This study sought to investigate the effect of state-level policies, pertaining to hate crimes and mental health care, on the association between sexual orientation and the prevalence of depression, suicidal ideation, suicide attempt, and bullying amongst adolescents. State-level policies included whether hate crime laws included sexual orientation as a protected category, and rates of follow-up care after hospital discharge amongst acutely mentally ill youth covered by public health insurance (Medicaid or the Children's Health Insurance Program; CHIP). Data were from the 2019 State-Level Youth Risk Behavior Survey (YRBS), completed by a representative sample (N = 153,215) of U.S. students in grades 9-12 across 44 states. The YRBS is one of the few population-based studies to gather sexual orientation data in a youth sample. Compared with living in states with hate crime laws extending protections to lesbian, gay, and bisexual (LGB) people, living in states without inclusive hate crime laws did not predict a significantly stronger association between LGB status and mental health. However, the association between LGB status and electronic (i.e., cyber) bullying was significantly greater in states with hate crime laws that excluded sexual orientation as a protected category than in states with inclusive hate crime laws. The association between LGB status and suicide attempt was significantly greater in states with lower rates of follow-up mental health care for acutely ill youth than in states with higher rates of follow-up care. This is the first known study to find an association between residing in a state with higher quality government-funded mental health care for acutely ill youth and reduced suicide attempt among LGB youth. These findings underscore the urgent need for state-level policies that increase legal protections and improve access to mental health care for sexual minority youth. / Doctor of Philosophy / This study investigated the relationship between state-level policies, mental health, and bullying among lesbian, gay, and bisexual (LGB) high school students. State-level policies included whether hate crime laws included sexual orientation as a protected category, and rates of follow-up care after hospital discharge amongst severely mentally ill youth enrolled in Medicaid or the Children's Health Insurance Program (CHIP). Data were from the 2019 State-Level Youth Risk Behavior Survey (YRBS), completed by 153,215 U.S. students in grades 9-12 across 44 states. The YRBS is one of the few large studies to gather information about sexual orientation in a youth sample. Participants were more likely to be cyber-bullied if they lived in states that didn't include sexual orientation as a protected category. LGB high school students living in these states were at even greater risk of being cyber-bullied than their heterosexual peers. Youth residing in states with better follow-up care were less likely to attempt suicide. LGB youth living in states with worse follow-up care were at even greater risk of attempting suicide than their heterosexual peers. This is the first known study to find a relationship between residing in a state with higher quality government-funded mental health care and reduced suicide attempt among LGB youth. These findings underscore the urgent need for state-level policies that increase legal protections and improve access to mental health care for sexual minority youth.

This thesis argues for providing spiritual care in primary care for Massachusetts persons with disabilities having Medicare and Medicaid as their primary insurers. It outlines an advocacy strategy to (1) increase awareness of the importance of spiritual care as key to primary care, (2) get buy-in for spiritual care as an optional primary care service to Medicaid beneficiaries needing nonmedical supports and services to live in the community due to mental health diagnosis or physical disability, and (3) put forward a statutory or regulatory proposal requiring One Care plans to provide certified peer chaplains as a covered service starting 2023.

Introduction: Historically, in Pennsylvania, the Salzmann Evaluation Index (SEI) (Figure 2) was used to evaluate the medical necessity of orthodontic care and whether the government will cover costs for low-income patients. Approval discrepancies occur between doctor index scoring and insurance funding with the SEI, leading to questions about how indices determine funding. Each state and insurance administrator decides which, if any, medically necessary malocclusions to include that automatically qualify for treatment coverage. As of 2022, a major insurance administrator in the state of Pennsylvania added an additional qualifying criterion: the orthodontic criteria index (OCI), ten occlusal characteristics that lead to an automatic qualification (Figure 3). This leaves the possibility that a patient may qualify on one or both indices. This study is the first to evaluate the frequency of approvals between SEI and OCI in Pennsylvania. The secondary objectives for this investigation are to evaluate the OCI criteria insurance administrator approval rate compared to the doctors’ scoring and to evaluate if sex, age, race/ethnicity, and submission year impact insurance funding decisions and to evaluate the OCI criteria insurance administrator approval rate compared to the doctors’ scoring. The results of this study may promote standardization for the state of Pennsylvania to readily adopt a list of Automatic Qualifiers for all Medicaid insurance administrators. Materials and Methods: All subjects had no orthodontic treatment and underwent routine screening and record-taking through the Temple University Kornberg School of Dentistry Orthodontic Screening Clinic from November 1, 2022, to March 31, 2023 (n = 171). For all orthodontic providers, scoring SEI and OCI was calibrated in September 2022. Malocclusion characteristics of 171 subjects between the ages of 9-20 were characterized for treatment need with standardized SEI and OCI criteria. SEI gives a numeric score of treatment need by accessing intra-arch and inter-arch tooth position relationships. OCI is a binary list for the presence of specific severe malocclusion criteria, which leads to automatic qualification for treatment. Approval thresholds were at least one OCI AQ or a SEI≥25. Patient data, including age, date of initial submission, sex, race and ethnicity, date of submission, insurance response, and orthodontist scoring, was recorded. Insurance submission records were analyzed, and funding decisions based on the Salzmann Evaluation Index (SEI) and the Orthodontic Criteria Index (OCI) were recorded. Malocclusion severity evaluation had an inter-examiner reliability of 90%, using the Salzmann Evaluation Index, with a score of >25 determining treatment need or one of the ten automatic qualifiers from the Orthodontic Criteria Index form was perceived regardless of the Salzmann Evaluation Index score. Both indices scored, along with intraoral and extraoral photographs, a cephalogram, a panoramic radiograph, and an intraoral impression, were sent to Insurance Administrator A, a primary Medicaid company for patients at TUKSoD. An employee of the insurance administrator received the records submitted and made a funding decision. Results: Overall insurance approval was 38.6%. Doctor approval rates were 42.7% for OCI and 24.6% for SEI. The overall doctor versus approval discrepancy was 39.7% for both SEI and OCI combined. Patients who qualified for treatment with one or more OCI had an average SEI of 18. Only 24.6% of SEI scores ≥25 were approved. The greatest agreement between insurance and doctor approvals was for the OCI category: impacted of canines or incisors. There was no statistically significant difference in the approval rate between the OCI and SEI for gender, ethnicity, or submission year. Age groups have a statistically significant discrepancy (P<0.01). Conclusion: There is a moderate level of agreement between insurance approval and doctor-determined scores. There is greater agreement between OCI doctor scores, and insurance approval compared to SEI. A significant approval rate variance occurs with age for SEI. Age group and % SEI Variance have an inversely proportional relationship, possibly due to differences in opinion about what constitutes a permanent dentition (impacted permanent or over-retained primary teeth). The newly implemented OCI criteria have less funding variance and produce greater agreement between insurance and clinician assessment than SEI. / Oral Biology

This study offers insights into the impact of competition among Managed Care organizations (MCOs) on infant birthing charges and birth outcomes. Kentucky provides one of the nation’s first case studies to determine successes and failures of Medicaid MCOs, and by doing so, provides a prediction of the impact of Patient Protection Affordable Care Act (PPACA) competition on healthcare costs and birth outcomes. An analysis of a natural policy experiment in the state of Kentucky reveals that infants insured by a Medicaid MCO stay longer in hospitals, are less healthy, and cost more than those insured under Traditional Medicaid prior to a policy change. Utilizing a difference-in-difference-in-difference (DDD) estimation, this study found initial evidence in a competitive MCO environment of Traditional Medicaid average birth charges substantially more than births under a Medicaid MCO, while outcomes also revealed the incidence of normal delivery increased almost identical to that of private insurance. However, after a short time, average birth charges for infants born under Medicaid MCO climb higher than other payer-types and infant health begins to decline. Outcomes of this study signal that Managed Care infants are actually less healthy and cost substantially more than anticipated but it is possible that these outcomes can be attributed to insurance selection.

No description available.

Purpose: To assess the impact of dental Medicaid reform in Virginia on dental practice settings (private practice, corporate practice and safety net clinics). Methods: This retrospective cohort study of 16.2 million dental claims is from the Virginia Department of Medical Assistance Services, which included claims for providers participating in Virginia’s Medicaid program during a 10-year period (2002-2012). The dividing date for the reform was July 1, 2005. The outcome measure was mean claims per participating provider. A Poisson regression model was used to predict the mean number of claims per provider with the following predictors: reform period, practice setting, provider specialty, practice location. Results: The mean number of claims after program reform was significantly higher depending on practice setting and provider specialty, but not practice location. Conclusion: Medicaid reform has resulted in a significant increase in the number of dental claims, providers, and practice settings in Virginia.

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

Expansion of Medicaid and private health insurance coverage through passage of the Affordable Care Act of 2010 was expected to increase primary care access and reduce emergency department (ED) use by reducing financial burden and improving affordability of care. The aim of this study was to examine the differences in utilization patterns that exist among the Medicaid population that participated in an optimal level of care (OLC) intervention inclusive of appointments scheduled to primary care providers. Using the integrated behavior model as a theoretical framework, the key research question focused on determining if there was a difference in ED use among Medicaid individuals who scheduled follow-up appointments compared to those that did not schedule follow-up appointments. The sample population consisted of 176 Medicaid enrollees who presented to the ED for treatment of nonurgent conditions and participated in an OLC intervention from June 2016 to July 2017. The results showed that there were no differences in ED utilization between the population that had scheduled appointments compared to the population that did not have scheduled appointments. A bivariate analysis on demographic variables also showed no differences in ED utilization among the variables. The social change implications of this study are that the practice of scheduling appointments with primary care providers does not reduce or affect ED utilization in the Medicaid population. This study contributes to positive social change through the findings that reducing ED utilization requires more than follow-up appointment scheduling with primary care providers. Further studies are warranted to understand the potential barriers and factors that affect ED utilization.

What is the importance of political speechmaking? Do state governors discuss presidential priorities? This study addresses these questions by analyzing the contents of annual State of the State addresses given by governors from 2012 to 2014 during the presidency of Barack Obama. A descriptive paper provides evidence that governors primarily discuss employment and economic issues in their addresses, are discussing greater number of policy issues than in previous decades, and are delivering their address before the presidential State of the Union message. Examining health care and immigration policy in separate empirical papers, I theorize that contextual factors, including legislative partisanship, public approval, and presidential influence may affect the extent to which policies supported by the Obama administration are rhetorically referenced by governors. Empirical analyses found limited support for the influence of divided government, but demonstrated significant evidence for the importance of including state-centric factors, including annual employment rate and proximity to Mexico, as well as temporal effects, into future analyses of gubernatorial rhetoric.

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.