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Scholarly Works (3 results)

  • Thesis
  • Peer Reviewed
UCLA Electronic Theses and Dissertations (2023)

Over the past decade, reforms to the U.S. health care system have sought to reduce spending on health care expenditures, while improving quality of care and population health. At the same time, increased attention to the social determinants of health has fostered a deeper discussion on the social responsibility of health care systems in furthering health equity at a population and community level. As the U.S. health care system attempts to meet the societal demands of delivering value and striving towards health equity, important questions arise—to what extent is health equity shaped by local government decisions on public budgets, hospital administrator decisions on community benefits spending, or individual decisions between clinicians and patients around low-value care? This dissertation provides a novel contribution on these questions with three studies that explicitly test hypotheses on these related issues. The first study used claims data from Medicare, the nation’s largest health plan, and government finance data to examine the relationship between local government spending on social programs and the use of primary care, emergency department, and inpatient services among low-income older adults. We found that higher spending on welfare, public transit, housing, and other social services was associated with greater primary care use. We also found that higher spending on housing and public transit were associated with lower preventable hospitalizations, specifically from acute conditions. The second study used data from non-profit hospital tax returns and Medicare claims to examine the relationship between hospital community benefits spending and the use of primary care and emergency department (ED) services among older adults living in the same zip code as a non-profit hospital. This study did not find evidence that variation in community benefit spending over time was associated with differences in primary care or ED visits. The third study used claims data from a single health care system to examine variation in the provision of low-value services by race and ethnicity. We observed that Asian, Black, and Latino older adults were less likely to receive low-value care in general, but were more likely to receive a low-value prescription.

Taken together, the findings from this dissertation clarify the relationships between health care organizations and their local communities. Moreover, this work highlights important systems and policy-level opportunities for improving equity, population health, and health care value.

    • Article
    • Peer Reviewed
    UCLA Previously Published Works (2021)

    Background

    Low-value care, or patient care that offers no net benefit in specific clinical scenarios, is costly and often associated with patient harm. The US Preventive Services Task Force (USPSTF) Grade D recommendations represent one of the most scientifically sound and frequently delivered groups of low-value services, but a more contemporary measurement of the utilization and spending for Grade D services beyond the small number of previously studied measures is needed.

    Objective

    To estimate utilization and costs of seven USPSTF Grade D services among US Medicare beneficiaries.

    Design

    We conducted a cross-sectional study of data from the National Ambulatory Medical Care Survey (NAMCS) from 2007 to 2016 to identify instances of Grade D services.

    Setting/participants

    NAMCS is a nationally representative survey of US ambulatory visits at non-federal and non-hospital-based offices that uses a multistage probability sampling design. We included all visits by Medicare enrollees, which included traditional fee-for-service, Medicare Advantage, supplemental coverage, and dual-eligible Medicare-Medicaid enrollees.

    Main measures

    We measured annual utilization of seven Grade D services among adult Medicare patients, using inclusion and exclusion criteria from prior studies and the USPSTF recommendations. We calculated annual costs by multiplying annual utilization counts by mean per-unit costs of services using publicly available sources.

    Key results

    During the study period, we identified 95,121 unweighted Medicare patient visits, representing approximately 2.4 billion visits. Each year, these seven Grade D services were utilized 31.1 million times for Medicare beneficiaries and cost $477,891,886. Three services-screening for asymptomatic bacteriuria, vitamin D supplements for fracture prevention, and colorectal cancer screening for adults over 85 years-comprised $322,382,772, or two-thirds of the annual costs of the Grade D services measured in this study.

    Conclusions

    US Medicare beneficiaries frequently received a group of rigorously defined and costly low-value preventive services. Spending on low-value preventive care concentrated among a small subset of measures, representing important opportunities to safely lower US health care spending while improving the quality of care.
      Cover page: The Utilization and Costs of Grade D USPSTF Services in Medicare, 2007–2016
      • Article
      • Peer Reviewed
      UC San Francisco Previously Published Works (2016)
      There is a need to understand the costs associated with supporting, implementing, and maintaining the system redesign of small and medium-sized safety-net clinics. The authors aimed to understand the characteristics of clinics that transformed into patient-centered medical homes and the incremental cost for transformation.The sample was 74 clinics in Greater New Orleans that received funds from the Primary Care Access and Stabilization Grant program between 2007 and 2010 to support their transformation. The study period was divided into baseline (September 21, 2007-March 21, 2008), transformation (March 22, 2008-March 21, 2009), and maintenance (March 22, 2009-September 20, 2010) periods, and data were collected at 6-month intervals. Baseline characteristics for the clinics that transformed were compared to those that did not. Fixed-effect models were conducted for cost estimation, controlling for baseline differences, using propensity score weights.Half of the 74 primary care clinics achieved transformation by the end of the study period. The clinics that transformed had higher total cost, more clinic visits, and a larger female patient proportion at baseline. The estimated incremental cost for clinics that underwent transformation was $37.61 per visit per 6 months, and overall it cost $24.86 per visit per 6 months in grant funds to support a clinic's transformation.Larger-sized clinics and those with a higher female proportion were more likely to transform. The Primary Care Access and Stabilization Grant program provided approximately $24.86 per visit over the 2 and 1/2 years. This estimated incremental cost could be used to guide policy recommendations to support primary care transformation in the United States.
        Cover page: Estimating the costs of supporting safety-net transformation into patient-centered medical homes in post-Katrina New Orleans
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