My research interest is focused in two areas: a) the study of the impact of health care reform, specifically related to the organization, delivery, and financing of health services to improve population health; and b) the impact of cross-sectorial collaboration on community health and efficient allocation of resources.
My dissertation papers examined the combined effect of Section 9007 of the ACA and the New York Prevention Agenda on population health investment by nonprofit hospitals (NFP) and drug-induced mortality. Section 9007 was implemented in 2012 and falls under the umbrella of federal community benefit regulation which all NFPs must adhere to in order to keep their tax-exempt status. It is a promising regulatory approach to steer NFPs towards providing community health activities that fall outside its acute care focus. It required NFPs to submit a triennial community health needs assessment and an implementation strategy. The NY Prevention Agenda requires NFPs and local health departments to collaborate on all three of the following local health planning activities: community health assessment, joint selection of two health priorities, and joint implementation of initiatives to address health priorities.
In one of my papers, I hypothesized that NFPs would invest more on population health as a result of the close collaboration and more tractable hospital community accountability. I estimated a difference-in-differences specification with state and year fixed effects, which compared the change in community benefit spending on population health pre and post Section 9007 and NY Prevention Agenda. The treatment effect was estimated using NFPs outside of NY that were not required to collaborate with the local health department. The model also controlled for state, county, and hospital characteristics. We found that NFP-local health department collaboration led to an incremental increase in population health spending by approximately 7% of hospital operating expenses. These results were robust to several sensitivity analyses and the more conservative permutation inference approach. This work can inform policymakers at the local, state, and federal levels on regulatory approaches that may encourage NFPs to invest more on population health. I presented this study at the American Public Health Association Annual Meeting in 2018.
My second paper leveraged the same policy changes but examined the effect of NFP and local health department collaboration on drug-induced mortality. I hypothesized that joint prioritization of prescription and/or illicit drug use and collaborative implementation of interventions would lead to lower drug-induced mortality in NY counties compared to control counties. I coded over 1,500 community health needs assessments and implementation strategy reports to determine whether the NFP prioritized prescription and/or illicit drug use in 2013. I estimated a difference-in-differences specification with county and year fixed effects, that compared the change in drug-induced mortality rate pre and post selection of prescription and/or illicit drug use as a health priority by the NFP. The treatment effect was estimated using counties outside of NY in which NFPs also prioritized prescription and/or illicit drug use but were not required to collaborate with the LHD. The model controlled for state, county, hospital, and health department characteristics. I found that collaboration in local health planning and prioritization of prescription and/or illicit drug use led to an incremental decrease in drug-induced mortality of approximately 3-4 deaths per 100,000 population. This represents a 18-20% decrease based on the national rate in 2016. These results were robust to sensitivity and falsification tests. The findings from this study are relevant to different stakeholders. Nonprofit hospitals can have a better understanding of the return-on-investment of their community benefit activities which may translate in sustained financial commitments to community health. Local health departments and other community institutions may deliberately seek out collaborations to address the drug crisis. Finally, policymakers may use regulatory levers to encourage collaboration in local health planning.
Finally, for my third paper, I used a social capital theoretical framework to understand the association of local health department social capital with drug-induced mortality. I used social network methods to operationalize measures of social capital using local health department data on organizational partnerships and collaboration. Using a cross-sectional design, I found that the availability of local health department social capital by itself was not associated with all-cause mortality or other causes that may be more amenable to public health interventions (e.g., cardiovascular, diabetes, etc).
In future work, I want to continue to explore the role of NPFs and local health departments in improving community health particularly as it relates to collaboration between the two institutions. First, I want to understand the impact of different regulatory approaches on NPF and health department collaboration. Second, I want to understand the effect of collaboration on community health outcomes, investment and hospital community accountability. This area of research aligns well with a relatively recent trend in which state governments either require or encourage NFPs and local health departments to collaborate in local health planning. This is achieved through regulation of NFPs, local health departments or both. Despite this trend, rigorous research is mostly lacking to understand whether this approach leads to desirable outcomes in relation to allocation of resources and community health outcomes.
I have begun to build on my dissertation research through a project with the Dean of the Colorado School of Public Health. We are developing an online platform that will house information on how counties throughout Colorado prioritize local health issues and the initiatives being implemented to address them. This will initially be focused on NFPs and local health department community health assessments and improvement plans. It will also track population health outcomes related to the top selected priorities. All data will be accessible to students and faculty to facilitate scholarly work focused on CO public health, as well as other stakeholders that can use the platform to guide improvements at the local level.
I am also developing a website which will house all the data I collected for my dissertation (e.g., community health needs assessment and implementation strategy for over 1,500 NFPs and IRS community benefit spending and hospital executive compensation data). My short-term plan is to provide a baseline for the priorities selected by all NFPs after the 2012 ACA requirement. It will monitor the health priorities selected in subsequent implementation plans, as well as community benefit spending and hospital executive compensation over time. The long term goal is to integrate information from local health department to understand the alignment and collaboration in local health planning by the two institutions. There will be several opportunities for engagement and contribution by students which will ensure the platform’s success and utility.
In addition to the research mentioned above, I contributed to a project funded by the Agency for Healthcare Research and Quality on hospital community benefit. I led the in-depth case study interviews that included members of the C-suite with oversight of community benefit activities, and community-based organizations that collaborate with the hospital to implement hospital community benefit activities. On the quantitative component, I helped curate a database that combined several data sources including but not limited to the Internal Revenue Service (IRS) Statistics of Income microdata files, Centers for Medicare & Medicaid Services (CMS) Healthcare Cost Report Information System (HCRIS), Provider of Services, American Hospital Association Annual Survey, US Census Bureau, Bureau of Labor Statistics, and Area Health Resource Files.
The combination of my original research with experience in these other research projects have shaped my future research interests which focus on different aspects of health care reform and its impact on population health and health equity.