Racial and Ethnic Disparities in the Use of Drug Therapy

The purpose of this research is to explain the variation in the utilization of drug therapy for the medical conditions of depression, high cholesterol, and hypertension between Hispanics, non-Hispanic blacks, and non-Hispanics whites using Oaxaca-type decomposition analysis based on logit estimates. We find that almost the entire share of the utilization differences in drug therapy between blacks and whites can be explained by the differences in the coefficients of observable characteristics, while the sources of the utilization difference between the whites and Hispanics are split between the differences in the observable characteristics and the coefficient estimates. This result implies that strategies to improve racial and ethnic disparities need to be tailored to each group by focusing on the specific factors that are attributed to causing the disparity.high cholesterol, depression, drug therapy, racial and ethnic disparities, hypertension, Oaxaca decomposition

The Impact of Nurse Turnover on Quality of Care and Mortality in Nursing Homes: Evidence from the Great Recession

We estimate the causal effect of nurse turnover on mortality and the quality of nursing home care with a fixed effect instrumental variable estimation that uses the unemployment rate as an instrument for nursing turnover. We find that ignoring endogeneity leads to a systematic underestimation of the effect of nursing turnover on mortality and quality of care in a sample of California nursing homes. Specifically, 10 percentage point increase in nurse turnover results in a facility receiving 2.2 additional deficiencies per annual regulatory survey, reflecting a 19.3 percent increase. Not accounting for endogeneity of turnover leads to results that suggest only a 1 percent increase in deficiencies. We also find suggestive evidence that turnover results in lower quality in other dimensions and may increase mortality. An implication of our mortality results is that turnover may be a mechanism for the procyclicality of mortality rates

The impact of firm, individual, and government choice on health outcomes

This dissertation is comprised of three essays that consider how choices made by firms, individuals, and governments have impacts on health outcomes. In the first essay, a legislative policy shock is used to determine why nursing home facilities converted to a new ownership type and how these conversions subsequently lead to changes in the quality of care provided between 1999 and 2004. As a result of a legislative change in reimbursement policy, nearly five percent of nursing homes converted. Conversions from a not-for-profit to for-profit was found to be associated with a decrease in the use of physical restraints while the proportion of residents with pressure ulcers in facilities that converted from for-profit to not-for-profit increased. The second essay analyzes how promotion of sickness insurance by the government contributed to the reduction in the infant mortality rate in six European countries between the Franco-Prussian War and the Great War. The results suggest that for every additional percentage point of the adult population that is covered by sickness insurance infant death rates declined by additional 0.39 to 1.11 deaths per 1000 live births in this period. The final essay studies how individual choice to purchase insurance affects out-of-pocket expenditures on antidepressant medications by elderly Medicare recipients. This essay discusses the econometric problems faced in the estimation of medical expenditures and finds that the average out-of-pocket expenditure on antidepressants decreases with supplemental insurance.Ph.D.Includes bibliographical references (p. 81-89)

Ownership conversion and closure in the nursing home industry

Ownership conversions and closures in the nursing home literature have largely been treated as separate issues. This paper studies the predictors of nursing home ownership conversions and closure in a common framework after the implementation of the Prospective Payment System in Medicare skilled nursing facilities. The switch in reimbursement regimes impacted facilities with greater exposure to Medicare and lower efficiency. Facilities that faced greater financial difficulty were more likely to be involved in an ownership conversion or closure, but after controlling for other factors the effect of exposure to Medicare is small. Further, factors that predict conversion were found to vary between not-for‐profit and for‐profit facilities, while factors that predict closure were the same for each ownership type. Copyright (C) 2010 John Wiley & Sons, Ltd.not‐for‐profit , for‐profit , closure , conversion , nursing homes ,

Health IT Adoption, Productivity and Quality in Primary Care

Within the last decade, there has been a growing push towards the use of electronic medical records and health information technology (IT) within primary care physician practices. Despite financial subsidies, smaller practices remain reluctant to adopt these information systems. Using a nationally representative survey of physicians, this study explores the relationship between physician, practice and area attributes and the adoption of health IT systems. Controlling for these attributes, the analysis subsequently studies the relationship between health IT, physician productivity and perceived quality of care. It finds that smaller practices and physicians with lower incomes are less likely to adopt health IT systems and that adoption varies with the type of medical conditions the practice typically treats. With regards to productivity, health IT adopters are more likely to see fewer patients and spend a larger amount of time on each visit with marginal increases in time on administrative tasks and no differences in perceived ability to deliver quality health care

Geographic Market Definition: The Case of Medicare-Reimbursed Skilled Nursing Facility Care

Correct geographic market definition is important to study the impact of competition. In the nursing home industry, most studies use geopolitical boundaries to define markets. This paper uses the Minimum Data Set to generate an alternative market definition based on patient flows for Medicare skilled nursing facilities. These distances are regressed against a range of nursing home and area characteristics to determine what influences market size. We compared Herfindahl-Hirschman Indices based on county and resident-flow measures of geographic market definition. Evidence from this comparison suggests that using the county for the market definition is not appropriate across all states

Nursing Home Staffing Requirements and Input Substitution: Effects on Housekeeping, Food Service, and Activities Staff

Objective: To study the effect of minimum nurse staffing requirements on the subsequent employment of nursing home support staff. Data Sources: Nursing home data from the Online Survey Certification and Reporting (OSCAR) System merged with state nurse staffing requirements. Study Design: Facility-level housekeeping, food service, and activities staff levels are regressed on nurse staffing requirements and other controls using fixed effect panel regression. Data Extraction Method: OSCAR surveys from 1999 to 2004. Principal Findings: Increases in state direct care and licensed nurse staffing requirements are associated with decreases in the staffing levels of all types of support staff. Conclusions: Increased nursing home nurse staffing requirements lead to input substitution in the form of reduced support staffing levels