archives@tulane.edu / This dissertation includes three essays analyzing the socio-economic impacts of healthcare policies and a public health issue in the areas of healthcare price transparency, disease management, and water pollution. The first chapter, Price Transparency and Healthcare Costs: The Case of the New Hampshire Healthcare Market, analyzes the effect of price transparency on supply side changes to healthcare spending. It finds New Hampshire Healthcare Cost reduced negotiated prices by 1.3%, due to responses of insurances and healthcare facilities. The effect was heterogenous across insurers depending on how much they paid to a facility relative to those their competitors paid before the price transparency. The second chapter, Can Chronic Diseases Be Managed to Cost Less? The Case of A Diabetes Disease Management Program, evaluates the effect of a private diabetes disease management program on healthcare costs. It finds disease management programs could reduce allowance by $127 per person per month on average. This reduction was contributed by lower costs for inpatient services, outpatient services, physician visits, and emergency room visits. The third chapter, Something in the Pipe: Flint Water Crisis and Health at Birth, estimates the effect of in utero exposure to water pollutions on birth outcomes. Using the Flint water crisis as a natural experiment, it finds the water crisis modestly increased the probability of low birth weight by 1.8 percentage points but had little effect on the length of gestation or prematurity. / 1 / Rui Wang

The prevalence of heart failure became a major and growing public health problem globally, with rising mortality numbers causing a great financial burden. In Mongolia, the hospitalization for cardiovascular diseases makes up 55% of all hospitalizations, and mortality rate of circulatory diseases was the highest nationwide, accounting for 36.7% of all deaths (S.Ariuntuya et al., 2011). However, there is still no formal research addressing the prevalence of heart failure in Mongolia. Therefore, this paper is meant to bring awareness of the problem of hidden heart failure in Mongolia, which might be contributing significantly to the cardiovascular disease mortality and health care costs. This paper describes the Mongolian health care structure and the high incidence of heart failure risk factors is identified. Moreover, this paper proposes to develop and adapt a heart failure disease management program, as well as the heart failure patient education program in Mongolia. It is important that Mongolian health care providers and health policy makers acknowledge that if a proper disease management plan is not adapted soon, the prevalence of heart failure will continue to increase along with health care costs. Mongolia needs more public health and clinical researchers addressing heart failure.

Diabetes mellitus is a group of metabolic disorders caused by a relative or absolute lack of insulin. Currently, 23.6 million Americans have diabetes. Diabetes can lead to serious microvascular and macrovascular complications, such as cardiovascular disease, blindness, kidney disease, lower-limb amputations, and premature death. Due to the potential cardiovascular complications and the high prevalence of co-morbid hypertension and/or hyperlipidemia in patients with diabetes, diabetes management should include close monitoring of blood glucose, blood pressure, and cholesterol levels. Medical management of diabetic patients is costly; approximately 1 in every 10 health care dollars is currently spent treating diabetes. Studies have shown that in chronic conditions such as diabetes, increased medication use results in demonstrable improvements in health outcomes, reduced hospitalization rates, and decreased direct health care costs. To date no studies have evaluated the impact of a pharmacist-led intervention on diabetic medication adherence. The purpose of this investigation was to analyze the impact of a pharmacist-led medication management program on medication adherence and pharmacy costs and to evaluate clinical measures of diabetes, hypertension, and hyperlipidemia. This study was a quasi-experimental, longitudinal, pre-post study, with a control group. Scott & White Health Plan (SWHP) patients with diabetes (type 1 or type 2), poor glycemic control (most recent A1C >7.5%), and living within 30 miles of participating pharmacies were invited to participate in the intervention which consisted of monthly appointments with a clinical pharmacist and a co-payment waiver for all diabetes medications and testing supplies. A total of 118 patients met study inclusion criteria and were enrolled in the intervention between August 2006 and July 2008. Intervention patients were matched on sex and age to SWHP patients with poor diabetes control living more than 30 miles from a participating pharmacy. To measure the impact of the intervention, medical and pharmacy data were evaluated for one year before and after the study enrollment date. A significant difference was seen in the percentage of patients with type 1 diabetes in the intervention group (14) and the control group (3). The medication management program significantly improved A1C levels in intervention patients relative to controls (-1.1% vs. 0.6%) and was more effective in lowering A1Cs in type 2 diabetics than type 1 patients. Although the generalized linear model did not show that the intervention significantly improved the percentage of patients achieving the ADA goal A1C of <7% compared to controls, the multivariate logistic regression, which controlled for factors such as diabetes type, showed that patients participating in the intervention were 8.7 times more likely to achieve the A1C goal. Persistence with diabetic medications and the number of medications taken significantly increased in the intervention group; however, adherence rates, as measured by medication possession ratio (MPR), did not significantly improve relative to controls. The expenditure on diabetic medications and testing supplies increased substantially more in the intervention group than in the control group. The percentage of patients adherent with antihypertensive medications (MPR ≥80%) increased from 76% to 91% in the intervention group and decreased from 68% to 63% in the control group (P<0.05); no significant difference in blood pressure control was observed. For hyperlipidemia medications, adherence and persistence increased and pharmacy costs decreased in both groups, likely due to the introduction of the first generic HMG-CoA reductase inhibitor into the market during the study period. Future research is needed on the impact of the intervention on medical resource utilization and costs. / text

The COVID-19 pandemic affected regular health care for patients with chronic diseases. However, the impact of the pandemic on primary care for patients with coronary artery disease (CAD) who are enrolled in a structured disease management program (DMP) in Germany is not clear. We investigated whether the pandemic affected primary care and health outcomes of DMP-CAD patients (n = 750) by using a questionnaire assessing patients’ utilization of medical care, CAD symptoms, as well as health behavior and mental health since March 2020. We found that out of concern about getting infected with COVID-19, 9.1% of the patients did not consult a medical practitioner despite having CAD symptoms. Perceived own influence on infection risk was lower and anxiety was higher in these patients compared to symptomatic CAD patients who consulted a physician. Among the patients who reported chest pain lasting longer than 30 min, one third did not consult a medical practitioner subsequently. These patients were generally more worried about COVID-19. Patients with at least one worsening CAD symptom (chest pain, dyspnea, perspiration, or nausea without apparent reason) since the pandemic showed more depressive symptoms, higher anxiety scores, and were less likely to consult a doctor despite having CAD symptoms out of fear of infection. Our results provide evidence that the majority of patients received sufficient medical care during the COVID-19 pandemic in Germany. However, one in ten patients could be considered particularly at risk for medical undersupply and adverse health outcomes. The perceived infection risk with COVID-19 might have facilitated the decision not to consult a medical doctor.