Master of Regional and Community Planning / Department of Landscape Architecture/Regional and Community Planning / Larry L. Lawhon / This report examines the Town of Frisco, Colorado development process utilized to implement an attainable housing development within a resort style community. This report begins with the review of historic trends in affordable housing initiatives in American culture that has led to the importance of creating a diverse housing stock. The report was conducted by review of articles, government records, private and public reports, and research on the housing demand and analysis in the regional area. This report was conducted to provide resort style communities, similar to the Town of Frisco, a clear process of implementing an attainable housing development through the use of private/public partnerships. Frisco’s private/public partnership with the development team of Ten Mile Partners serves as a plausible process a community can undertake to increase a community’s housing stock diversity and affordability for long term residents.

Master of Regional and Community Planning / Department of Landscape Architecture/Regional and Community Planning / Larry L. Lawhon / Affordable housing is an important component of Transit-Oriented Development (TOD) because it provides lower income households the option to live an automobile-free lifestyle. A TOD, for this research, can be defined as a development located next to a transit line which provides small-scaled amenities and pedestrian activities. It also integrates a mix of uses, such as residential, retail, and public uses. This report focuses on the residential portion of TOD by identifying the importance of affordable housing in Transit-Oriented Development. In order to explore affordable housing in TOD, a case study was conducted of an existing TOD in the Denver metropolitan region. This TOD, known as the CityCenter Englewood TOD, is specifically located in Englewood, Colorado. This report explores the policy decisions that Englewood made when deciding not to integrate affordable housing provisions into the development. The affordable housing situation in Englewood is rather complicated. A review of census data suggests that affordable housing is needed in the community, while community officials state that Englewood is contextually affordable compared to the Denver metropolitan region. The conclusion of this report identifies the characteristics of the Englewood community that portray little tangible need for additional affordable housing units in the year 2010. However, according to the “Best Practices” Study of this report, other TOD communities do show various levels of tangible need for a mixed-income environment.

Smart Growth is a comprehensive approach to planning that aims to shape more compact and well-connected communities across the United States. Among its principles are leveraging existing infrastructure, developing around transit, providing a mix of housing types and price ranges, and increasing community participation in the planning process. However, research suggests the comprehensive approach at times obscures potential tensions between these principles, in particular when Smart Growth principles are applied to a specific property. This is the case in Austin, Texas’ Lamar/Justin Lane TOD, where the City of Austin is currently evaluating development scenarios for a publicly-owned 5.6 acre parcel located within the TOD area. How equity and access is addressed in Smart Growth comes to fore in conversations between the City and affluent, neighborhood residents. This report examines the history of Smart Growth, reviews its implementation in cities across the U.S., and considers how the City of Austin may learn from other cities. / text

Hospital readmissions are a source of reduced payment as mandated by the Centers for Medicare and Medicaid Services as part of the Affordable Care Act (ACA). The number of dollars used for hospital readmissions has sky rocketed above $17 million for heart failure alone. The changes in the ACA reimbursement guidelines has put stress on many hospitals as they are facing reduced income, increased use of resources, and increased length of stay. This project evaluated the implementation of Project BOOST, its components, and their predictability for hospital readmission. Sample groups were evaluated both pre- and post-implementation of Project BOOST, which included individuals aged 18 and older, who were of Anglo, Hispanic or Native American descent, and living in Northern Arizona. A retrospective chart review was performed and descriptive and predictive statistics were used to analyze obtained data. Patients with cardiovascular disease admitted to the study hospital have high risks for readmission, such as problem medications, polypharmacy, psychological Issues, and principal diagnoses. Integrating elements from Project BOOST significantly decreased 30-day hospital readmissions. Data from this study revealed a statistically significant reduction in 30-day hospital readmission rates from 22% in the pre-intervention period to just 4% in the post-intervention period. Patients who did not receive the risk assessment tool were 14 times more likely to be readmitted to the hospital within 30 days of the index hospitalization.

The Patient Protection and Affordable Care Act (PPACA) expanded access to insurance coverage and health care services for many citizens, and has increased access for women in particular by including preventive reproductive health services as essential health benefits. The current national rates of sexually transmitted infections (STIs), reproductive cancer diagnoses, and unintended pregnancy serve as major areas of concern for women’s health and public health. The present study examined how knowledge of the PPACA influences receipt of preventive reproductive health services among women. Results indicate that higher levels of knowledge of the PPACA are associated with a greater likelihood of receiving cancer and STI screenings, as well as contraceptive counseling, and that increasing contraceptive knowledge, rates of contraceptive counseling, and pap screenings are related to greater use of highly effective contraception. The present study offers support for increased outreach and education efforts, along with additional policy and provider involvement.

The Low Income Housing Tax Credit Program is the primary federal program for producing new units of affordable housing. The program provides financial incentives to private developers to develop and operate affordable rental housing. In recent years, evidence has emerged that the program has led to clusters of subsidized housing in some cities. It is hardly surprising that some clustering would exist in a program in which the housing is constructed and owned by private developers. Despite the significant number of units produced by the program and despite the potential tendency for clustering of units built under this program, the locational patterns within the LIHTC program remain largely unexamined. Instead, most studies of the LIHTC program have focused on the national level rather than on individual cities. In contrast to previous studies, this study seeks to improve our understanding of variations in the LIHTC program across cities. The hypothesis of this study is that, because private developers produce housing in the LIHTC program and because the factors that influence private developers vary across cities, there is likely to be significant variation in the locational patterns of LIHTC developments across cities. The results of this study show, among other things, that clustering of LIHTC properties exists in the study cities, this clustering is extreme in some cases, and the clusters are associated with high poverty tracts in some cities. Given the LIHTC program's emphasis on market-driven policies and a similar emphasis in some other federal housing programs, such findings will likely be applicable to other affordable housing programs.

Thesis advisor: Rocío Calvo / Hispanics are less likely than non-Hispanic whites to use mental health service, even after controlling for various social, environmental, and health factors. Mental health services disparities between Hispanics and non-Hispanic whites have been well-documented and consistent over time. However, very little is known about the impact mental health care organizations have on Hispanics’ access to mental health care, especially since the implementation of the Patient Protection and Affordable Care Act (ACA). The three papers in this dissertation utilize the 2010, 2014, and 2016 waves of the National Mental Services Survey (N-MHSS) to assess the impact of the ACA on Hispanics’ access to mental health care and mental health care organizations’ provision of integrated services. The N-MHSS is a national repository of data on the mental health organizations in the United States. This dataset was created to report the characteristics and client enrollment at mental health care organizations. Paper 1 uses the 2014 N-MHSS to describe the structural characteristics of mental health care organizations according to the proportion of Hispanics they serve and the organizations’ structural characteristics in Medicaid expansion and non-expansion states. Paper 2 uses the 2010, 2014, and 2016 N-MHSS waves to examines the impact of the ACA and the health safety net on Hispanic admissions at mental health care organizations. These three waves were merged together using a repeated cross-sectional design to assess whether Hispanic admissions increased after the implementation of the ACA. The final paper uses the 2014 and 2016 N-MHSS waves to assesses whether integrated care has increased at Hispanic-serving organizations compared with mainstream organizations two years after the implementation of the ACA. This paper also assessed whether the increased funding for integrated services under the ACA has disproportionately affected mainstream organizations compared with Hispanic-serving organizations. / Thesis (PhD) — Boston College, 2018. / Submitted to: Boston College. Graduate School of Social Work. / Discipline: Social Work.

The South African National Antiretroviral Treatment Guidelines recommend the use of HIV-1 viral load assays for routine monitoring of HIV-1 positive patients receiving highly active antiretroviral therapy (HAART). This thesis describes the innovative approaches to developing more affordable HIV-1 diagnostics and monitoring assays for South Africa, which take into account the tiered laboratory infrastructure of this country. An in-house HIV-1 viral load assay – the LUX assay, was developed and evaluated with a view of implementing this more affordable option in high tier laboratories. The LUX assay represents quantitative real-time RT-PCR that utilizes the LightCycler® technology (Roche) in a novel combination with a LUXÔ primer. The assay showed good analytical sensitivity, specificity and reproducibility of its linear dynamic range of 4x102 to 4x106 RNA copies/ml. Preliminary clinical evaluation (n = 458) of the LUX assay showed good agreement with the COBAS Amplicor assay, and demonstrated its usefulness for long term monitoring of HAART patients. ELISA based viral load testing approaches were investigated as low cost and less technically complex alternatives for medium tier laboratories. The HiSens HIV-1 p24 Ag Ultra (Perkin Elmer) and the ExaVir™ Load Quantitative HIV-RT kits (CAVIDI) were compared with the Roche Amplicor assay. Both assays showed strong association with the Roche Amplicor assay, with R2 = 0.686 and R2 = 0.810, respectively (n = 117). These alternative assays seemed most useful in the serial monitoring of patients on HAART. Major drawbacks included the wide variability of both assays, insufficient sensitivity of the p24 antigen assay and low throughput of the RT assay. Development of a point-of-care HIV-1 RNA assay could address issues related to early and cost effective diagnosis of acute HIV infection. A novel isothermal amplification technique termed the Reverse Transcription Loop Dependant Amplification (RT-LDA) was developed as one component for a potential point-of-care HIV-1 RNA assay. The RT-LDA converted RNA into partially looped ssDNA amplicons, over a wide RNA concentration range (4x103 to 4x108 copies/ml) using a 1 hour incubation at 53ºC. The RT-LDA technology is fully compatible with a lateral flow detection system using dipsticks and highly suitable for point-of-care testing. Overall, this study demonstrates the feasibility of developing novel, more affordable HIV-1 testing options that would be appropriate for the tiered laboratory infrastructure present in South Africa. Evaluation of commercially available, less expensive alternative HIV viral load assays in local settings facilitates their implementation.

The Hospital Value-Based Purchasing Program (HVBP), created by Section 3001 of the Patient Protection and Affordable Care Act passed in 2010, enacted a major industry shift in Medicare towards "pay for performance," or paying for high marks on a variety quality metrics rather than the traditional reliance on volume of care delivered. This study examines one of these quality metrics in particular: patient satisfaction. The trajectory of this paper begins with an overview of the current focus on patient satisfaction as a modern quality metric in American healthcare, contextualizes this emphasis on satisfaction within the intellectual movement of "patient-centered care," and moves on to a review of the relevant scholarship that attempts to explain the numerous determinants of patient satisfaction scores (with special attention to the inpatient hospital setting), as well as the robust academic debate over whether satisfaction is even an appropriate quality metric at all relative to clinical outcomes in care. The second half of my discourse moves on to more practical applications - first I break down the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey and the impact of its methodology on providers, then the Medicare HVBP program itself and its various directions towards the value-based care model. I conclude with a quantitative analysis of trends in patient satisfaction over time between 1) HVBP-participating providers (as of FY2014) and 2) those providers who have not opted in (including those ineligible to do so). My comparison aims to study the strength of the HVBP incentives to improve patient satisfaction in those subject to the financial incentive relative to those who are not. Additionally, I preface this analysis whether patient satisfaction scores are associated with either clinical process of care scores or outcome scores in the HVBP program. My research questions aim to shed light on the academic debate between patient satisfaction and more traditional clinical outcomes - are they related in the context of FY2014 HVBP? Are the new incentives to improve patient satisfaction actually doing so in a meaningful way among providers newly accountable to these incentives? Finally, in a market defined by zero-sum resources, is there evidence that a financial incentives around patient satisfaction are channeling resources and by extension improvement away from clinical outcome performance? I believe this last question is the true concern of patient satisfaction skeptics, and hope to address it with applicable data. By providing a thorough qualitative grounding in the topic followed by current quantitative analysis, my goal is to create an informed perspective on the use of patient satisfaction as a quality metric in U.S. healthcare, which can be applied meaningfully from policy, provider, and consumer vantage points. With patient satisfaction becoming increasingly more internalized in the value-based care model, these analyses of the initial results in HVBP potentially serve as predictive insight into provider behavior in this area moving forward.

In most markets, competition induces efficiency by ensuring that goods are priced according to their marginal cost. This is not the case in health insurance markets. This is due to the fact that the cost of a health insurance policy depends on the characteristics of the consumer purchasing it, and asymmetric information or regulation often precludes an insurer from matching the price an individual pays to her expected cost. This disconnect between cost and price causes inefficiency: When the premiums paid by consumers do not match their expected costs, consumers may sort inefficiently across plans. In this dissertation, I study the effects of policies used to alleviate selection problems. In Chapter 1, I develop a model to study the effects of risk adjustment on equilibrium prices and sorting. I simulate consumer choice and welfare with and without risk adjustment in the context of a Health Insurance Exchange. I find that when there is no risk adjustment, the market I study unravels and everyone enrolls in the less comprehensive plan. However, diagnosis-based risk adjustment causes over 80 percent of market participants to enroll in the more comprehensive plan. In Chapter 2, we study an unintended consequence of risk adjustment: upcoding. When payments are risk adjusted based on potentially manipulable risk scores, insurers have incentives to maximize those risk scores. We study upcoding in the context of Medicare, where private Medicare Advantage plans are paid via risk adjustment but Traditional Medicare is not. We find that when the same individual enrolls in a private plan her risk score is 5% higher than if she would have enrolled in Traditional Medicare. In Chapter 3, we study two forms of insurance for insurers: Reinsurance and risk corridors. Protecting insurers from risk can lower prices and improve competition by inducing entry into risky markets. It can also induce inefficiencies by causing insurers to manage risk less carefully. We use simulations to compare the power of reinsurance and risk corridors to protect insurers against risk while limiting efficiency losses. We find that risk corridors are always able to limit insurer risk with the lowest efficiency cost.