xiii, 123 p. : ill. (some col.) A print copy of this thesis is available through the UO Libraries. Search the library catalog for the location and call number. / To complement a varied and growing literature in health economics, this dissertation is conducted in three substantive parts. First, I investigate the effect of public policy on health use and health outcomes, exploiting variation in the generosity of Medicaid eligibility to low income pregnant women across states and over time to identify an effect on common, yet costly, pregnancy complications. I provide new evidence on this important question from a nationally representative sample of hospital discharges for 12 states between 1989 and 2001. Second, I explore heterogeneity in individual demand for health risk reductions. Utilizing individual stated-preference data from matching surveys conducted in both Canada and the United States, I employ the Value of a Statistical Illness Profile framework to investigate differences in average willingness-to-pay (WTP) for health risk reductions across the two different cultures. Although existing literature has allowed for systematic variation in age to explain differences in health care demand, the differences in WTP have not been explained through systematic variation across other socio-demographic characteristics, subjective risks of the diseases in question, or differences between the Canadian and U.S. health care systems. I extend the literature by controlling for an expanded set of observable individual heterogeneity and comment on the degree to which estimates can be applied across cultures to inform varying policy decisions. The third paper studies factors affecting adolescent health risk behavior. Previous study finds that community size and the degree to which social networks are interconnected affect three economically significant outcomes: the frequency of adolescent misbehavior in school, degree of perceived safety in school, and grade performance. Other research has suggested peer effects on smoking behavior and drinking behavior. I investigate the degree to which social connectedness impacts adolescent health, specifically looking at outcomes for drinking and smoking, and the degree to which these effects can be disentangled from more commonly studied "peer effects" in health behavior. / Committee in charge: Trudy Cameron, Co-Chairperson, Economics; Glen Waddell, Co-Chairperson, Economics; Anne van den Nouweland, Member, Economics; Jessica Greene, Member, Planning Public Policy & Mgmt; David Levin, Outside Member, Mathematics

O câncer é atualmente a segunda maior causa de mortalidade no mundo, depois das doenças cardiovasculares. A prevalência de câncer em países em desenvolvimento tem alcançado patamares próximos à registrada em países desenvolvidos. No caso do câncer de mama, há evidências crescentes quanto à influência de inovações em tratamentos oncológicos na chance de sobrevivência de pacientes após diagnóstico e tratamento, assim como em termos de redução do risco de reincidência e melhoria da qualidade de vida durante tratamento. A avaliação de tecnologias em saúde constitui importante instrumento para alocação racional dos recursos escassos em saúde, especialmente no apoio ao cumprimento dos princípios do Sistema Único de Saúde quanto à equidade, integralidade e universalidade no atendimento em saúde da população brasileira. O presente trabalho tem como objetivo geral efetuar uma análise de custo-efetividade no tratamento de pacientes com câncer de mama HER2 positivo inicial e localmente avançado no âmbito do Sistema Único de Saúde (SUS). Os resultados da simulação computacional apontam razão custo-efetividade favorável à quimioterapia adjuvante com trastuzumabe somente caso seja adotado limiar acima de três vezes valor do Produto Interno Bruto (PIB) per capita brasileiro por anos de vida ganhos ou anos de vida ganhos ajustados por qualidade de vida. O presente estudo encontrou resultados similares ao Herceptin Adjuvant (HERA), em que quimioterapia adjuvante com trastuzumabe reduziu recorrência e, particularmente, recorrência à distância, porém a sobrevida global apresentou um acréscimo modesto. Contudo, ainda é necessária extensão da investigação proposta, preferencialmente por meio de avaliação de prontuários de pacientes na rotina em prática clínica que utilizam quimioterapia adjuvante com trastuzumabe / Cancer is currently the second leading cause of death worldwide, behind heart diseases only. The prevalence of cancer in developing countries has been reaching levels close to the ones recorded in developed countries. Regarding breast cancer, there are uprising evidences in terms of the influence on innovations of oncological treatments on the chances of patients to survive after diagnosis and treatment, as in terms of the fall in the risk of recurrence and the improvement on the quality of life during the treatment. The evaluation of health technologies represents an important instrument for the reasonable allocation of the scarce resources in the health system, especially in the endorsement of the compliance of the Unified Health System (UHS) in regards to the equity, integrality and universality of the health care service to the Brazilian people. The goal of this study has as a general objective to analyze the costs and outcomes for the treatment of patients with HER2-positive breast cancer in early and locally advanced stages in the scope of the Unified Health System (UHS). The computer simulation results reveal a favourable cost-effectiveness ratio to the adjuvant chemotherapy with trastuzumab only if the threshold above of three times the Brazilian Gross Domestic product (GDP) per capita is taken according to surviving years or surviving years adjusted by quality of life. This study reflected similar results to Herceptin Adjuvant (HERA), in which adjuvant chemotherapy with trastuzumab reduced recurrence and, particularly, distant recurrence, although global survival presented a modest increase. However, the strech on the proposed investigation is necessary, preferably via reviewing patients\' records in the routine of the clinical practice who are in the use of adjuvant chemotherapy with trastuzumab

O câncer é atualmente a segunda maior causa de mortalidade no mundo, depois das doenças cardiovasculares. A prevalência de câncer em países em desenvolvimento tem alcançado patamares próximos à registrada em países desenvolvidos. No caso do câncer de mama, há evidências crescentes quanto à influência de inovações em tratamentos oncológicos na chance de sobrevivência de pacientes após diagnóstico e tratamento, assim como em termos de redução do risco de reincidência e melhoria da qualidade de vida durante tratamento. A avaliação de tecnologias em saúde constitui importante instrumento para alocação racional dos recursos escassos em saúde, especialmente no apoio ao cumprimento dos princípios do Sistema Único de Saúde quanto à equidade, integralidade e universalidade no atendimento em saúde da população brasileira. O presente trabalho tem como objetivo geral efetuar uma análise de custo-efetividade no tratamento de pacientes com câncer de mama HER2 positivo inicial e localmente avançado no âmbito do Sistema Único de Saúde (SUS). Os resultados da simulação computacional apontam razão custo-efetividade favorável à quimioterapia adjuvante com trastuzumabe somente caso seja adotado limiar acima de três vezes valor do Produto Interno Bruto (PIB) per capita brasileiro por anos de vida ganhos ou anos de vida ganhos ajustados por qualidade de vida. O presente estudo encontrou resultados similares ao Herceptin Adjuvant (HERA), em que quimioterapia adjuvante com trastuzumabe reduziu recorrência e, particularmente, recorrência à distância, porém a sobrevida global apresentou um acréscimo modesto. Contudo, ainda é necessária extensão da investigação proposta, preferencialmente por meio de avaliação de prontuários de pacientes na rotina em prática clínica que utilizam quimioterapia adjuvante com trastuzumabe / Cancer is currently the second leading cause of death worldwide, behind heart diseases only. The prevalence of cancer in developing countries has been reaching levels close to the ones recorded in developed countries. Regarding breast cancer, there are uprising evidences in terms of the influence on innovations of oncological treatments on the chances of patients to survive after diagnosis and treatment, as in terms of the fall in the risk of recurrence and the improvement on the quality of life during the treatment. The evaluation of health technologies represents an important instrument for the reasonable allocation of the scarce resources in the health system, especially in the endorsement of the compliance of the Unified Health System (UHS) in regards to the equity, integrality and universality of the health care service to the Brazilian people. The goal of this study has as a general objective to analyze the costs and outcomes for the treatment of patients with HER2-positive breast cancer in early and locally advanced stages in the scope of the Unified Health System (UHS). The computer simulation results reveal a favourable cost-effectiveness ratio to the adjuvant chemotherapy with trastuzumab only if the threshold above of three times the Brazilian Gross Domestic product (GDP) per capita is taken according to surviving years or surviving years adjusted by quality of life. This study reflected similar results to Herceptin Adjuvant (HERA), in which adjuvant chemotherapy with trastuzumab reduced recurrence and, particularly, distant recurrence, although global survival presented a modest increase. However, the strech on the proposed investigation is necessary, preferably via reviewing patients\' records in the routine of the clinical practice who are in the use of adjuvant chemotherapy with trastuzumab

Submitted by Rosina Valeria Lanzellotti Mattiussi Teixeira (rosina.teixeira@unisantos.br) on 2017-09-19T14:49:22Z No. of bitstreams: 1 Vanessa Meira Cintra Ribeiro.pdf: 1270789 bytes, checksum: c0f9c7a1f1d0c3c4f74468f35832fb2a (MD5) / Made available in DSpace on 2017-09-19T14:49:22Z (GMT). No. of bitstreams: 1 Vanessa Meira Cintra Ribeiro.pdf: 1270789 bytes, checksum: c0f9c7a1f1d0c3c4f74468f35832fb2a (MD5) Previous issue date: 2017-05-25 / Introduction: The structure of Pharmaceutical Care (FC), based on the National Medicines Policy and the National Pharmaceutical Assistance Program, is organized to guarantee a broad spectrum of drug assistance to prevalent pathologies. However, even with this AF structure and organization profile, there has been an increase in the number of users who resort to health judicializations, requesting inputs or specific drugs often not covered by SUS. Objective: To analyze the judicialization of health related to the Pharmaceutical Assistance of the State of Paraíba, through the lawsuit lawsuits for the purchase of medicines under the responsibility of the State Health Department (SES / PB) of 2013. Methods: Cross-sectional study , Quantitative data from the lawsuits for the acquisition of medicine and health supplies of 2013. The database of the Health Economics Center (NES / PB) and financial database of the Pharmaceutical Assistance Center (NAF) were used. Descriptive and inference statistical analyzes (p> 0.05) performed in the R® program. A coroplast map was drawn from the TabWin® program. The research was approved by the Research Ethics Committee of the Catholic University of Santos (CAAE: 64520316.0.0000.5536). Results: 3510 cases were requested with 4339 medications, with an average of 1.2 (± 0.68) per requesting user, which processed in 47 varas of the state, being the majority of João Pessoa and Campina Grande, representing 92% . Profile of the population: 59.6% were female, 48.9% were elderly. There was a higher proportion in the group of elderly patients who used continuous medication, 73.5% (p <0.001). With regard to the diseases that led to the judicialization, it was observed that 40.7% were endocrine diseases, respiratory diseases, neoplasms and the circulatory system, especially diabetes whose proportion was 26.2%. The IJ (Judicialization index) of Paraíba was 0.9 judgments for every 10,000 inhabitants. There was an association between IJ and HDI variables (municipality, longevity, income and schooling), total population and demographic density by municipality, illiteracy rate and percentage of extremely poor population by means of the Kendall test and bivariate linear regression, both With p <0.05. It was observed in a multiple regression analysis (p <0.001) that the population (¿ = 1,950) and the HDI of the municipality (¿ = 3.701) interfered positively in IJ growth. Regarding the economic aspects, it was observed that: the judicialization accounted for 4.2% of the state's own health expenditure, 44.8% with oncology, and the per capita expenditure was R $ 10548.79 (40 times more than The state's per capita health investment), 372 types of drugs were purchased, of which 12 had a price variation of> 90%. Increase in judicialization in the biennium 2012/2013 in number (512) and financial impact (50.95%). Conclusion: The study verified the increase in the judicialization in the state of Paraíba, following a national trend, associated to social factors related to population development, reinforcing the need for stimulus in the articulation between the judiciary and health sector with a view to optimizing access to medicines. This is reinforced by the importance of epidemiological studies and the identification of weaknesses in favor of management and SUS. / Introdução: A estrutura da assistência farmacêutica (AF), fundamentada na Política Nacional de Medicamentos e no Programa Nacional de Assistência Farmacêutica, é organizada para garantir um amplo espectro de assistência medicamentosa a patologias prevalentes. Entretanto, mesmo com este perfil de estrutura e organização da AF, tem aumentado o número de usuários que recorrem às judicializações em saúde, solicitando insumos ou medicamentos específicos muitas vezes não cobertos pelo SUS. Objetivo: Analisar a judicialização da saúde ligada a Assistência Farmacêutica do Estado da Paraíba, por meio dos processos de demanda judicial para aquisição de medicamentos sob a responsabilidade da secretaria de Saúde do Estado (SES/PB) do ano de 2013. Métodos: Estudo transversal, quantitativo a partir dos processos judiciais de aquisição de medicamento e insumos para saúde de 2013. Utilizou-se o banco de dados do Núcleo de Economia da Saúde (NES/PB) e banco de dados financeiro do Núcleo de Assistência Farmacêutica (NAF). Análises estatísticas descritivas e de inferência (adotado p>0,05) realizadas no programa R®. Elaborou-se um mapa coroplético a partir do programa TabWin®. A pesquisa recebeu a aprovação do Comitê de Ética em Pesquisa da Universidade Católica de Santos (CAAE: 64520316.0.0000.5536). Resultados: Foram 3510 processos com solicitação de 4339 medicamentos, sendo uma média de 1,2 (±0,68) por usuário requisitante, os quais tramitaram em 47 varas do estado, sendo a maioria de João Pessoa e Campina Grande, representado 92%. Perfil da população: 59,6% era do sexo feminino, 48,9% de idosos. Verificou-se maior proporção no grupo dos idosos que faziam uso de medicação contínua, 73,5% (p<0,001). Com relação às doenças que levaram à judicialização observou-se que 40,7% foram doenças endócrinas, respiratórias, neoplasias e do aparelho circulatório, com destaque para o diabetes cuja proporção foi de 26,2%. O IJ (índice de Judicialização) da Paraíba foi de 0,9 judicializações para cada 10.000 habitantes. Verificou-se associação entre o IJ e as variáveis IDH (município, longevidade, renda e escolaridade), população total e densidade demográfica por município, taxa de analfabetismo e percentual de população extremamente pobre por meio do teste de Kendall e regressão linear bivariada, ambos com p<0,05. Observou-se, em análise de regressão múltipla (p<0,001), que a população (¿=1,950) e o IDH do município (¿= 3,701) interferiram positivamente no crescimento do IJ. Sobre os aspectos econômicos observou-se que: a judicialização representou 4,2% dos gastos com recursos próprios do estado na saúde, destes 44,8% com oncológicos, o per capita gasto foi de R$10548,79 (40 vezes a mais que o investimento per capita em saúde do estado), foram aquisitados 372 tipos de medicamentos, destes 12 tiveram variação de > 90% nos preços. Aumento na judicialização no biênio 2012/2013 em número (512) e impacto financeiro (50,95%). Conclusão: O estudo verificou o aumento na judicialização presente no estado da Paraíba, seguindo uma tendência nacional, associado a fatores sociais ligados ao desenvolvimento da população, reforçando a necessidade de estímulo na articulação entre o judiciário e setor saúde com vistas à otimizar o acesso aos medicamentos. Para tal reforça-se a importância de estudos epidemiológicos e levantamento de fragilidades para favorecer à gestão e ao SUS.

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This paper assesses how women of different racial backgrounds and their contraceptive method choices impact their economic well-being. While there is extensive literature on the impact of contraceptive use and women’s economic outcomes, there is less concerning women’s contraceptive method choice and their economic outcomes. However, birth control is only as effective at supporting women’s economic advancement as it is effective at preventing unintended pregnancy. Given a legacy of reproductive and economic disempowerment, Women of Color in the United States have unevenly reaped the economic benefits of contraception. Therefore, it is important to look at how race and contraceptive method choice may factor into women’s economic health. In this paper, I define women’s economic well-being in terms of human capital, through the lens of educational attainment, and income. Further, I stratify contraceptive methods into three categories: high, medium, and low, based on the method’s effectiveness rate and user maintenance requirements. Using a Simple Linear Regression Model, I find that medium forms of birth control have the greatest impact on educational attainment and earnings for both White women and Women of Color.

Understanding how health care markets function is important not only because competition has a direct influence on the price and utilization of health care services, but also because the proper functioning, or lack thereof, of health care markets has a very real impact on patients who depend on health care markets and providers for their personal well-being. In this dissertation, I examine the role of government policies and regulation in health care markets, with a focus on the response of health care providers. In Chapter 1, I analyze the impact of Medicare payment rules on hospital ownership of physician practices. Since the mid-2000’s, there has been a rapid increase in hospital ownership of physician practices, however, there is little empirical research which addresses the causes of this recent wave of integration. Medicare’s “provider-based” billing policy allows hospital-owned physician practices to charge higher reimbursement rates for services provided compared to a freestanding, independent physician practice, without altering how or where services are provided. This “site-based” differential creates a premium for physicians to integrate with hospitals, and the size of this differential varies with the types of health care services provided. I find that Medicare payment rules have contributed to hospital ownership of physician practices and that the response varies across physician specialties. A 10 percent increase in the relative reimbursement rate paid to integrated physicians leads to a 1.9 percentage point increase in the probability of hospital ownership for Medical Care specialties, including cardiology, neurology, and dermatology, which explains about one-third of observed integration of these specialties from 2005 through 2015. Magnitudes for Surgical Care specialties are similar, but more sensitive across specifications. There is no significant response for Primary Care physicians. In combination with other empirical literature which finds that integration between physicians and hospitals typically results in higher prices with no impact on costs or quality of care, I cautiously interpret this responsiveness as evidence that Medicare’s provider-based billing policy overcompensates integrated physician practices and leads to an inefficiently high level of vertical integration between physician and hospitals. In Chapter 2, I analyze the effect of anti-fraud enforcement activity on Medicaid spending, with a particular focus on the False Claims Act. The False Claims Act (FCA) is a federal statute which protects the government from making undeserved payments to contractors and suppliers. Individual states have chosen to enact their own versions of the federal FCA, and these statutes have increasingly been used to target health care fraud. FCA statutes commonly include substantial monetary penalties such as “per-violation” monetary fines and tripled damages, as well as a “whistleblower” provision which allows private plaintiffs to initiate a lawsuit and collect a portion of recoveries as a reward. Using variation in statelevel FCA legislation, I find state FCAs reduce Medicaid prescription drug spending by 21 percent, while other spending categories - which are less lucrative for FCA lawsuits - are unresponsive. Within the prescription drug category, drugs prone to off-label use show larger declines in response to the whistleblower laws, consistent with FCA lawsuits being used to prosecute pharmaceutical manufacturers for off-label marketing and promotion. Spending and prescription volume for drugs prone to off-label use fall by up to 14 percent. This effect could be driven by pharmaceutical manufacturers’ changes in physician detailing for drugs prone to off-label use and/or physicians’ changes in prescribing behavior.

This dissertation consists of three essays examining the role of transfer-program interactions for families and households who participate in the social safety net. The safety net is comprised of many different programs, run by different agencies, governed by different rules, and often administered by disparate and secluded entities. However, many households participate in multiple programs, subjecting them to the milieu of administrative hurdles. In this dissertation, I try to untangle some of the intended and unintended effects of program participation that may be experienced by these households. In Essay 1, I examine the effect of the Patient Protection and Affordable Care Act of 2010 (ACA) on food hardship in US households, utilizing food security information from the Food Security Supplement of the Current Population Survey. Because states adopted the Medicaid expansions provided under the ACA at different times beginning in 2014, the cross-state, over time variation allows me to separate the impact of the ACA on food hardship using triple difference specifications. The richness of questions in the Food Security Supplement allows me to examine the effect of the ACA across different measures of food hardship, and also examine differential response for households participating in the Supplemental Nutrition Assistance Program (SNAP). Examining the mechanisms through which the ACA could affect food insecurity, I find the ACA not only increased average weekly food expenditure, but also the probability a household participates in SNAP. I employ a two-stage, control function approach to address reverse causality between SNAP and food insecurity. I find that the ACA reduced the probability that a household participating in SNAP falls into the two lowest food security categories by 6.5 percentage points and reduced the probability of being food insecure by 14.2 percentage points. Across specifications, I find strong evidence for increasing returns to program participation, and evidence of a differential impact of the ACA across the distribution of food hardship. In Essay 2, I examine how grant funding and fiscal structure affect program response over the business cycle. I compare child enrollment in Medicaid, a matching grant funding program, with enrollment the State Children's Health Insurance Program, a block grant funded program, utilizing the similarities in beneficiaries, program benefits, and administration to isolate the impact of fiscal structure. I utilize administrative enrollment records, along with individual level participation data, and find a one percentage point increase in the unemployment rate leads to a 7.6% decrease in the number of beneficiaries per person enrolled in block grant funded programs, and a 10% decrease in state expenditure per person decreases the probability of enrollment in a block grant program by 0.58 percentage points. I also find that enrollment is much more persistent among matching grant funded programs, and being enrolled in a block grant funded program the previous period increases the probability of enrolling in a matching grant program this period 75% more than remaining enrolled in the block grant funded program. Finally, in Essay 3 I explore the effect of the minimum wage on the self-reported value of public assistance program benefits, and the joint effect of the minimum wage and public assistance programs on the income to poverty ratio using data from the 1995-2016 Current Population Survey Annual Social and Economic Supplement. In the first stage, I estimate a Tobit model controlling for the censoring of received benefits from below at zero, and examine the effect of changes in the minimum wage on the self-reported dollar value of benefits received for food stamps/the Supplemental Nutrition Assistance Program (SNAP), Aid to Families with Dependent Children (AFDC)/Temporary Assistance to Needy Families (TANF), Supplemental Security Income (SSI), and the Earned Income Tax Credit (EITC), as well as the total sum of benefits. I find that the minimum wage reduces the value of means-tested benefits, but that this effect is strongest for programs with strong work requirements. Utilizing the residuals from the first stage, I employ a control function approach to estimate the joint effect of the minimum wage and program benefits on the income to poverty ratio. I find the own-effect of the minimum wage provides a small increase in the income to poverty ratio, but that the total effect, accounting for changes in benefits, attenuates by approximately 30%.

This thesis investigates how proximity to parks, historic district designations, and water quality are valued at residential housing prices. The first essay argues that the negative influences of parks and historic districts, if not noticed, could promote negative externalities and unincentivized investments. I find a negative impact on housing values for a close proximity to a park, suggesting disamenities in park features. When the boundary discontinuity and park amenities are considered, I find a positive valuation for a park. Overall, these results imply a mixed influence of parks on homeowners. From the historic district standpoint, I find a positive valuation of the local historic districts over the surrounding neighborhoods. The latter findings indicate that the benefits of locally designated areas outweigh the negative impacts. The second essay researches a probable lead risk in the water supply on the residential market. I argue strongly for the possibility of hidden-type information relative to lead in water supplies. I find that the influence of lead risk in their water supply is not statistically significant. The test for asymmetric information validates the expectation that homes in the relatively high lead-risk neighborhoods might not be informed of the level of lead-risk in their water supply.

Both economists and policy makers are interested in understanding the welfare effect of economic policies, especially in small open economies such as Turkey and Iran. This knowledge is crucial for priority setting in any informed policy discussion. This dissertation aims to study the impoverishing effect of high levels of out-of-pocket (OOP) payments in the health sector, referred to as catastrophic health expenditure (CHE), and investigates the impact of exchange rate pass-through (ERPT) on both the microeconomic and macroeconomic indicators of a country. For millions of people worldwide, health payments present a huge financial risk. A high rate of OOP health care payments can lead to CHE, which can force households to cut down their consumption, minimize access to their needs, or face poverty. This makes the design of financial risk protection necessary for governments in order to secure people against the financial hardship at the time of incurring CHE. This thesis comprises three essays. The first investigates financial risk protection indicators related to OOP health care payments through CHE mean positive overshoot and incidence and depth of impoverishment. This research observes that in the absence of universal health care insurance in Iran, together with a high share of OOP spending for health care (more than 52%), the Iranian households facing CHE will eventually face poverty. In the second essay, using a difference-in-differences propensity score matching approach, I seek to analyze the degree to which Iranian universal health care insurance protects households from high rates of OOP health expenditure. In this study, I evaluate the effect of the universal health insurance program on Iranian CHE. The results show that the program was successful in decreasing the rate of OOP health expenditures and CHE in Iran during the sample period. The third essay estimates the ERPT using product-level daily data on wholesale prices of imported agricultural products, where the identification is possible by using daily data on the domestic inflation rate. The results of standard empirical analyses are in line with existing studies that employ lower frequencies of data by showing evidence for incomplete daily ERPT of about 5 percent.