivors but remained higher than for controls. Long-term survivors in the full sample accrued cumulative Medicare costs of $172426 over 16yrs-46% higher than for controls. Limitations include omission of indirect costs and reliance on traditional Medicare.Conclusions
While a bladder cancer diagnosis incurs initial high Medicare cost, particularly in patients with advanced cancers, the cumulative costs of bladder cancer in long-term survivors are higher still. Bladder cancer prevention saves Medicare money. However, while early detection, better therapies, and life extension of bladder cancer patients are worthwhile goals, they come at the cost of higher Medicare outlays.Patient summary
The lifetime cost of bladder cancer, reflecting surveillance, treatment, and management of complications, is substantial. Since care is ongoing, cost increases with the length of life after diagnosis as well as the severity of initial diagnosis.Item Open Access The effects of participation level on recidivism: a study of drug treatment courts using propensity score matching.(Subst Abuse Treat Prev Policy, 2014-09-24) Gifford, Elizabeth J; Eldred, Lindsey M; McCutchan, Sabrina A; Sloan, Frank ABACKGROUND: Empirical evidence has suggested that drug treatment courts (DTCs) reduce re-arrest rates. However, DTC program completion rates are low and little is known about the effectiveness of lower levels of program participation. OBJECTIVES: We examined how DTC program referral, enrollment without completion, and completion, affected re-arrest rates during a two-year follow-up. RESEARCH DESIGN: We used statewide North Carolina data from criminal courts merged with DTC data. Propensity score matching was used to select comparison groups based on demographic characteristics, criminal histories, and drug of choice (when available). Average treatment effects on the treated were computed. MEASURES: DTC participation levels included referral without enrollment, (n = 2,174), enrollment without completion (n = 954), and completion (n = 747). Recidivism measured as re-arrest on a substance-related charge, on a violent offense charge not involving an allegation of substance abuse, and on any charge (excluding infractions) was examined by felony and misdemeanor status during a two-year follow-up period. RESULTS: Re-arrest rates were high, 53-76 percent. In general, re-arrest rates were similar for individuals who were referred but who did not enroll and a matched comparison group consisting of individuals who were not referred. In contrast, enrollees who did not complete had lower re-arrest rates than a matched group of individuals who were referred but did not enroll, for arrests on any charge, on any felony charge, and on substance-related charges (felonies and misdemeanors). Finally, relative to persons who enrolled but did not complete, those who completed had lower re-arrest rates on any charge, any felony charge, any misdemeanor charge, any substance-related charge, any substance-related misdemeanor or felony charge, and any violent felony charge. CONCLUSIONS: Enrolling in a DTC, even without completing, reduced re-arrest rates. Given the generally low DTC completion rate, this finding implies that only examining effects of completion underestimates the benefits of DTC programs.Item Open Access The Impact of Medicaid Expansion on Health Care Access, Utilization, and Health(2017-12-06) Yan, Brandon W.Under the Affordable Care Act (ACA), 32 states expanded Medicaid coverage to include adults with household incomes up to 138% of the Federal Poverty Level. Today, Medicaid remains a subject of intense state and federal budgetary and policy debates. To analyze the impact of the ACA’s Medicaid expansion on adults in poverty, I used national data from the 2011-2016 Behavioral Risk Factor Surveillance System to assess trends in health access, preventive service utilization, and health outcomes. I further stratified the analysis to investigate differential impacts on subpopulations including breakdowns by income, race, and age. As measured by rates of uninsurance, inability to afford doctor visits, and lacking a personal doctor, health care access improved significantly more in states that expanded Medicaid than those that did not. Medicaid expansion was associated with a 5.4% decrease in the uninsured rate and a 1.9% increase in the probability of having a routine checkup in the past 12 months. Whites and adults ages 55-64 experienced some of the greatest gains in health care access and routine checkup utilization. Health status improvement approached significance nationally but was significant among those in the $10,000-$14,999 income group. Medicaid expansion was also associated with increases in diagnoses of high blood pressure and high cholesterol. These findings indicate sustained improvements in access to care and evidence of changes in utilization and health that differ by population subgroups. Federal and state policymakers should weigh these benefits in considering Medicaid reforms and Medicaid expansion adoption.Item Open Access The Impact of Medicare Nonpayment: a Quasi-Experimental Approach(2020-04-20) Kornkven, AudreyIn October 2008, a provision of the Deficit Reduction Act of 2005 known as Medicare “Nonpayment” went into effect, eliminating reimbursement for the marginal costs of preventable hospital-acquired conditions in an effort to correct perverse incentives in hospitals and improve patient safety. This paper contributes to the existing debate surrounding Nonpayment’s efficacy by considering varying degrees of fiscal pressure among hospitals; potential impacts on healthcare utilization; and differences between Medicare and non-Medicare patient populations. It combines data on millions of hospital discharges in New York from 2006-2010 with hospital-, hospital referral region-, and county-level data to isolate the policy’s impact. Analysis exploits the quasi-experimental nature of Nonpayment via difference-in-differences with Mahalanobis matching and fuzzy regression discontinuity designs. In line with results from Lee et al. (2012), Schuller et al. (2013), and Vaz et al. (2015), this paper does not find evidence that Nonpayment reduced the likelihood that Medicare patients would develop a hospital-acquired condition, and concludes that the policy is not likely the success claimed by policymakers. Results also suggest that providers may select against unprofitable Medicare patients when possible, and are likely to vary in their responses to financial incentives. Specifically, private non-profit hospitals appear to have been most responsive to the policy. These findings have important implications for pay-for-performance initiatives in American healthcare.