Browsing by Subject "health economics"
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Item Cost-Effectiveness and the Role of Socioeconomic Support Services in Ending the HIV/AIDS Epidemic in the United States(2022-08) Wheatley, MargoThere is still no cure for human immunodeficiency virus (HIV), meaning infected individuals must remain on lifelong treatment. While the United States has made substantial progress on HIV prevention, there are still more than 1.2 million people living with HIV (PLWH) in the U.S. and prevalence continues to increase. Treatment not only extends life expectancy and improves quality of life for PLWH, it also reduces the risk of HIV transmission by suppressing HIV viral loads to undetectable levels. However, only 58% of diagnosed PLWH in the U.S. were retained in care and only 66% were virally suppressed in 2019, which is well-below the National HIV/AIDS Strategy goal of reaching 95% viral suppression and ending the HIV epidemic by 2030. This dissertation summarizes existing evidence on the cost-effectiveness of improving retention in HIV care. It then presents new findings on the potential costs, benefits, and cost-effectiveness of socioeconomic support services funded by the U.S. Ryan White HIV/AIDS Program (RWHAP), the largest federally funded program focused on HIV care for low-income populations. Specific aims are to: 1) Systematically review evidence on the cost-effectiveness of HIV retention and re-engagement interventions. A systematic review of literature published in the past 10 years on retention interventions in high-income settings was conducted. Findings on methods, cost-effectiveness, quality, and overall strength of evidence were summarized. 2) Estimate the impact of support services on sustained viral suppression among low-income PLWH. Five years (2015-2019) of RWHAP data from the Minneapolis-St. Paul region was analyzed. Logistic and linear regressions using generalized estimating equations and propensity scores to adjust for the probability of service use were used to estimate the causal effect of support service use on sustained viral suppression. 3) Investigate the barriers, opportunities, and potential costs of expanding HIV socioeconomic support services. Semi-structured interviews were conducted with service providers in Minneapolis-St. Paul to explore current barriers, potential opportunities, estimated costs, and anticipated outcomes of program expansion for food, financial, transportation, and housing support services for low-income people living with HIV. 4) Evaluate the potential cost-effectiveness of expanding food aid vouchers to fill unmet need. An individual-based microsimulation model of post-diagnosis HIV care was developed and parameterized to reflect the RWHAP client population in the Minneapolis-St. Paul region. Using results from Aims 2 and 3, the model was used to estimate the potential cost-effectiveness of expanding food aid vouchers. Preliminary results from the base case and relevant sensitivity and scenario analyses are reported. Outcomes from this project provide support for continued funding of programs that address socioeconomic challenges for PLWH and can be used to inform local resource allocation decisions for HIV care. Socioeconomic support programs such as food aid, financial assistance, housing, and transportation could be integrated into multifaceted strategies aimed at improving HIV outcomes and achieving national HIV treatment goals.Item Essays on Disruptions in Medicaid Coverage(2022-06) Frenier, ChrisThis dissertation presents three empirical papers investigating how disruptions in Medicaid coverage affect enrollees. Medicaid is unique among public insurance programs in the United States because eligibility is means tested and, in most states, enrollment in private managed care plans is mandatory. Medicaid enrollees are low-income adults, children, and seniors, as well as people with disabilities, and these populations often face barriers to navigating the complexities of Medicaid enrollment, eligibility, and managed care. Changes in personal circumstance or state and federal policies can lead Medicaid enrollees to experience unanticipated changes to their health insurance coverage. Most Medicaid enrollees receive coverage through publicly financed, privately administered Medicaid managed care plans. States contract with Medicaid managed care organizations and offer most enrollees a choice of several plans. The high dollar amount of managed care contracts has led most states to select Medicaid plans using competitive bidding. When states conduct competitive bidding to select which plans to offer, enrollees may be forced to change managed care organizations if their plan's contract is not renewed. There is a sizable literature about plan switching in private insurance, but this type of disruption has not been extensively studied in Medicaid. Chapter 1 investigates how being forced to switch Medicaid managed care plans affects health care use and continuity of care for Medicaid enrollees. In 2016, Minnesota's state government used competitive bidding to contract with a new set of Medicaid managed care organizations. More than half of enrollees in the state were forced to change plans as a result of the bidding. I use data from the Minnesota All Payer Claims Database to show that enrollees who were forced to switch plans used fewer health care services after enrolling in their new plan. Plan switching also led to increased new provider visits, which is a sign of disrupted continuity of care. The effects on health care use were large, representing 30 percent reductions across a wide range of health care services, but were concentrated among enrollees who joined a specific managed care organization. These findings suggest that while states may be able to leverage competition between managed care plans to generate financial savings, being forced to switch insurers can be disruptive for Medicaid enrollees. Disenrollment from Medicaid is a second type of disruption. Some people lose Medicaid benefits because changes in their income or circumstances make them ineligible for the program, but others are disenrolled despite remaining eligible. This can occur when enrollees do not complete the necessary steps to renew or re-certify their Medicaid eligibility. Many people who are disenrolled later return to Medicaid. Losing Medicaid may result in uninsurance, even if benefits are restored in subsequent months. Transitioning in and out of Medicaid coverage may make it difficult for some people to receive regular medical care. Chapter 2 uses ten years of Medicaid enrollment data to measure the frequency of disenrollment and coverage disruption in Minnesota. I estimate the rate at which individuals disenroll from Medicaid, the share of disenrollments that result in uninsurance, and the share of enrollees who disenroll but return to the program within twelve months, which is called churn. I use medical and pharmacy claims data to show that the adults and children who experience disruptions in coverage are a lower spending population and leverage a unique feature of the Minnesota All Payer Claims Database to show that most enrollees do not have private insurance coverage during periods outside of Medicaid. This chapter demonstrates the role that All Payer Claims Databases can play in understanding coverage transitions in the fractured American health insurance system. I discuss state and federal policies that can help streamline Medicaid renewal and enrollment, with the goal of improving retention in the program and reducing the frequency of churn. Chapter 3 expands on Chapter 2 by examining how health care spending and use patterns differ between Medicaid enrollees who churn. I show that re-enrollment is highly correlated with short-term increases in medical spending and health care use and that enrollees who churn back into Medicaid coverage have higher spending throughout the re-enrollment period. This is the first paper to use administrative data to estimate the association between Medicaid churn and spending among non-elderly adults and shows how Medicaid enrollment policies like retroactive eligibility interact with disenrollment and churn.Item Essays on Hospital Infrastructure Investment(2023-07) Levin, ZacharyIn this dissertation, I present three essays related to infrastructure investment by acute care hospitals. When hospitals use revenue to invest in their facilities, there is an opportunity cost in terms of staffing, technology, community benefits, and other possible forms of investment. While some level of improvement to facilities may be necessary due to depreciation, infrastructure investment is also a potential way to attract (or maintain) patient demand through signals of high quality and pleasant patient experience. Over $30 billion in construction is invested by hospitals annually in the United States, but little is known on whether this investment impacts demand and/or quality. I provide the first comprehensive look at hospital construction projects, using novel data from California. In Chapter 1, I provide a descriptive overview of significant construction projects. I identify nearly seventy major projects, defined as changing a hospital footprint through either complete rebuilding, additions to general acute care, or service-specific expansions. These projects range in cost from over $2.5 million to add capacity at a small community hospital to nearly $600 million for an urban hospital replacement. Hospitals undertaking these projects are more likely to have above-average volumes of discharges and are less likely to have for-profit ownership structure. They additionally have higher market share than facilities not undergoing a major construction project in my sample period. My results reveal that major infrastructure investment is a non-random occurrence and influenced by hospital and local conditions. I analyze the impact of major construction projects on demand for hospital care in Chapter 2. I perform a difference-in-difference analysis of admissions at the hospital and market level linking data from California’s state discharge dataset. At the hospital level, I find a significant increase in own-hospital admissions after a facility undergoes a major construction project. The impact is especially large among patients with private insurance, which is significant given these insurers typically offer the most generous reimbursement. At the market level, I find strong evidence that admission growth results from market expansion as opposed to purely business-stealing, though I cannot definitively rule out competitive effects. Preliminary evidence suggests market growth occurs particularly among elective procedures. These results suggest certificate-of-need law repeal may not have dramatic anti-competitive effects, but supplier-induced demand remains a concern. Finally, in Chapter 3, I look at the impact of major construction projects on the quality of care received. High quality care is both a policy goal and a potential justification for undergoing construction. I examine quality in terms of both patient experiences, measured using survey data, and clinical outcomes, measured using administrative data. I again employ difference-in-difference analysis for estimation. I find significant improvement across a variety of patient experience measures after a hospital construction project is completed. Among clinical measures, however, there is no significant impact. My results suggest that at least one dimension of quality improves because of construction. This finding raises equity concerns for improving quality at safety net hospitals, given their financial situation makes it more difficult for investment in infrastructure.Item Essays on Innovation in the Medical Device Industry(2021-07) Everhart, AlexanderThis dissertation includes three empirical papers on the development and adoption of medical devices in the United States. Economists attribute as much as half of recent gains in life expectancy in the United States to the use of new medical technologies. When developing medical technologies, manufacturers must consider the “total product lifecycle” of devices, spanning from development costs to regulatory approval to insurer coverage and ultimately patient and physician adoption. The three chapters of this dissertation examine different stages of the total product lifecycle for medical devices.In Chapter 1, I study how medical device firms change their investments in research and develop following external shocks to production costs. Using damage to device manufacturing facilities caused by Puerto Rican hurricanes as a natural experiment, I find that increases in storm exposure cause firms to spend less on research and development and bring fewer medical devices to market. I also find that devices brought to market following storms are cited in competitor regulatory submissions no more or less often than the average medical device. This suggests that device firms do not meaningfully target more or less scientifically innovative projects at the margin when reducing investments in research and development. In Chapter 2, I describe the availability of cost-effectiveness analyses for medical devices in the United States. Cost-effectiveness analyses are not consistently used by insurers when making coverage decisions in the United States. I find that one of the barriers to using cost-effectiveness analyses is the timing of when analyses become available. Cost-effectiveness analyses are not available until several years after regulatory approval. In Chapter 3, I examine the effect of industry payments on physicians’ adoption of Medtronic’s Micra leadless pacemaker in fee-for-service Medicare. Leadless pacemakers have lower complication rates but a higher cost compared to traditional leaded pacemakers. I find that physicians who receive more payments from pacemaker manufacturers are more likely to adopt leadless pacemakers. However, this relationship is not robust to either physician fixed effects or an instrumental variables analysis predicting receipt of manufacturer payments as a function of distance from Medtronic headquarters.Item A modeling-based evaluation of the evidential basis for and cost effectiveness of intensive post-diagnosis extra-colonic surveillance of non-metastatic colorectal cancer patients(2018-03) Popp, JonahBetween 70-80% of colorectal cancer (CRC) patients present with non-metastatic disease and can potentially be cured with surgical resection. However, between 5-60% of these patients will suffer a recurrence, generally in the form of late-occurring metastatic disease. For this reason, most professional-society guidelines recommend intensive extra-colonic-focused surveillance (CT scans and routine testing for tumor-markers) of these patients for 3-5 years post-diagnosis with the aim of detecting recurrence at an earlier stage when it is more likely to be amenable to salvage surgery with a curative intent. Until recently, this practice was corroborated by the results of meta-analyses of randomized control trials (RCTs) comparing more intensive with less intensive (or no) surveillance. However, the negative results of two large recently-published RCTs – the UK FACS trial and the Italian GILDA trial - and of subsequently updated meta-analyses have cast doubt on the value of aggressive follow-up and ultimately the value of aggressive treatment of recurrent CRC. In this dissertation I use a modeling analysis to argue that the results of these two trials have been misinterpreted. Accordingly, the conclusions of the most recent meta-analyses are misguided and calls to throw in the towel on intensive follow-up are premature. The negative trial results are not surprising given the low recurrence rates of contemporary practice and thus the small proportion of patients who could potentially benefit from aggressive follow-up. I show that, if aggressive follow-up were to confer a survival advantage in virtue of increasing the chances of salvage therapy with a curative intent, the average benefit would be very small. Moreover, the two trials would have had essentially no chance to detect an effect of that size, and this problem of insufficient power was likely exacerbated in at least one of the trials by a sizable chance recurrence imbalance. I further show that it is unlikely that a RCT with adequate power could ever or will ever be possible. However, I argue there is reason to take seriously the hypothesis that aggressive use of follow-up testing and subsequent salvage therapy can offer a small survival advantage on average. Finally, I report the results of a modeling-based cost-effectiveness analysis to identify follow-up strategies that would be cost-effective if this hypothesis is correct.Item The Price is Right: Examining Demand for Medical Care in the Presence of Deductibles(2015-12) Trenz, YelenaResearch in health economics has traditionally considered only the current price of care in the estimations of demand for medical services. However, given the typical structure of insurance contracts that include cost-sharing features such as deductibles, the price of medical care is not constant throughout the year and depends on past and future medical expenditures. This study explicitly incorporates this nonlinearity by using the more appropriate concept of expected end-of-year price and applying it to the analysis of the demand for medical care by a sample of insured pregnant women who face different end-of-year prices depending on the timing of labor. Additionally, it investigates whether this group of consumers is myopic or forward-looking by examining which price, current or expected end-of-year, women use when making purchasing decisions. The results show that women who give birth in a calendar year face lower expected end-of-year prices, but combined with other health factors, use less non-pregnancy related medical care than those who do not give birth within the same period. The findings point to the presence of forward-looking behavior, while not fully rejecting myopia. Additionally, when the probability of reaching the deductible is used as the price-changing event, rather than labor, there is more evidence of forward-looking behavior among women in the sample, as those who reach the deductible spend more on medical care in response to the lower end-of-year price.