Significant efforts have been undertaken in medicine to identify hospital and primary care service areas (eg, the Dartmouth Atlas of Health Care) using patient origin information. Similar research in dentistry is nonexistent. The goal of this dissertation was to develop and refine methods of defining dentist service areas (DSAs) using dental insurance claims. These service areas were then used as spatial units of analysis in studies that examined relationships between utilization of oral health services, dentist workforce supply, and service area characteristics. Enrollment and claims data were obtained from the Iowa Medicaid program for children and adolescents ages 3-18 years during calendar years 2008 through 2010. The first study described rates of treatment by orthodontists in children ages 6-18 years. Orthodontic DSAs were identified by small area analysis in order to examine regional variability in utilization. The overall rate of utilization was approximately 3%; 19 DSAs were delineated. Interestingly, children living in small towns and rural areas were significantly more likely to have received orthodontic services than those living in metropolitan and micropolitan areas. The second study identified 113 DSAs using claims submitted by primary care dentists (ie, general and pediatric dentists). Characteristics of these primary care DSAs were then compared with counties. Localization of care was used as a measure of how well each region approximated a dental market area. Approximately 59% of care received by Medicaid-enrolled children took place within their assigned service area versus 52% of care within their county of residence. Hierarchical logistic regression was used in the final study to examine the influence of spatial accessibility and the importance of place on the receipt of preventive dental visits among Medicaid-enrolled children. Children living in urban areas were more likely to have received a visit than those living in more rural areas. Spatial accessibility assessed using measures of dentist workforce supply and travel cost did not appear to be a major barrier to care in this population. More studies are needed to explore the importance of spatial accessibility and other geographic barriers on access to oral health services. The methods used in this dissertation to identify service areas can be applied to other populations and offer an appropriate method for examining revealed patient preferences for oral health care.

Older individuals overwhelmingly prefer to receive long-term services and supports (LTSS) in home and community-based settings. Medicaid elderly 1915(c) waivers have become the primary mechanism that states use to provide home and community-based services (HCBS) to older individuals. Given the positive effects elderly waivers have on the quality of life of older individuals, I examined why states adopt elderly waivers; the extent of the substantive differences in program quality across elderly waivers; and the factors associated with elderly waiver program quality, contrasted with the factors associated with elderly waiver program size (i.e., number of participants and expenditures). I examined how state contextual, institutional, and political factors, as well as factors external to the states, including neighboring state and federal policy activity, influenced state policy decisions pertaining to elderly waiver adoptions and program quality and size. First, I performed a retrospective analysis using state-level longitudinal data from 1992-2010 to conduct a discrete time-series repeated event history analysis (EHA) to identify the variables associated with state adoptions of elderly waivers. Second, I created a measure of elderly waiver program quality consisting of four equally weighted components of waivers thought to be associated with the provision of higher quality HCBS to older individuals, including: eligibility criteria, self-determination supports, range of services provided, and participant protections. Using correlational analyses, I examined the relationships between program quality and size. Third, I performed retrospective ordinary least squares (OLS) analyses using waiver program-level data from 2015 to examine elderly waiver program quality and size and fixed-effects OLS using data from 1993-2010 to examine elderly waiver program size. I identified 63 elderly waiver adoptions across 35 states between 1992 and 2010, which were significantly associated with state contextual and external factors. Consistent with previous research, I found that contextual factors, including the number of older individuals, the supply of long-term care facilities and whether the state already had an elderly waiver program, affected state decisions to adopt elderly waivers. There was significant variation in each of the four component and overall quality scores and weak associations between program quality and size. I found that state contextual factors, including market and Medicaid program characteristics, influenced elderly waiver program quality and size. In addition, program quality was shaped by the capacity of state policymaking institutions (e.g., governorships and legislatures), while program size was shaped by neighboring state and federal policy activity. The findings from this research suggest that elderly waiver adoptions and program quality and size are shaped through different policymaking pathways. Efforts to improve the quality of elderly waiver programs should consider the capacity of state executive officials in addition to contextual determinants and focus on improving existing elderly waiver programs. Given that most waivers scored well on eligibility and participant protections, efforts to improve the quality of elderly waiver programs should focus on expanding self-direction supports opportunities, the types of waiver services, and eliminating restrictions placed on service delivery (e.g., waiting lists).

From February to September of 2001, a significant body of qualitive data was collected to investigate barriers for Hispanic participation in Oregon's managed care Medicaid program. As a means to investigate this topic, comments were solicited from physicians, hospital administrators, social service agencies, and low-income Hispanics through semi-structured focus groups and individual interviews. This methodology presents the reader with a rich enthnohistoric and cultural context to the local issues surrounding Hispanic under-participation in Oregon's managed care Medicaid program. Finally, through an analytical framework of critical medical anthropology, connections are drawn from local barriers to state and corporate policies. / Graduation date: 2002

Thesis (M.A.)--Marshall University, 2003. / Title from document title page. Document formatted into pages; contains ii, 46 p. Includes vita. Includes bibliographical references (p. 43).

This study used the Andersen Model for Health Services Utilization to examine a pharmacist-provided telephone MTM program among Medicare Part D beneficiaries. Predisposing (age, gender, race) and need factors (number of medications, number of chronic diseases, medication regimen complexity) were assessed. The health behavior, MTM utilization, distinguished the intervention and control groups. The health outcomes were change in number of medication-related problems, change in medication adherence [using the medication possession ratio (MPR)], and change in total drug costs. Medication knowledge, medication adherence (using the Morisky Scale), and patient satisfaction were also measured in the intervention group. The intervention and control groups were not significantly different in age (71.2 ± 7.5 vs. 73.9 ± 8.0 years), number of medications (13.0 ± 3.2 vs. 13.2 ± 3.4), number of chronic diseases (6.5 ± 2.3 vs. 7.0 ± 2.1), and medication regimen complexity [21.5 (range 8 – 43) vs. 22.8 (range 9 – 42.5)], respectively. For the subset of problems that was evaluated in the intervention and control groups, 4.8 (± 2.7) and 9.2 (± 2.9) problems were identified at baseline and 2.7 (± 2.3) and 8.6 (± 2.9) problems remained at the 3-month follow-up, respectively. Cost-related and preventative care needs and drug-drug interactions were the three most common problems identified. Multivariate regression analysis revealed that the intervention group had significantly more problems resolved (p < 0.0001) when compared to the control group, while controlling for predisposing and need factors. Significantly fewer problems were resolved (p = 0.01) as number of diseases increased and significantly more problems were resolved (p = 0.01) as medication regimen complexity increased. There were no significant predictors of change in MPR or total drug costs from baseline to the 3-month follow-up. Medication knowledge and medication adherence measured by the Morisky scale did not change significantly from baseline to the 2-week follow-up. However, patients were very satisfied with the service. A pharmacist-provided telephone MTM program was an effective method for identifying and resolving medication and health-related problems. A longer follow-up period may be necessary to detect the impact of pharmacist provision of MTM on adherence, total drug costs, and knowledge. / text

The Affordable Care Act (ACA) seeks to increase the low-income population’s access to health care coverage by expanding Medicaid eligibility and providing subsidies to individuals meeting certain income thresholds. The citizens of Texas would benefit greatly from the ACA provisions, as the state offers limited opportunities for individuals to access insurance, evidenced by the 6.3 million residents without health care coverage. But political leaders in Texas have a long-standing commitment to limited government, low taxes, and states’ rights in a federal system of government. In the 1990s, Texas legislators, with bipartisan support, laid the groundwork over the last decade for the minimal, yet significant preparations that administration used to coordinate ACA implementation. Yet legislators’ commitment to limited government and states’ rights placed additional constraints on the ability of the Texas Health and Human Services Commission (HHSC) to implement ACA provisions by refusing to utilize the 82nd legislative session to prepare the state for impending deadlines. Instead, administrators developed an interagency effort, the Eligibility Modernization Project (EMP), to streamline eligibility determinations and increase clients’ access to information and services. EMP’s initiatives mirror ACA provisions, but also seeks to achieve policy goals that both Republican and Democratic legislators support, such as providing effective and efficient eligibility determinations. Nevertheless, legislators and administrators must go beyond EMP’s efforts to adequately prepare the eligibility system for impending ACA deadlines. Policy recommendations include further streamlining and integrating the health subsidy system with a state-based health insurance exchange, increasing access to coverage by expanding Medicaid eligibility, adequately preparing the workforce for changes, and promoting long-term planning. These solutions will provide a sounder infrastructure for HHSC to prepare for ACA coordination and implementation, while increasing access to health care coverage for the low-income population. / text

Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most widely used medications globally. There are generally two types: selective (COX-2) and traditional NSAIDs (COX-1). They are primarily used for the treatment of pain. They gained attention after a study about their basic mechanisms highlighted their toxicity. Several studies have reported an association between NSAIDs and risk of myocardial infarction (MI). However, the direction of the relationship is not conclusive. Further studies are needed to ascertain the direction of this relationship and evaluate the present situation with available drugs. Due to the seriousness of cardiovascular diseases as one of the leading cause of death, continuous monitoring of the NSAIDs-MI association is needed. The purpose of this dissertation was to investigate the association between NSAIDs and MI in a younger (30-64 years) Kentucky Medicaid population with a 12 year window of data. The three specific aims were: (1) to understand the characteristics of the Kentucky Medicaid population with respect to NSAID use: (2) to evaluate the NSAID-MI relationship with a 12 year follow-up in a young heavily-burdened population for cardiovascular diseases: and (3) to investigate the MI risk of meloxicam, celecoxib and naproxen compared to no exposure. A retrospective study was conducted employing data from January 1st 2000 and December 31st 2012. The data comprised demographic, prescription and medical files. Within this cohort, a nested case control study was conducted. Cases of MI were matched to four controls on race and gender. The results suggested that exposure to COX 2 presented an increased adjusted risk for MI (1.138(0.983, 1.318)). However, this risk was significantly increased for COX-2 only users compared to COX-1 only users (1.221 (1.03, 1.485)) and 30-40 year olds (1.600 (1.082, 2.367)). Meloxicam, celecoxib and naproxen compared to no exposure showed meloxicam presented a non-significant different risk for MI (1.26 (0.98, 1.63)) and celecoxib presented a significantly increased risk for MI (1.52 (1.26, 1.82)). This study considered pattern of use in determining continuous usage by looking at both continuous and sporadic users of NSAIDs and also considered patient switching patterns between classes of NSAIDs.

Immigrant women often lack the social support and help from extended family and other social relationships, which is very significant during the pregnancy, delivery, and postnatal period. This research was conducted among Bangladeshi immigrant women living in the United States, in order to understand their experiences during pregnancy and childbirth: how they coped with the settings of a different country during that period, and how they felt about this situation. While there are several studies on immigrant women and maternal health issues in anthropology, to my knowledge, there have been none that focused specifically on the childbirth experiences of Bangladeshi immigrant women in the US. These women have very specific culturally-based perceptions about the US health care system around issues such as communication with service providers, dealing with the hospital system, the role of health insurance, and so on. This research was conducted among Bangladeshi women in Tampa, Florida, and sought to understand their experiences during pregnancy and childbirth and perceptions of access and quality in the health care system. Fifteen women were selected through purposive and snowball sampling. Data was collected using in-depth interviews. This study examines the experiences of these Bangladeshi immigrant women within their socioeconomic context and immigration status.

The objective of this dissertation is to evaluate whether two different types of policy interventions in the United States are associated with health service utilization and economic outcomes. Paper 1: The number of government lawsuits accusing pharmaceutical companies of off-label marketing has risen in recent years. We use Medicare and Medicaid claims data to evaluate how an off-label marketing lawsuit and its accompanying media coverage affected utilization and spending on gabapentin as well as other anticonvulsant medications. In this interrupted time series analysis of dual eligible patients with bipolar disorder, we found that the lawsuit and accompanying media coverage corresponded with a decrease in market share of gabapentin, a substitution of newer and expensive anticonvulsants, and a substantial increase in overall spending on anticonvulsants. Paper 2: Medicare Part D was a major expansion of Medicare benefits to cover pharmaceuticals. There were initial concerns about how the dually eligible population who previously had drug coverage through Medicaid would fare after transitioning to Part D plans. Using a nationally representative longitudinal panel survey of Medicare Beneficiaries that are dually eligible for Medicaid, we investigated whether differences in generosity of Medicaid drug benefits were associated with differential changes in drug utilization and out-of-pocket spending for duals after they transitioned to Part D. Our finding suggest that those who previously encountered a monthly drug cap prior to Part D implementation experienced a differentially higher increase in annual prescription drug fills compared with those who did not face a cap.

This dissertation consists of three quantitative papers addressing contemporary issues in health policy. The first paper draws on a survey of 2,678 adults from the United States and four European countries to assess demand for a hypothetical early medical test for Alzheimer's disease (AD). Overall, 67% of respondents reported that they would be "very" or "somewhat" likely to get the test if it were available. Through logistic regression analysis, we find that interest was higher among those worried about developing AD, with an immediate blood relative with AD, and who have provided care for AD patients. Knowing that AD is fatal did not influence demand, except among those with an affected blood relative. We expect that a test becoming available could precipitate the creation of a large constituency of asymptomatic, diagnosed adults, affecting a range of health policy decisions. The second paper utilizes Current Population Survey data to explore state-level Medicaid enrollment rates among eligible parents between 2003 and 2010, focusing on the interaction of race and ethnicity and political ideology. Using logistic regression analysis, we find that average take-up for Hispanics in conservative states was 23%, whereas take-up was 38% for both whites and blacks in those states, adjusting for state and individual demographics. These differences abated in liberal and moderate states. Among eligible Hispanics, enrollment rates were less than half as high in conservative states than in liberal states (23% versus 61%). Adjusting for differences in state Medicaid policies narrowed these disparities significantly, highlighting the importance of new provisions aimed at streamlining enrollment procedures across all states. The last paper draws on public and private data from 2007 to 2010 to analyze how administrative spending by health insurers and providers varied across states with different levels of insurance and hospital market concentration. Using regression analysis, we find that in provider offices, high levels of insurance concentration were associated with lower administrative costs. If all states were as concentrated as the most concentrated state in our sample, we would expect nationwide savings of $3.6 billion in administrative expenses. However, market concentration did not reduce administrative spending by insurers or hospitals.