Date

2013

Document Type

Dissertation

Degree

Doctor of Philosophy

Department

Economics

First Adviser

Chou, Shin-Yi

Other advisers/committee members

Decker, Sandra L.; Deily, Mary E.; Meyerhoefer, Chad D.

Abstract

Medicaid and Medicare are two major public programs that help vulnerable groups of people to gain coverage of health care services. There are various ongoing debates on the Medicaid- and Medicare-related issues. Among those, some topics draw most of attentions.First of all, how do we contain cost of Medicaid programs? In the 90's, Medicaid expenditures grew fast. In response to this, many states began to enroll large numbers of Medicaid patients in managed care programs. The first chapter examines the effect of Pennsylvania Medicaid mandatory HMO program, HealthChoices program on the outcomes of pregnant women. I utilize the Pennsylvania Health Care Cost Containment Council inpatient data file and American Hospital Association survey data to perform difference-in-difference-in-difference estimation and find robust results indicating that HealthChoices program helps Medicaid mothers reduce the incidence of preventable complications, utilization of C-section procedure and decrease the delivery charge.Second, how do we improve the access to a certain health care service. In January 2006, Medicare introduced a new prescription drug benefit through Part D, therefore lowering the out-of-pocket cost of prescription drug for Medicare beneficiaries. The second chapter uses data from the National Ambulatory Medical Care Survey (NAMCS), Medical Expenditure Panel Survey (MEPS) and the National Inpatient Sample from the Healthcare Cost and Utilization Project (NIS-HCUP) 2002-2004 and 2006-2009 and a difference-in-discontinuity approach to estimate the differential discrete jumps in outcomes at 65 years old for the sample after 2006 and before 2006. We find a 33% increase in the number of prescription drugs and a 55% increase in the number of generic drugs prescribed in physicians' offices for each visit following policy implementation. We also find the existence of anticipatory effects for prescribing patterns before the adoption of Part D. We do not find evidence that Part D resulted in significant changes in medical expenditures for other services or inpatient health outcomes.Last but not the least, how do we assure the quality of health care for vulnerable groups of people while containing costs of the program? Centers for Medicare and Medicaid Services started ``the Medicaid/CHIP Quality Initiative", and promoting Pay-for performance (P4P) program for Medicaid managed care plans as a part of this initiative. The third chapter studied the effect of Medicaid managed care P4P programs on the use of preventive care services and the different effectiveness of P4P incentive designs. We used data from the National Health Interview Survey (NHIS), and the National Immunization Survey (NIS). Results suggested that among those on Medicaid, state adoption of a P4P program is positively associated with the likelihood that adults have received mammograms, blood pressure checks and Pap smear tests. P4P adoption is also associated with increases in the probability that children on Medicaid are up-to-date on the Haemophilus influenza type B vaccine, the 4:3:1, and the 4:3:1:3:3 vaccine series, respectively. These average effect sizes are larger in states with higher Medicaid managed care penetration rates and in states that use negative financial incentives, such as withholds and penalties, rather than states with positive financial incentives and non-financial incentives.

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