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Thesis (D.P.H.)--University of Michigan.

Dissertation (D.P.H.)--University of Michigan.

In the wake of the Affordable Care Act, some US states expanded Medicaid eligibility to low-income, working-age adults while others did not. This study investigates whether this divergence induces migration across state borders to obtain Medicaid, especially in border regions of expansion states. It compares border with interior regions’ in-migration in the concerned subgroup before and after the Medicaid expansion in linear probability difference-in-difference and triple difference regression frameworks. Using individual-level data from the American Community Surveys over 2012–2017, this study finds only a statistically significant increase in in-migration to border regions after the expansion in Arkansas. The differing results across states could stem from statistical power issues of the employed regression analysis but might also result from state peculiarities. In Arkansas, the odds of having migrated increase by about 48% in its border regions after the Medicaid expansion compared to before and control regions. If all additional migrants take up Medicaid, the number of Medicaid beneficiaries in these regions increases by approximately 4%. Thus, even if the induced migration is statistically significant, it appears unlikely to impose meaningful fiscal externalities at the regional level. / Im Zuge des Affordable Care Acts haben einige US-Bundesstaaten den Anspruch auf Medicaid auf einkommensschwache Erwachsene im arbeitsfähigen Alter ausgeweitet, während andere Bundesstaaten dies nicht taten. Diese Studie untersucht, ob diese Divergenz zu einer Migration über die Bundesstaatsgrenzen führt, um Medicaid zu erhalten, insbesondere in Grenzregionen von Reformbundesstaaten. Sie vergleicht die Zuwanderung in Grenzregionen mit der Zuwanderung in das Landesinnere in der betroffenen Gruppe vor und nach der Medicaid-Ausweitung in linearen Wahrscheinlichkeits-Differenz-in-Differenz- und Dreifach-Differenz-Regressionsanalysen. Unter Verwendung von Daten auf Individualebene aus den American Community Surveys der Jahre 2012–2017 findet diese Studie nur in Arkansas einen statistisch signifikanten Anstieg der Zuwanderung in die Grenzregionen nach der Ausweitung. Die unterschiedlichen Ergebnisse in den einzelnen Bundesstaaten könnten von Problemen mit der statistischen Aussagekraft der durchgeführten Regressionsanalyse herrühren. Sie könnten aber auch aus Besonderheiten der jeweiligen Bundesstaaten resultieren. Eine zufällig ausgewählte Person in den Grenzregionen von Arkansas hat nach der Medicaid-Ausweitung eine um 48% erhöhte Wahrscheinlichkeit zugewandert zu sein im Vergleich zu vorher und den Kontrollregionen. Falls alle zusätzlichen Migranten Medicaid in Anspruch nehmen, steigt die Zahl der Medicaid-Empfänger in diesen Regionen um etwa 4%. Es scheint somit unwahrscheinlich, dass die induzierte Migration zu bedeutenden fiskalischen Externalitäten auf regionaler Ebene führt, selbst wenn der Migrationseffekt statistisch signifikant ist.

Objectives: Managed care organizations reduce healthcare costs and may improve patient health outcomes by encouraging better control of prevalent chronic diseases. The purpose of this study was to determine whether changing from a fee-for-service program to a capitated managed care program improved medication adherence for Medicaid patients in Kentucky with hypertension, hypercholesterolemia, or type 2 diabetes. Methods: We conducted a quasi-experimental study of patients enrolled in Kentucky Medicaid to evaluate the impact of transitioning to capitated managed care in November 2011. Medication adherence was measured using the proportion of days covered (PDC) method. Multivariable analyses measured the adjusted differences in adherence as a result of the implementation of capitated managed care. Results: Adjusted analyses indicate an average decrease in PDC by about 17-22 days of therapy coverage in the post-policy time period. However, no significant difference in adherence rate changes between the treatment and control populations were observed. Conclusions: Results indicate clinically inconclusive evidence regarding the immediate effect of the implementation of Medicaid managed care in Kentucky on medication adherence rates in patients with prevalent chronic diseases. There is a need to address the decline in average adherence rates, and the efficacy of Medicaid managed care based on medication adherence.

In this thesis we provide statistical and model-based data mining methods for pattern detection with applications to biomedical and healthcare data sets. In particular, we examine applications in costly acute or chronic disease management. In Chapter II, we consider nuclear magnetic resonance experiments in which we seek to locate and demix smooth, yet highly localized components in a noisy two-dimensional signal. By using wavelet-based methods we are able to separate components from the noisy background, as well as from other neighboring components. In Chapter III, we pilot methods for identifying profiles of patient utilization of the healthcare system from large, highly-sensitive, patient-level data. We combine model-based data mining methods with clustering analysis in order to extract longitudinal utilization profiles. We transform these profiles into simple visual displays that can inform policy decisions and quantify the potential cost savings of interventions that improve adherence to recommended care guidelines. In Chapter IV, we propose new methods integrating survival analysis models and clustering analysis to profile patient-level utilization behaviors while controlling for variations in the population’s demographic and healthcare characteristics and explaining variations in utilization due to different state-based Medicaid programs, as well as access and urbanicity measures.

Rheumatoid arthritis (RA) is a progressive autoimmune disorder of joints that is associated with high health care costs and yet lacks guidance on how early to initiate biologic disease-modifying antirheumatic drugs (DMARDs), a class of medications that is the major cost driver in RA management. The main purpose of this study was to examine patient socio-demographics, medication use patterns, and clinical characteristics associated with initiation of biologic DMARDs. This was a retrospective study using Texas Medicaid prescription and medical claims database during the study period of July 1, 2003 – December 31, 2010. Patients (18 – 63 years) with an RA diagnosis (ICD-9-CM code 714.xx), no non-biologic DMARD or biologic DMARD use during the pre-index period, and a minimum of 2 prescription claims for the same non-biologic DMARD during the post-index period were included in the study. The primary study outcomes were time to initiation of biologic DMARDs and likelihood of initiating biologic DMARDs. There was a total of 2,714 subjects included in the study. The majority had claims for pain medications (92.4%), glucocorticoids (64.9%), and non-biologic DMARD monotherapy (86.4%); while 24.3% initiated on biologic DMARDs and 58.9% had a Charlson Comorbidity Index (CCI) score=1. Compared to time to initiation (days) of biologic DMARDs for methotrexate (539.7±276.9) users, it was longer for sulfasalazine (670.2±167.8) and hydroxychloroquine (680.2±158.7) users and similar to leflunomide users (541.6±286.5; p<0.0001). There were no significant differences in time to initiation between non-biologic DMARD mono vs. dual therapy. Younger age, glucocorticoid use, methotrexate user (vs. sulfasalazine, hydroxychloroquine users), and non-biologic DMARD monotherapy user (vs. dual therapy user) were significantly associated with higher likelihood to initiate biologic DMARDs. In conclusion, age, glucocorticoid use, non-biologic DMARD type and therapy were significant factors associated with initiation of biologic DMARDs. Healthcare providers and Texas Medicaid should recognize these potential driving factors and take efforts to achieve optimal therapy for RA patients through thorough RA medication evaluation, well-structured RA monitoring programs, and patient education. / text

Introduction: Access to family planning services is a major public health issue. State policies and funding for family planning services may increase access to contraceptive services and help women avoid unintended pregnancies. Study Design: We identified sexually active, fertile women participants of the National Survey of Family Growth (2006-2008). Women were categorized as consistent or inconsistent users of contraceptives based on self-report. States were classified based on 2006 Medicaid family planning waiver status (income expansions, limited expansions, or no Medicaid family planning expansions), 2006 public funding for family planning in dollars per woman, and insurance coverage of contraceptive mandate status (comprehensive mandate, partial mandate, or no mandate). Multi-level logistic regression was used to estimate the extent to which state-level constructs increase consistent contraceptive use among reproductive aged women at risk of unintended pregnancy. Results: Women living in states with an Medicaid family planning income expansion waiver had 44% increased likelihood of consistent contraceptive use relative to women living in states with no Medicaid expansions (adjusted odds ratio (aOR): 1.44; 95% confidence interval (CI): 1.06-1.96). Limited Medicaid expansion was also associated with consistent contraceptive use (aOR: 1.30; 95% CI: 0.91-1.87). Nationwide a median of $86 (Interquartile range: $59-$133) of total public family planning funding was spent per woman in 2006. Higher levels of total public funding per woman for family planning services were not associated with an increase in the odds of consistent contraceptive use among all women (OR:1.05; 95% CI:0.98-1.12) or among women with incomes <250% of the federal poverty level (OR:1.06; 95%CI: 0.96-1.17). Comprehensive insurance coverage of contraceptives mandates increased the likelihood of consistent contraceptive use for privately insured women (aOR: 1.64; 95% CI: 1.08-2.50). Partial mandates were not associated with consistent contraceptive use. No association was observed among uninsured women (aOR: 0.77; 95%CI: 0.38-1.55). Conclusions: Comprehensive insurance mandates and income-based Medicaid eligibility expansions are associated with increased likelihood of consistent contraceptive use. More research is needed to understand the association between public funding for family planning and contraceptive use among women in need of publicly funded services.

Objective: The purpose of the study was to determine if a co-payment resulted in a differential preference for general anesthesia (GA) or oral sedation (OS) and, if so, to examine whether age, the number of appointments, perceived risks of treatment, child's awareness during treatment, or insurance type appeared to play a role in this preference.Methods: Using a cross-sectional survey design, questionnaires were distributed to caregivers of patients in the waiting room of the Virginia Commonwealth University Pediatric Dental Clinic. Two different questionnaires were distributed randomly. Both surveys described a scenario with the need for dental treatment under general anesthesia (GA) or oral conscious sedation (OS). Seventy five surveys required a $50 co-payment for treatment completed under general anesthesia and the other 75 required the same co-payment for treatment completed under oral conscious sedation. Caregivers were asked to choose treatment modalities as well as to rate factors in their decision making including perceived risks and the number of dental visits. Results: Seventy seven survey respondents selected GA as their preferred treatment option for the described scenario. The other sixty six respondents chose OS sedation. For the insured population, the GA/OS odds ratio for the OS-co-payment group versus the GA-co-payment group was OR=2.21 (95% CI = 1.06, 4.60). In terms of the uninsured, the GA/OS odds ratio for the OS-co-payment group versus the GA-co-payment group was OR=17.5 (95% CI = 1.60, 191). The child's age, awareness during treatment, and type of insurance (public versus private) were not significantly related to treatment choice. The importance of the number of appointments was found to be significant (p-value = 0.0170) and outweighed the effect of the co-payment (p-value = 0.1757). The importance of associated risks was found to be significant (p-value = 0.0171) and this outweighed the effect of the co-payment (p-value = 0.8157).Conclusions: The presence of a co-payment does not as significantly impact the GA versus OS preference while the number of appointments and perceived risks associated with the treatment remain significant.

Background: Regular access to dental services is a well-known factor in the oral health and development of children.1 As such, the United States federal government mandates each state to include dental services for children enrolled in Medicaid through the age of 21. Despite this mandate, the utilization rate of dental services among Medicaid enrolled children has remained remarkably low.2 In July 2005, Virginia implemented a sweeping Medicaid policy reform titled “Smiles for Children,” specifically aiming to increase Medicaid pediatric dental utilization rates. The purpose of this study aims to assess the effect of this 2005 policy reform on the utilization of dental services by children enrolled in Medicaid. Objective: The purpose of this study is to examine the impact of the 2005 Virginia Smiles for Children Medicaid policy reform on the utilization of dental services among Medicaid enrolled children. Methods: This was a retrospective cohort study of children (pre-reform n=559,820, post-reform n=690,538) enrolled in Virginia Medicaid from 2002 through 2008. Descriptive statistics and repeated measures multivariate logistic regressions were used to determine the relationship between enrollment (Pre- and Post-policy reform) and the utilization of dental services (1+ Dental Visits vs. No Dental Visits). Results: Descriptive analysis of the cohort found that 34% of pre-reform children had a dental visit while 44% of post-reform children. The logistic regression models revealed that children in the post reform period were 1.39 as likely to have had a dental visit. Stratifying for enrollment length reveals that as the length of exposure time to the post-reform policy increases, the odds of having a dental visit also increase as compared to the pre-reform period: for 31-36 months of enrollment the odds increase 1.54 times. Conclusions: Medicaid policy reform can significantly improve access to dental services for children and can therefore play an important role in promoting public health.