Browsing by Subject "Health Services Research, Policy and Administration"

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Cancer and the medicare disabled.
(2008-11) Habermann, Elizabeth Anne
This dissertation examines relationships between cancer in working-age adults and enrollment in Medicare due disability. We examine whether cancer diagnosis and treatments affect enrollment in Medicare due to disability, whether there is pent-up demand for cancer diagnosis during the 29-month waiting period between application and receipt of Medicare benefits, and whether disabled working-age adults receive quality cancer care when enrolled in Medicare.
Cost-effectiveness analysis of dental sealant using econometric modeling
(2009-05) Ouyang, Wei
Dental sealants have been shown to be effective in reducing caries. Most believe sealants are still underused, particularly among children who need sealants the most. Because the caries prevalence continues to decline, and the disparities in children's dental heath and dental care still exist, more efficient sealant placement strategies should be implemented based on the scientific information from cost-effectiveness analysis (CEA) of dental sealant at the community level. Previous CEAs of sealant using observational datasets were unreliable because they did not address the self-selection problem. The objectives of this study are to examine the utilization of dental sealants and its determinants, evaluate the incremental effectiveness and expenditure associated with sealant placement after correcting the potential selection issue, and explore the differences in sealant's cost-effectiveness among subpopulations. This study mainly utilized enrollment data and encounter data from a large Health Maintenance Organization in Minnesota. The study sample included 3,700 children aged 6 to 17 years during 1997 to 2001 and were continuously enrolled for 5 years. They all had a caries risk assessment (CRA), which was conducted at the beginning of the observation period, and no prior caries record for their included first permanent molars (FPMs). The CRAs were classified into three scores: low, moderate and high risk. Information on the 64 dentists who participated in the study was linked to the encounter data to identify those who conducted CRAs. Outcome variables included discounted effectiveness, as measured by the duration of caries-free state (healthy months) of a FPM, and the discounted cost associated with caries treatments, within the study period. The key independent variables included demographic variables (e.g., age, gender, race), caries risk level, socio-economic status, sealant placement, and preventive care utilization. Bivariate analysis and logistic analysis were performed to examine the pattern of sealant utilization and identify the determinants affecting sealant placement decision. Econometric models including classic Tobit model, selectivity-corrected Tobit model, classic two-part model, and selectivity-corrected two-part model were used to examine the selection issue and obtain unbiased marginal effects of sealant on caries-free duration and caries-related treatment cost. The working experience of the dentists who conducted the initial CRAs was used as the instrumental variable. The bootstrap method was used to obtain standard errors and confidence intervals for the incremental cost-effectiveness ratios. Sensitivity analysis and subgroup analysis were performed. In this study, approximately 77% of the sample had one or more FPM sealed during the entry period, more than half of them had all four FPMs sealed. Children aged 6 to 8 were more likely to receive sealant than children aged 9 or older. Children at relatively high caries risk, as well as children who visited dentists for preventive care more than once a year, had greater odds of receiving sealants. Non-white children or those from families with low incomes or low education level were more likely to receive sealant. This study also identified some dentists' characteristics, such as age, gender, and working experience as the good predictors of sealant decision. After 5 years, the sealant group had more individuals (83.9%) and more FPMs (94.3%) that stayed healthy compared with the non-sealant group in which 83.1% of the sample individuals and 91.8% of FPMs stayed healthy. A sealed FPM was associated with $56.84 expenditure (initial sealant charge was $39.00) over 5 years, and an unsealed FPM was associated with $13.13 expenditure. The sample-average incremental cost-effectiveness ratio (ICER) was $38/caries-free month for each FPM. Based on the results from econometric models, sealants were associated with a lower probability of having any caries, longer caries-free duration, an increased probability of using any resource, and less resources consumption. The final ICER indicates that sealant cost $42.16 more than non-sealant treatment to get one more caries-free month for each FPM. The 95% CI was $22.64 to $85.40 per one more caries-free month for each FPM. Significant selection or endogeniety issue was not found in either the effectiveness or cost analysis based on the whole sample, but it existed when analyzing sealant effects among certain subgroup children. The results from subgroup analysis show that sealing children at high risk for caries appears to be highly cost effective. In contrast, sealing children at low risk for caries would be much less cost effective. Sealing the FPMs of infrequent utilizers of preventive care appears to be more cost effective than frequent utilizers of preventive care. There is no significant difference in ICERs between sealing younger children and sealing older children. In conclusion, sealant application is not always cost effective. A uniform and fixed sealant utilization goal may not be appropriate. Sealant application should be increased among the high risk populations, such as those with previous caries or low dental care utilizers, or those directly deemed at high caries risk by dentists. The caries risk assessment procedure can improve clinical decisions on sealant application and increase efficient sealant delivery.
Determinants of oral medication compliance in osteoporosis: the role of medication beliefs.
(2009-01) Schousboe, John T.
As medical technology has advanced and the age structure of the population has increased, much of the focus of medical therapy has shifted from treating acute symptomatic illness to prevention and management of chronic illness. Medications play a central role in the management of many chronic conditions (such as hypertension, hyperlipidemia, non-insulin dependent diabetes, and osteoporosis) that are risk factors for a variety of adverse disease outcomes. Non-compliance to medications has been shown to be a significant impediment to more comprehensive control of these conditions and avoidance of associated adverse health outcomes, and remains poorly understood. Beliefs regarding the potential benefits and harms associated with medications may be an important determinant of medication non-adherence. The relationship between these beliefs and adherence, adjusted for the perceived threat of the target condition and other variables that influence adherence, has not been explicated. The aims of this cross-sectional study of persons prescribed oral bisphosphonate medication to prevent osteoporotic fractures are as follows. Estimate the associations of perceived necessity of and concerns about medication and three aspects of medication use behavior Non-persistence due to side effects Non-persistence for reasons other than side effects Non-compliance (missed doses) Estimate associations of perceived need for medication Susceptibility to and severity of fractures Patient-provider relationship quality Objective indicators of fracture risk Estimate the associations of patient-provider relationship quality and self-reported adherence Directly Indirectly through other variables A conceptual framework is presented of medication persistence and compliance with fracture prevention medication. Four medication attitude variables, perceived necessity of fracture prevention medication, concerns about the long-term safety of and dependence upon medication, medication use self-efficacy, and perceived medication cost burden were postulated to be predictors of fracture prevention medication use behavior. These attitudinal variables were postulated to be mediating variables between fracture prevention medication use behavior and other predictors, such as perceived susceptibility to and severity of fractures, the patient-provider relationship quality, and objective indicators of fracture risk. Medication persistence and compliance was assessed by self-report, and medication beliefs by a mailed survey. Non-persistence was defined as stopping fracture prevention medication for more than one month, and non-compliance as missing one or more doses over the past 4 weeks. A multivariate path model, consisting of six regression equations, was used to estimate this model. Perceived need for fracture prevention medication was moderately strongly associated with non-persistence due to side effects and for other reasons, but not with non-compliance. Concern about medications was associated with non-persistence due to side effects and with non-compliance, but not with non-persistence for other reasons. Medication use self-efficacy was strongly associated with non-compliance and modestly with non-persistence for other reasons, but not with non-persistence due to side effects. The patient-provider relationship quality was modestly associated with non-persistence, but this effect was indirect through perceived need for fracture prevention medication, concern about medications, and medication use self-efficacy. Documentation of a prevalent vertebral fracture was associated with a higher perceived need for fracture prevention medication, and indirectly with mildly lower self-reported non-persistence. Providers can leverage the trust patients have in them to modestly improve persistence and compliance with fracture prevention medication by assessing whether or not the patient's perceived need for fracture prevention medication is congruent with their actual fracture risk and soliciting and addressing concerns about medications. Wider use of lateral spine imaging to identify clinically unrecognized vertebral fractures may also encourage persistence with fracture prevention medication among that subset of older men and women at highest risk of fracture, and for whom the benefits of fracture prevention medication have been extensively demonstrated.
The effect of medicare's new technology add-on payment policy.
(2010-06) Bockstedt, Lindsay A.
The new technology add-on payment (NTAP) is the first payment incentive under Medicare's inpatient prospective payment system (IPPS) related to technology. Implemented in 2001, the NTAP reimburses hospitals up to fifty percent of the cost related to the use of eligible new technologies in addition to the prospective Medicare Severity Diagnostic Related Group (MS-DRG) payment. The NTAP was implemented to ensure access of new clinically beneficial technologies to Medicare beneficiaries while the prospective payment system recalibrated to reflect the cost of new technology. For a technology to be eligible for NTAP, it must meet three criteria: (1) the technology must be considered new, as defined by the Centers for Medicare and Medicaid Services (CMS) as within two to three years following FDA approval; (2) the technology must be considered costly and inadequately reimbursed under the current MS-DRG assignment; (3) the technology must provide a substantial clinical improvement to Medicare beneficiaries. Once a technology is granted new technology add-on payment status, a hospital is eligible to receive NTAPs for up to three years. Upon the sunset of the NTAP, the prospective DRG rates are recalibrated to reflect the utilization of the new technology and a hospital will receive only the associated DRG payment when the technology is used. As of September 30, 2007, seven technologies have been granted NTAP status. With the exception of one pharmaceutical technology, all of the technologies have been implantable medical devices. This research evaluates the effect of Medicare's NTAP program. The NTAP policy offers the unique opportunity to evaluate hospitals' response to payment incentives under a mature prospective system. This research is the first to evaluate the value of the NTAP policy and empirically estimate the effect of the NTAP policy on the utilization of new technology. The thesis is organized around three research questions: 1) does the presence of the NTAP policy affect the probability new technology is used? 2)does the amount of the NTAP affect the probability a new technology is used? 3) what is the value of the NTAP policy? The results increase the understanding of how hospitals respond to payment incentives, which is becoming increasingly important as health care reform seeks to develop incentives to improve the efficiency, quality and safety of health care delivered.
Effect of residence on receipt of preventive care by adults with mental retardation/developmental disabilities.
(2009-09) Bershadsky, Julie
Main goal . to explore relationship between place of residence and receipt of selected preventive health care services for adults with intellectual disabilities, while controlling for level of disability. Data sources . Medicaid and Medicare utilization files, Minnesota's Medicaid Management Information System (MMIS) (contains DD screening documents for all recipients of HCBS Waiver and ICF/MRs). Conclusions . Disability varies by residence. Higher disability lowers likelihood of receiving preventive health care (with exception of behavior disability). Likelihood of receiving preventive health care varies with residence. Residents of family homes and own homes least likely to receive preventive health care, even (especially) after controlling for disability. Failure to control for disability may mask differences between residences.
Impact of Consumer-Driven Health Plans (CDHPs) on medication adherence and health care spending.
(2011-06) Chen, Song
This dissertation is comprised of three papers that look at the impact of Consumer-Driven Health Plans (CDHPs) enrollment on medication adherence, health care expenditure, and incentives of CDHPs for people with different health status. The first paper evaluated the impact of enrolling in full replacement CDHPs on medication adherence for eight therapeutic drug classes. We found that the continuation rate was relatively high for all drug classes, although the CDHP cohort had a lower probability of continuing cardiac and cholesterol drugs. We found that CDHP patients took slightly longer on average to refill their first prescription in the post-year for cardiac, hypertension, cholesterol, and thyroid drugs. The compliance rate dropped over time in both cohorts, but the reduction was bigger among CDHP patients for asthma, cardiac, and cholesterol drugs. We also found that the CDHP patients terminated their continuous drug supply earlier for epilepsy drugs and cholesterol drugs. The second paper examined the long-term impact of enrolling in CDHPs on health care expenditures. We found that enrolling in optional HRAs was associated with higher spending compared with staying in traditional plans. Enrolling in optional HSAs was associated with spending comparable with continuous enrollment in traditional plans, though higher spending was observed in some years. Full replacement HRAs are cost neutral to optional HRAs, while full replacement HSAs saved costs over optional HSAs. The third paper evaluated how health care spending for enrollees in CDHPs might be different for members with different health status, ranging from low risk to high risk. We found that healthy CDHP enrollees tended to spend less in the post-CDHP years than a comparison group of healthy employees who elected to keep their traditional health insurance coverage. However, CDHP enrollees with high predicted spending spent more than their comparison group of traditional health insurance enrollees in the post-CDHP years. Among CDHP enrollees, HSA enrollees with low risk health status spent less than HRA enrollees with comparable health status, whereas HSA enrollees with high risk health status spent more than their comparison group of HRA enrollees.
Moral exemplars, outpatient medical clinic climate, temporal affect and patient care errors.
(2010-02) Mullen, Deborah Michelle
Objective: To evaluate the relationship between the rate of patient care errors, the clinic climate in outpatient medical practices and health care provider personality and temporal affects Study Design: This research created and tested a new survey, the Outpatient Medical Clinic Safety Climate. The instrument was created through cognitive interviews and pilot testing between June - August 2008. Primary data was collected with surveys between February and May 2009. The surveyed population included every Nurse Practitioner and Certified Nurse Midwife holding current 2009 Minnesota licensure within all types of outpatient specialty and primary care clinics. The final instrument was administered to 2,576 advanced practice nurses resulting in a 52% response rate (AAPOR RR1). The survey data was collected through a mail, return mail process; non-respondents received a second copy of the survey four weeks after the initial mailing. Returned mail surveys were keyed as well as scanned into SAS data sets with the assistance of the HPRF Survey Center. Survey dimensions included: reported error rates, clinic climate and culture, as well as individual respondent's temporal affect and personality traits (moral exemplarism). Error reporting frequency rates, including adverse events, near misses and accidents waiting to happen, were collected by self report for both the respondent and their clinic. Latent variable development focused on identification of climate, culture, moral exemplarism, and temporal affect. Exploratory factor analysis allowed for the grouping of survey items into scale scores. After scale scores were created, univariate and bivariate analysis was undertaken to further test the model and variables. Generalized linear modeling was utilized for final modeling. Final models included separate models for personal and clinic errors reported. Principal Findings: For personal errors, those made by the respondent, the presence of a safety climate and a medication reconciliation process increased the number of reported errors. For those errors made in the clinic (clinic errors, medical errors, adverse events, near misses, and accidents waiting to happen) multiple culture scales were significant as well as the existence of a safety climate. Culture scales: formal communication about safety, error reporting process and just culture as well as safety climate all correlated with increased reported clinic error. Temporal affect - causal beliefs and moral exemplarism scales were not found to be meaningful contributors to any of the models. Conclusions: For personal errors, relatively little of the overall model is explained by climate and culture factors; alternately clinic errors, medical errors, adverse events, near misses, and accidents waiting to happen are strongly related to by the clinic's culture and climate. As climate and culture are shared perceptions, then it seems reasonable that for the clinic as a whole these factors would explain more of the error model.
Perceived need for mental health care, mental health service utilization, and satisfaction with care in elderly people.
(2008-06) Nelson, Melissa Marie
Background. Elderly people experience symptoms, diagnosis, and treatment of mental illnesses differently than younger people, and only half of elderly people with a probable mental illness use mental health care services. Nevertheless, most mental health care research has focused on younger people. This study examined relationships among attitudes toward care, quality of social support, severity of mental illness, presence of physical comorbidities or alcohol abuse problems, sociodemographics, possession of supplemental insurance, perceived need for care, rates of utilization, and satisfaction with mental health care for elderly people. Methods. Data were used from the Collaborative Psychiatric Epidemiology Surveys (CPES), a nationally representative, cross-sectional study of community-dwelling people's mental illnesses and mental health care utilization patterns. Logistic and linear regression models were used to study perceived need, utilization, and satisfaction with care. Results. Perceived need for mental health care increased with severity of depression and anxiety, history of chronic physical conditions, and pressure to seek care. Among respondents who met diagnostic criteria for depression or anxiety, the number of mental illness symptoms experienced was still related to perceived need for care. The odds of using formal mental health care increased with severity of depression or anxiety and with history of chronic physical illnesses. When utilization was measured among respondents who perceived a need for care, however, most measures of mental illness severity and history of chronic physical illness were no longer significant. There was little variation in the satisfaction measure, and multivariate models of satisfaction were unstable. Conclusion. Many elderly people who meet diagnostic criteria for depression and/or anxiety disorders do not use mental health services or even perceive a need for these services. Additionally, physical and mental health are associated with perceived need, but other factors are responsible for determining utilization among those with perceived need. Further studies that include more detailed measures of psychosocial factors and satisfaction with mental health care are necessary to understand what factors lead elderly people to perceive a need for mental health care and what factors influence those who perceive a need for care to actually seek treatment and adhere to it.
Use of complementary and alternative medicine (CAM) in racial, ethnic and immigrant (REI) populations: assessing the influence of cultural heritage and access to medical care.
(2011-03) Zhang, Lixin
Background --- Though substantial and growing use of complementary and alternative medicine (CAM) in the general population has been documented in recent years, little is known about CAM utilization patterns among racial, ethnic and immigrant (REI) populations groups. Objectives --- To examine variation in the use of CAM among REI populations, and assess the influence of cultural heritage and access to medical care on CAM use Conceptual Model --- Adapted Behavioral Model of Vulnerable Population with added REI domains. Method --- Data are from Survey of Health of Adults, the Population and the Environment (SHAPE) collected in Hennepin County, Minnesota in 2002. The final sample consists of 9,959 respondents with 2,794 from racial and ethnic minorities and 1,007 interviews were completed in languages other than English. The outcome measures were the use of five CAM therapies in the previous 12 months. Results --- Overall, 42% of the adults in the total population used at least one of the five CAM therapies in the past 12 month. CAM use is prevalent among REI populations, particularly among American Indians, Asians and Whites. The use of individual CAM varies across racial and ethnic populations and the pattern of use conforms to the racial and ethnic origins of the modalities. Cultural heritage influences CAM use and the level of influence is stronger for culturally-relevant CAM. Lack of insurance coverage, delayed medical care and not having a physician’s clinic as regular source of care are associated with a higher likelihood of CAM use. Lack of access to conventional health care has a stronger influence on CAM use in some racial and ethnic groups. Lack of insurance coverage and barriers to needed medical care play a larger role in the use of CAM among immigrants. Conclusion --- CAM has an important role in promoting culturally competent care particularly in REI populations. CAM may serve as an alternative option for those lacking adequate access to medical care, particularly among immigrants and people of racial and ethnic populations.
Variation in the use of differentially-reimbursed hip fracture procedures.
(2010-02) Forte, Mary Lee
Background: This series of three papers examine the patient, surgeon and hospital factors that were associated with intramedullary nail (IMN) use, the geographic variation in IMN use, and the association between provider volume and short-term mortality following the surgical treatment of Medicare intertrochanteric hip fracture patients during 2000 through 2002. Methods: Medicare claims and enrollment data 2000-2002 identified Medicare beneficiaries age 65 or older who underwent an inpatient surgery to treat an intertrochanteric femur fracture using either an IMN or plate/screws. Surgeon and hospital characteristics from the MPIER physician enrollment and Provider of Services (hospital) files were merged with the claims. Logistic regression was used to examine the geographic variation in IMN use by state and year, with and without adjustment for patient factors. Generalized linear mixed models with fixed and random effects were used to model the association between surgeon and hospital factors, and device choice (IMN or plate/screws), while controlling for patient factors. Fixed effects regression analyses using generalized estimating equations (GEE) were used to examine the association of provider volume and inpatient through 90-day mortality following intertrochanteric hip fracture surgery with internal fixation. Results: Geographic variation in IMN use from 2000-2002 was extensive, was largely not explained by patient factors, and the observed surgeon practice patterns persisted over time. Surgeon factors, resident case involvement and teaching hospital status were strong predictors of IMN use. Surgeons under age 45, those operating at more than one hospital and doctors of osteopathy were significantly more likely to use IMN. Surgeon more than hospital factors accounted for high IMN use. For the short-term mortality outcomes, the magnitude of the positive hospital volume effect was smaller among hip fracture patients than has been noted among elective arthroplasty patients. There were no significant mortality differences among patients of the lowest compared with the highest volume hip fracture surgeons. Conclusions: Device choice for Medicare intertrochanteric hip fracture patients was not based primarily on patient factors in 2000-2002. Device choice was and continues to be driven by factors other than substantial clinical outcomes evidence, particularly within certain subsets of providers. Both orthopaedic faculty involved in the training of new surgeons and early-career surgeons who are taught evidence-based medicine principles were the providers observed to have the highest IMN use. In addition to preferential training, higher Medicare reimbursement to surgeons for IMN is likely contributing to substantial increases in IMN use when a less-expensive procedure would give similar outcomes in the majority of cases. Subsequent to an RVU payment incentive, IMN use has increased dramatically, yet this increased IMN use has resulted in no better quality for most patients and at a higher cost to both hospitals and Medicare.
What can physicians tell us about managed care tools?
(2010-12) Davis, Margaret King
Over the past three decades, physician-directed managed care tools have been used extensively by health plans to influence physician practice and control health care costs. The success of these tools varies widely as do the specifics of how they are implemented. Organizations involved in implementation of managed care tools are evolving, as are the tools themselves. Gaining insight into physicians' views on how managed care tools impact quality of care could help in the development of more effective tools. The purpose of this thesis is to address two questions regarding physicians' attitudes towards managed care tools: Do physicians practicing in the same clinics have similar views of managed care tools? Do physicians' views of managed care tools differ across practice settings and organizational structures (e.g., types of clinics and health plans)? Using the literature on physician job attitudes and sociological and economic theory to guide the investigation, these questions are addressed by looking at the effects of physician, clinic and health plan characteristics on physicians' attitudes toward managed care tools. Data for this study come from the PEHP survey of physicians in 15 health plans and 5 major cities nationwide with supplementary health plan information from Interstudy (1997). The data was collected in 1998-99. The initial sample of 4,800 physicians was stratified to be half generalists and half specialists. The overall response rate was 68% and N = 3,459. The first part of the analysis consists of structural equation modeling (SEM) to test the new typology of managed care tools. The scales developed in the first part are then used as dependent variables in a hierarchical linear modeling (HLM) analysis to explore the role of physicians' work setting and health plan affiliation on attitudes toward managed care tools. Results of the SEM indicate that managed care tools can be described and classified in terms of the types of control they exert on physicians. Results of the HLM analysis suggest that physicians practicing in the same clinic and health plans share some similar attitudes toward managed care tools, but the majority of differences are still at the physician level. Physician characteristics included in this study do not explain these differences, leaving open the question of whether the majority of variation is due to real differences in how individual physicians experience managed care tools, or due to measurement error. Future analysis could clarify this issue if clinic associations can be identified more accurately and/or better physician level predictors are developed.

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