Health care policy analysis of Medicaid's early and periodic screening, diagnosis, and treatment (EPSDT) benefit in Colorado

The purpose of this thesis is to identify "best practice" recommendations for successful implementation of the EPSDT outreach program at Memorial Health System's Hospital for Children in Colorado Springs through a policy analysis of Medicaid EPSDT services in Colorado. A successful program at Memorial will increase education and awareness of EPSDT services, enrollment, and access to and utilization of health care services for eligible children. Methodology utilized in this study included questionnaires designed for the EPSDT contract administrator and outreach coordinators/workers; analysis of current federal and state policies; and studies conducted at the federal and state level, and by various advocacy groups. The need for this analysis of EPSDT came about in part through an awareness of increasingly high numbers of children in poverty and who are uninsured. Though the percentage of children living in poverty in Colorado is slightly below the national average (see Table 2), according to data analyzed by The Annie E. Casey Foundation, the percentage of children (0-18) living in poverty in Colorado increased from 10% in 2000 to 16% in 2006, a dramatic increase of 60% surpassed by only one other state in the nation (The Annie E. Casey Foundation, 2008). By comparison, the U.S. percentage of children in poverty during the same time frame rose from 17% to 18% (The Annie E. Casey Foundation, 2008). What kind of health care services are available to this vulnerable and growing group of Coloradans, and what are the barriers that affect their enrollment in, access to and utilization of these health care services? Barriers identified included difficulty with the application process; system and process issues; a lack of providers; and a lack of awareness and knowledge of EPSDT. Fiscal restraints and legislation at the federal and state level are also barriers to increasing enrollment and access to services. Outreach services are a critical component of providing EPSDT services, and there were several recommendations regarding outreach and case management that will benefit the program in the future. Through this analysis and identification of a broad range of barriers, a clearer picture emerged of current challenges within the EPSDT program as well as a broad range of strategies and recommendations to address these challenges. Through increased education and advocacy for EPSDT and the services it encompasses; stronger collaboration and cooperation between all groups involved, including providing a Medical Home for all eligible children; and new legislation putting more money and focus on comprehensive health care for low-income uninsured children; enrollment, access to and utilization of developmentally appropriate and quality health care services can be achieved. ^

Factors associated with needle sharing among Black male injection drug users in Harris County, Texas

Background. Injection drug users (IDUs) are at increased risk for HIV transmission due to unique risk behaviors, such as sharing needles. In Houston, IDUs account for 18% of all HIV/AIDS cases among Black males. ^ Objectives. This analysis compared demographic, behavioral, and psychosocial characteristics of needle sharing and non-sharing IDUs in a population of Black males in Harris County, Texas. ^ Methods. Data used for this analysis were from the second IDU cycle of the National HIV Behavioral Surveillance System. This dataset included a sample of 288 Black male IDUs. Univariate and multivariate statistical analysis were performed to determine statistically significant associations of needle sharing in this population and to create a functional model to inform local HIV prevention programs. ^ Results. Half of the participants in this analysis shared needles in the past 12 months. Compared to non-sharers, sharers were more likely to be homeless (OR=3.70, p<0.01) or arrested in the past year (OR=2.31, p<0.01), inject cocaine (OR=2.07, p<0.01), report male-to-male sex in the past year (OR=6.97, p<0.01), and to exchange sex for money or drugs. Sharers were less likely than non-sharers to graduate high school (OR=0.36, p<0.01), earn $5,000 or more a year (OR=1.15, p=0.05), get needles from a medical source (OR=0.59, p=0.03), and ever test for HIV (OR=0.17, p<0.01). Sharers were more likely to report depressive symptoms (OR=3.49, p<0.01), lower scores on the family support scale (mean difference 0.41, p=0.01) and decision-making confidence scale (mean difference 0.38, p<0.01), and greater risk-taking (mean difference -0.49, p<0.01) than non-sharers. In a multivariable logistic regression, sharers were less likely to have graduated high school (OR=0.33, p<0.01) and have been tested for HIV (OR=0.12, p<0.01) and were more likely to have been arrested in the past year (OR=2.3, p<0.01), get needles from a street source (OR=3.87, p<0.01), report male-to-male sex (OR=7.01, p<0.01), and have depressive symptoms (OR=2.36, p=0.02) and increased risk-taking (OR=1.78, p=0.01). ^ Conclusions. IDUs that shared needles are different from those that did not, reporting lower socioeconomic status, increased sexual and risk behaviors, increased depressive symptoms and increased risk-taking. These findings suggest that intervention programs that also address these demographic, behavioral, and psychosocial factors may be more successful in decreasing needle sharing among this population.^

THE EFFECTS OF COST-SHARING ON USE OF SERVICES AND CONSUMER CHARACTERISTICS IN A STATE'S CRIPPLED CHILDREN'S DIVISION

The present study analyzed some of the effects of imposing a cost-sharing requirement on users of a state's health service program. The study population consisted of people who were in diagnosed medical need and included, but was not limited to, people in financial need.^ The purpose of the study was to determine if the cost-sharing requirement had any detrimental effects on the service population. Changes in the characteristics of service consumers and in utilization patterns were analyzed using time-series techniques and pre-post policy comparisons.^ The study hypotheses stated that the distribution of service provided, diagnoses serviced, and consumer income levels would change following the cost-sharing policy.^ Analysis of data revealed that neither the characteristics of service users (income, race, sex, etc.) nor services provided by the program changed significantly following the policy. The results were explainable in part by the fact that all of the program participants were in diagnosed medical need. Therefore, their use of "discretionary" or "less necessary" services was limited.^ The study's findings supported the work of Joseph Newhouse, Charles Phelps, and others who have contended that necessary service use would not be detrimentally affected by reasonable cost-sharing provisions. These contentions raise the prospect of incorporating cost-sharing into programs such as Medicaid, which, at this writing, do not demand any consumer payment for services.^ The study concluded with a discussion of the cost-containment problem in health services. The efficacy of cost-sharing was considered relative to other financing and reimbursement strategies such as HMO's, self-funding, and reimbursement for less costly services and places of service. ^

Policy analysis of iron micronutrient programs at USAID: The FANTA program in East Africa and the micronutrient initiative in Bihar region of India, using comparative cost effective and cost benefit analysis

It is the aim of this paper to examine iron supplementation programs which receive funding from United States Agency for International Development (USAID) but approach combating iron deficiency anemia in two vastly different ways. A brief literature review and background information on iron deficiencies and the differences between supplementation programs and micronutrient fortification were reviewed. Two non-governmental organizations (NGO's) were examined for this paper: the Food and Nutrition Technical Assistance II (FANTA) and the MicroNutrient Initiative. The FANTA program included an educational component to their supplementation program while the MicroNutrient Initiative solely used supplementation of micronutrients to their population. Methods used were cost-benefit analysis and cost-effectiveness analysis to determine the overall effectiveness of each program in reducing iron deficiency anemia in each population, if the added costs of the incentives in the FANTA program changed the cost-effectiveness of the program compared to the MicroNutrient Initiative program and to determine which program imparted the greatest benefit to each population by reducing the disease burden in Disability Adjusted Life Years (DALY). Results showed that the unit cost of the FANTA program per person was higher than the MicroNutrient Initiative program due to the educational component. The FANTA program reduced iron deficiency anemia less overall but cost less for each percentage point of anemia decreased in their respective populations. The MicroNutrient Initiative program had a better benefit cost ratio for the populations it served. The MicroNutrient Initiative's large scale program imparted many advantages by reducing unit cost per person and decreasing iron deficiency anemia. The FANTA program was more effective at decreasing iron deficiency anemia with less money: $5,660 per 1% decrease in iron deficiency anemia versus $18,450 per 1% decrease in iron deficiency anemia for the MicroNutrient Initiative program. ^ In conclusion, economic analysis cannot measure all of the benefits associated with programs that contain an educational component or large scale supplementation. More information needs to be gathered by NGOs and reported to USAID, such as detailed prevalence rates of iron deficiency anemia among the populations served. Further research is needed to determine the effects an educational supplementation program has on compliance rates of participants and motivation to participate in supplementation programs whose aim is to decrease iron deficiency anemia in a targeted population.^

A practice-based culminating experience: Writing a HRSA grant application with Texas Organ Sharing Alliance for public education efforts to increase solid organ donation

In November 2010, nearly 110,000 people in the United States were waiting for organs for transplantation. Despite the fact that the organ donor registration rate has doubled in the last year, Texas has the lowest registration rate in the nation. Due to the need for improved registration rates in Texas, this practice-based culminating experience was to write an application for federal funding for the central Texas organ procurement organization, Texas Organ Sharing Alliance. The culminating experience has two levels of significance for public health – (1) to engage in an activity to promote organ donation registration, and (2) to provide professional experience in grant writing. ^ The process began with a literature review. The review was to identify successful intervention activities in motivating organ donation registration that could be used in intervention design for the grant application. Conclusions derived from the literature review included (1) the need to specifically encourage family discussions, (2) religious and community leaders can be leveraged to facilitate organ donation conversations in families, (3) communication content must be culturally sensitive and (4) ethnic disparities in transplantation must be acknowledged and discussed.^ Post the literature review; the experience followed a five step process of developing the grant application. The steps included securing permission to proceed, assembling a project team, creation of a project plan and timeline, writing each element of the grant application including the design of proposed intervention activities, and completion of the federal grant application. ^ After the grant application was written, an evaluation of the grant writing process was conducted. Opportunities for improvement were identified. The first opportunity was the need for better timeline management to allow for review of the application by an independent party, iterative development of the budget proposal, and development of collaborative partnerships. Another improvement opportunity was the management of conflict regarding the design of the intervention that stemmed from marketing versus evidence-based approaches. The most important improvement opportunity was the need to develop a more exhaustive evaluation plan.^ Eight supplementary files are attached to appendices: Feasibility Discussion in Appendix 1, Grant Guidance and Workshop Notes in Appendix 2, Presentation to Texas Organ Sharing Alliance in Appendix 3, Team Recruitment Presentation in Appendix 5, Grant Project Narrative in Appendix 7, Federal Application Form in Appendix 8, and Budget Workbook with Budget Narrative in Appendix 9.^

Sharing scholastic life : What do children think about it?

In this article we present the results found in a descriptive- exploratory study, in which we investigated a group of scholar's (9 and 10 years old) conceptions of their classmates with psychological disorders at school. The answers of 90 students who belong to low and average socio- cultural level groups were analyzed. These groups were identified in relation to the parent's occupational category and educational level. The instrument elaborated to such aim was a semi- structured interview which included different aspects related to: which the most frequent problems are, how these problems are expressed at school, which their determinants are and the consequences for the children, as well as the their self referred knowledge of these problems.

ERA-interim reanalysis debiased at FLUXNET sites

(preliminary) Exchanges of carbon, water and energy between the land surface and the atmosphere are monitored by eddy covariance technique at the ecosystem level. Currently, the FLUXNET database contains more than 500 sites registered and up to 250 of them sharing data (Free Fair Use dataset). Many modelling groups use the FLUXNET dataset for evaluating ecosystem model's performances but it requires uninterrupted time series for the meteorological variables used as input. Because original in-situ data often contain gaps, from very short (few hours) up to relatively long (some months), we develop a new and robust method for filling the gaps in meteorological data measured at site level. Our approach has the benefit of making use of continuous data available globally (ERA-interim) and high temporal resolution spanning from 1989 to today. These data are however not measured at site level and for this reason a method to downscale and correct the ERA-interim data is needed. We apply this method on the level 4 data (L4) from the LaThuile collection, freely available after registration under a Fair-Use policy. The performances of the developed method vary across sites and are also function of the meteorological variable. On average overall sites, the bias correction leads to cancel from 10% to 36% of the initial mismatch between in-situ and ERA-interim data, depending of the meteorological variable considered. In comparison to the internal variability of the in-situ data, the root mean square error (RMSE) between the in-situ data and the un-biased ERA-I data remains relatively large (on average overall sites, from 27% to 76% of the standard deviation of in-situ data, depending of the meteorological variable considered). The performance of the method remains low for the Wind Speed field, in particular regarding its capacity to conserve a standard deviation similar to the one measured at FLUXNET stations.

Sharing scholastic life : What do children think about it?

In this article we present the results found in a descriptive- exploratory study, in which we investigated a group of scholar's (9 and 10 years old) conceptions of their classmates with psychological disorders at school. The answers of 90 students who belong to low and average socio- cultural level groups were analyzed. These groups were identified in relation to the parent's occupational category and educational level. The instrument elaborated to such aim was a semi- structured interview which included different aspects related to: which the most frequent problems are, how these problems are expressed at school, which their determinants are and the consequences for the children, as well as the their self referred knowledge of these problems.

Sharing scholastic life : What do children think about it?

In this article we present the results found in a descriptive- exploratory study, in which we investigated a group of scholar's (9 and 10 years old) conceptions of their classmates with psychological disorders at school. The answers of 90 students who belong to low and average socio- cultural level groups were analyzed. These groups were identified in relation to the parent's occupational category and educational level. The instrument elaborated to such aim was a semi- structured interview which included different aspects related to: which the most frequent problems are, how these problems are expressed at school, which their determinants are and the consequences for the children, as well as the their self referred knowledge of these problems.

Experiment: Marine fungi may benefit from ocean acidification

Recent studies have discussed the consequences of ocean acidification for bacterial processes and diversity. However, the decomposition of complex substrates in marine environments, a key part of the flow of energy in ecosystems, is largely mediated by marine fungi. Although marine fungi have frequently been reported to prefer low pH levels, this group has been neglected in ocean acidification research. We present the first investigation of direct pH effects on marine fungal abundance and community structure. In microcosm experiments repeated in 2 consecutive years, we incubated natural North Sea water for 4 wk at in situ seawater pH (8.10 and 8.26), pH 7.82 and pH 7.67. Fungal abundance was determined by colony forming unit (cfu) counts, and fungal community structure was investigated by the culture-independent fingerprint method Fungal Automated Ribosomal Intergenic Spacer Analysis (F-ARISA). Furthermore, pH at the study site was determined over a yearly cycle. Fungal cfu were on average 9 times higher at pH 7.82 and 34 times higher at pH 7.67 compared to in situ seawater pH, and we observed fungal community shifts predominantly at pH 7.67. Currently, surface seawater pH at Helgoland Roads remains >8.0 throughout the year; thus we cannot exclude that fungal responses may differ in regions regularly experiencing lower pH values. However, our results suggest that under realistic levels of ocean acidification, marine fungi will reach greater importance in marine biogeochemical cycles. The rise of this group of organisms will affect a variety of biotic interactions in the sea.

Did the least developed countries benefit from duty-free quota-free access to the Japanese market?

Countries classified as least developed countries (LDCs) were granted duty-free quota-free (DFQF) access to the Japanese market. This study examines the impact of that access and finds that, in general, it did not benefit the LDCs. The construction of concordance tables for Japan's 9 digit tariff line codes enables analysis at the tariff line level, which overcomes a possible aggregation bias. The exogenous nature of DFQF access mitigates the endogeneity problem. Various estimation models, including the triple difference estimator, show that in general the LDCs did not benefit from DFQF access to the Japanese market. The total value of imports from LDCs has been increasing, but the imports granted both zero tariffs and substantial preference margins over non-LDC countries were not successful. These findings suggest that for LDCs the tariff barrier is a relatively small obstacle: Trade is affected more strongly by other factors, such as infrastructure, nontariff barriers, geographic distance, and cultural differences.

Production sharing, demand spillovers and CO2 emissions : the case of Chinese regions in GVCs

This study adopts the perspective of demand spillovers to provide new insights regarding Chinese domestic-regions' production position in global value chains and their associated CO2 emissions. To this end, we constructed a new type of World Input-Output Database in which China's domestic interregional input-output table for 2007 is endogenously embedded. Then, the pattern of China's regional demand spillovers across both domestic regions and countries are revealed by employing this new database. These results were further connected to endowments theory, which help to make sense of the empirical results. It is found that China's regions locate relatively upstream in GVCs, and had CO2 emissions in net exports, which were entirely predicted by the environmental extended HOV model. Our study points to micro policy instruments to combat climate change, for example, the tax reform for energy inputs that helps to change the production pattern thus has impact on trade pattern and so forth.

Heterogeneous firms and cost sharing in China's marketplaces

This study extends Melitz's model with heterogeneous firms by introducing shared fixed costs in a marketplace. It aims to explain heterogeneous firms' choice between traditional marketplaces and modern distribution channels on the basis of their productivities. The results reveal that the co-existence of a traditional marketplace and modern distribution channels improves social welfare. In addition, a deregulation policy for firm entry outside a marketplace and accumulation of human capital are factors that contribute to improve the social welfare.