Todd P Gilmer

University of California, San Diego, San Diego, California, United States

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Publications (81)350.31 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: This study examined whether receipt of outpatient psychiatric services after hospital discharge was associated with reduced risk of readmission. Treatment records from patients admitted to San Diego County psychiatric hospitals over a one-year period were obtained from the San Diego County Behavioral Health Services electronic health record system. A discrete-time proportional hazards model was used to examine the association of receipt of outpatient psychiatric services with readmission within 30 days of discharge from the index hospitalization. Of the 4,663 patients, 16% were readmitted within 30 days. In an adjusted model, receipt of outpatient therapy after discharge was associated with a greater likelihood of being readmitted (hazard ratio=1.36, 95% confidence interval=1.14-1.67), whereas receipt of case management or medication management was not associated with readmission. The differential risk of readmission by service type suggests a need for studies that explore reasons for an increased risk of readmission with certain types of services.
    Psychiatric services (Washington, D.C.) 03/2015; 66(5):appips201400092. DOI:10.1176/ · 1.99 Impact Factor
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    ABSTRACT: This paper describes how individuals struggling with severe mental illness experience stigma along multiple dimensions including their experiences of discrimination by others, their unwillingness to disclose information about their mental health, and their internalization or rejection of the negative and positive aspects of having mental health problems. This cross-sectional study employs descriptive analyses and linear regression to assess the relationship between demographics, mental health diagnoses and self-reported stigma among people receiving mental health services in a large and ethnically diverse county public mental health system (n = 1,237) in 2009. We used the King Stigma Scale to measure three factors related to stigma: discrimination, disclosure, and positive aspects of mental illness. Most people (89.7 %) reported experiencing some discrimination from having mental health problems. Regression analyses revealed that younger people in treatment experienced more stigma related to mental health problems. Women reported experiencing more stigma than men, but men were less likely to endorse the potentially positive aspects of facing mental health challenges than women. Although people with mood disorders reported more discomfort with disclosing mental illness than people with schizophrenia, they did not report experiencing more discrimination than people with schizophrenia. Study findings suggest that the multidimensional experiences of stigma differ as a function of age, gender, and diagnosis. Importantly, these findings should inform anti-stigma efforts by describing different potential treatment barriers due to experiences of stigma among people using mental health services, especially among younger people and women who may be more susceptible to stigma.
    Social Psychiatry and Psychiatric Epidemiology 11/2014; 50(5). DOI:10.1007/s00127-014-0979-9 · 2.58 Impact Factor
  • Yuyan Shi · Victoria D. Ojeda · Todd Gilmer
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    ABSTRACT: Objectives. Prior research suggests that medical marijuana laws (MMLs) have no effects on prevalence of marijuana use among adolescents and adults. Yet, adult-based studies employed aggregate state-level data, and adolescent-based studies relied on biennial surveys with limited state-year observations. This study examines the effects of MMLs on the prevalence of marijuana use and provides new evidence regarding perceived access to marijuana, and social norms against use by analyzing detailed individual-level data for an eight-year period. Methods. Individual observations (adolescents=175,900, adults=356,600) were obtained from SAMHSA’s annual National Survey on Drug Use and Health confidential data 2004-2011. Difference-in-difference regression models estimated the within-state changes in marijuana outcomes before and after passing MMLs versus control states experiencing no changes in MMLs status. Results. Among adults, passing MMLs increased the likelihood of past-month marijuana use (OR=1.17, p=.014) and past-year frequent use (OR=1.20, p=.012), and decreased the likelihood of perceiving frequent use harmful (OR=.91, p=.039). No discernable effects on MMLs were found on perceived access to marijuana. Adolescents were more likely to perceive access to marijuana as easy after passing MMLs (OR=1.13, p=.016), but there is no evidence suggesting that passing MMLs affected adolescents’ marijuana use or social norms. Conclusions. This unparalleled and timely analysis suggests that MMLs has increased the use of marijuana and undermined the social norms against use among adults, whereas MMLs have had limited effects on marijuana outcomes among adolescents. Future research needs to examine the long-term impacts of MMLs among adolescents.
    142nd APHA Annual Meeting and Exposition 2014; 11/2014
  • Benjamin Henwood · Todd Gilmer
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    ABSTRACT: This presentation focuses on a policy experiment being conducted in Los Angeles County (LAC), where the Department of Mental Health (DMH) has funded several models of integrated mental and physical health care (24 total programs). One of the models consists of using a housing first approach that combines supportive housing, assertive community treatment (ACT), and primary care (n=5). An implementation evaluation was conducted through interviews and observations conducted through site-visits to each program. Outcome data was entered into a web-based secure database developed for the project. A total of 465 adults with serious mental enrolled in the housing first programs. Days homeless decreased significantly, recovery measures showed significant improvement, but overall health measures were unchanged. These findings will be discussed in terms of challenges and solutions to providing integrated care for those who have experienced chronic homelessness and are now living in supportive housing.
    142nd APHA Annual Meeting and Exposition 2014; 11/2014
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    ABSTRACT: Objectives Despite the significant prevalence of elevated blood pressure (BP) and body mass index (BMI) in children, few studies have assessed their combined impact on healthcare costs. This study estimates healthcare costs related to BP and BMI in children and adolescents. Study Design Prospective dynamic cohort study of 71,617 children aged 3 to 17 years with 208,800 child years of enrollment in integrated health systems in Colorado or Minnesota between January 1, 2007, and December 31, 2011. Methods Generalized linear models were used to calculate standardized annual estimates of total, inpatient, outpatient, and pharmacy costs, outpatient utilization, and receipt of diagnostic and evaluation tests associated with BP status and BMI status. Results Total annual costs were significantly lower in children with normal BP ($736, SE = $15) and prehypertension ($945, SE = $10) than children with hypertension ($1972, SE = $74) (P <.001, each comparison), adjusting for BMI. Total annual cost for children below the 85th percentile of BMI ($822, SE = $8) was significantly lower than for children between the 85th and 95th percentiles ($954, SE = $45) and for children at or above the 95th percentile ($937, SE = $13) (P <.001, each), adjusting for HT. Conclusions This study shows strong associations of prehypertension and hypertension, independent of BMI, with healthcare costs in children. Although BMI status was also statistically significantly associated with costs, the major influence on cost in this large cohort of children and adolescents was BP status. Costs related to elevated BMI may be systematically overestimated in studies that do not adjust for BP status.
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    ABSTRACT: Objectives: Permanent supported housing programs are being implemented throughout the United States. This study examined the relationship between fidelity to the Housing First model and residential outcomes among clients of full service partnerships (FSPs) in California. Methods: This study had a mixed-methods design. Quantitative administrative and survey data were used to describe FSP practices and to examine the association between fidelity to Housing First and residential outcomes in the year before and after enrollment of 6,584 FSP clients in 86 programs. Focus groups at 20 FSPs provided qualitative data to enhance the understanding of these findings with actual accounts of housing-related experiences in high- and low-fidelity programs. Results: Prior to enrollment, the mean days of homelessness were greater at high-versus low-fidelity (101 versus 46 days) FSPs. After adjustment for individual characteristics, the analysis found that days spent homeless after enrollment declined by 87 at high-fidelity programs and by 34 at low-fidelity programs. After adjustment for days spent homeless before enrollment, days spent homeless after enrollment declined by 63 at high-fidelity programs and by 53 at low-fidelity programs. After enrollment, clients at high-fidelity programs spent more than 60 additional days in apartments than clients at low-facility programs. Differences were found between high- and low-fidelity FSPs in client choice in housing and how much clients' goals were considered in housing placement. Conclusions: Programs with greater fidelity to the Housing First model enrolled clients with longer histories of homelessness and placed most of them in apartments.
    Psychiatric services (Washington, D.C.) 07/2014; 65(11). DOI:10.1176/ · 1.99 Impact Factor
  • Todd P Gilmer · Ana Stefancic · Sam Tsemberis · Susan L Ettner
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    ABSTRACT: OBJECTIVE California's full-service partnerships (FSPs) provide a combination of subsidized permanent housing and multidisciplinary team-based services with a focus on rehabilitation and recovery. The goal of the study was to examine whether participation in FSPs is associated with changes in health service use and costs compared with usual care. METHODS A quasi-experimental, pre-post, intent-to-treat design with a propensity score-matched contemporaneous control group was used to compare health service use and costs among 10,231 FSP clients and 10,231 matched clients with serious mental illness who were receiving public mental health services in California from January 1, 2004, through June 30, 2010. RESULTS Among FSP participants, the mean annual number of mental health outpatient visits increased by 55.5, and annual mental health costs increased by $11,725 relative to the matched control group. Total service costs increased by $12,056. CONCLUSIONS Participation in an FSP was associated with increases in outpatient visits and their associated costs. As supportive housing programs are implemented nationally and on a large scale, these programs will likely need to be more effectively designed and targeted in order to achieve reductions in costly inpatient services.
    Psychiatric services (Washington, D.C.) 05/2014; 65(9). DOI:10.1176/ · 1.99 Impact Factor
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    Benjamin F. Henwood · Marian L. Katz · Todd P. Gilmer
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    ABSTRACT: Objectives This study examined whether and how permanent supportive housing (PSH) programs are able to support aging in place among tenants with serious mental illness.DesignInvestigators used a mixed-method approach known as a convergent parallel design in which quantitative and qualitative data are analyzed separately and findings are merged during interpretation. Quantitative analysis compared 1-year pre-residential and post-residential outcomes for PSH program enrollees, comparing adults aged 35–49 years (n = 3990) with those aged 50 years or older (n = 3086). Case study analysis using qualitative interviews with staff of a PSH program that exclusively served older adults identified challenges to providing support services.ResultsSubstantial declines in days spent homeless and in justice system settings were found, along with increases in days living independently in apartments and in congregate settings. Homelessness and justice system involvement declined less for older adults than younger adults. Qualitative themes related to working with older adults included increased attention to medical vulnerability, residual effects of institutional care, and perceived preference for congregate living.ConclusionsPSH is an effective way to end homelessness, yet little is known about how programs can support housing stability among aging populations. Additional support and training for PSH staff will better promote successful aging in place. Copyright © 2014 John Wiley & Sons, Ltd.
    International Journal of Geriatric Psychiatry 04/2014; 30(1). DOI:10.1002/gps.4120 · 3.09 Impact Factor
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    ABSTRACT: This study examined variation in the implementation of California's Full Service Partnerships (FSPs), which are supported housing programs that do "whatever it takes" to improve outcomes among persons with serious mental illness who are homeless or at risk of homelessness. Ninety-three FSPs in California. A mixed methods approach was selected to develop a better understanding of the complexity of the FSP programs. The design structure was a combined explanatory and exploratory sequential design (qual→QUAN→qual) where a qualitative focus group was used to develop a quantitative survey that was followed by qualitative site visits. The survey was used to describe the breadth of variation based on fidelity to the Housing First model, while the site visits were used to provide a depth of information on high- versus low-fidelity programs. We found substantial variation in implementation among FSPs. Fidelity was particularly low along domains related with housing and service philosophy, indicating that many FSPs implemented a rich array of services but applied housing readiness requirements and did not adhere to consumer choice in housing. There remains room for improvement in the recovery-orientation of FSPs. Fortunately, we have identified several processes by which program managers and counties can increase the fidelity of their programs.
    Health Services Research 10/2013; 48(6pt2). DOI:10.1111/1475-6773.12119 · 2.49 Impact Factor
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    ABSTRACT: In California, the Mental Health Services Act allocated substantial funding to Full Service Partnerships (FSPs): programs that do whatever it takes to improve residential stability and mental health outcomes. The state-guided, but stakeholder-driven, approach to FSPs resulted in a set of programs that share core similarities but vary in their specific approaches. This qualitative study examines FSP variations within the framework of fidelity to the Housing First model. Semistructured interviews with 21 FSP program managers identified through purposeful sampling were coded and analyzed to identify variations across programs in their approaches to housing and services. Through the process of constant comparison, FSP characteristics were condensed into a set of broad themes related to fidelity to the Housing First model. We identified three broad themes: (a) FSPs varied in the degree to which key elements of Housing First were present; (b) program recovery orientation and staff experience were associated with fidelity; and (c) FSPs for older adults, adults exiting the justice system, and transitional age youth made specific adaptations to tailor their programs for the needs of their specific populations. FSPs bring a considerable level of community-based housing and treatment resources to homeless persons with serious mental illness. However, when examined individually, there exists enough variation in approaches to housing and treatment to raise the question whether some programs may be more or less effective than others. An opportunity exists to employ the variation in FSPs implemented under this initiative to analyze the importance of fidelity to HF for client outcomes, program costs, and recovery-oriented care.
    American Journal of Psychiatric Rehabilitation 10/2013; 16(4). DOI:10.1080/15487768.2013.847769
  • Todd P Gilmer · Ana Stefancic · Marisa Sklar · Sam Tsemberis
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    ABSTRACT: OBJECTIVES Programs that use the Housing First model are being implemented throughout the United States and internationally. The authors describe the development and validation of a Housing First fidelity survey. METHODS A 46-item survey was developed to measure fidelity across five domains: housing process and structure, separation of housing and services, service philosophy, service array, and team structure. The survey was administered to staff and clients of 93 supported-housing programs in California. Exploratory and confirmatory factor analyses were used to identify the items and model structure that best fit the data. RESULTS Sixteen items were retained in a two-factor model, one related to approach to housing, separation of housing and services, and service philosophy and one related to service array and team structure. CONCLUSIONS Our survey mapped program practices by using a common metric that captured variation in fidelity to Housing First across a large-scale implementation of supported-housing programs.
    Psychiatric services (Washington, D.C.) 09/2013; 64(9):911-4. DOI:10.1176/ · 1.99 Impact Factor
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    ABSTRACT: OBJECTIVE To describe a needs assessment, practice description, practice innovation and reimbursement of a psychiatric pharmacist medication therapy management (MTM) clinic with related challenges and opportunities. SETTING An MTM clinic established in collaboration with the Outpatient Psychiatric Services (OPS) at the University of California San Diego (UCSD), under contract with the San Diego County Health and Human Services Agency Adult and Older Adult Mental Health Services (A/OAMHS). PRACTICE DESCRIPTION Two board-certified psychiatric pharmacists provided direct patient care using a collaborative practice protocol 3 days per week. Clinical services included pharmacotherapy management, laboratory monitoring, medication counseling, and psychosocial referrals to other providers. PRACTICE INNOVATION Payment to UCSD OPS for clinical services was based on a contract between the San Diego County A/OAMHS and the clinic. Two pharmacists co-managed mental health patients and billed for medication management based on face-to-face contact time (medication minutes) and documentation time with each patient. MAIN OUTCOME MEASURES Number of patients comanaged, dropout rates, visit duration, and billed minutes. RESULTS From May 2009 to December 2010, two pharmacists comanaged 68 patients, mean (± SD) age 48.6 ± 11.6 years, diagnosed with major depressive, schizophrenic, schizoaffective, and/or bipolar disorder. A total of 56 (82.3%) patients were clinically stable and remained on the pharmacist caseload, but 12 (17.6%) patients were lost to follow-up (10 lost contact, 1 moved, 1 expired). On average, patients had 7.7 patient visits , for 491 total visits (with an average of 26 minutes per visit) that were billed at a rate of $4.82 per minute for medication minutes, translating to $84,542.80. CONCLUSION With provider education and appropriate physician champions, pharmacists are able to work collaboratively with psychiatrists in a mental health clinic.
    Journal of the American Pharmacists Association 11/2012; 52(6):e252-8. DOI:10.1331/JAPhA.2012.11215
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    ABSTRACT: San Diego County Mental Health system clients completed a questionnaire after the October 2007 wildfires. As compared to those not in an evacuation area, those residing in an evacuation area reported significantly more impact of the fires. Clients who evacuated were most affected, followed by those in an evacuation area who did not evacuate. Evacuation strongly impacted client-reported emotional effects of the fire, confusion about whether to evacuate, and ability to obtain medications. Gender and clinical diagnosis interacted with evacuation status for some fire impact variables. Loss of control and disruption of routine are discussed as possibly related factors.
    Administration and Policy in Mental Health and Mental Health Services Research 06/2012; DOI:10.1007/s10488-012-0425-9 · 3.44 Impact Factor
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    ABSTRACT: BACKGROUND AND OBJECTIVE: Medical groups have invested billions of dollars in electronic medical records (EMRs), but few studies have examined the cost-effectiveness of EMR-based clinical decision support (CDS). This study examined the cost-effectiveness of EMR-based CDS for adults with diabetes from the perspective of the health care system. DATA SOURCES/SETTING: Clinical outcome and cost data from a randomized clinical trial of EMR-based CDS were used as inputs into a diabetes simulation model. The simulation cohort included 1,092 patients with diabetes with A1c above goal at baseline. STUDY DESIGN: The United Kingdom Prospective Diabetes Study Outcomes Model, a validated simulation model of diabetes, was used to evaluate remaining life years, quality-adjusted life years (QALYs), and health care costs over patient lifetimes (40-year time horizon) from the health system perspective. PRINCIPAL FINDINGS: Patients in the intervention group had significantly lowered A1c (0.26 percent, p = .014) relative to patients in the control arm. Intervention costs were $120 (SE = 45) per patient in the first year and $76 (SE = 45) per patient in the following years. In the base case analysis, EMR-based CDS increased lifetime QALYs by 0.04 (SE = 0.01) and increased lifetime costs by $112 (SE = 660), resulting in an incremental cost-effectiveness ratio of $3,017 per QALY. The cost-effectiveness of EMR-based CDS persisted in one-way, two-way, and probabilistic sensitivity analyses. CONCLUSIONS: Widespread adoption of sophisticated EMR-based CDS has the potential to modestly improve the quality of care for patients with chronic conditions without substantially increasing costs to the health care system.
    Health Services Research 05/2012; 47(6). DOI:10.1111/j.1475-6773.2012.01427.x · 2.49 Impact Factor
  • Richard Kronick · Todd P Gilmer
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    ABSTRACT: Proposals to move toward reducing geographic differentials in health care spending have focused on patterns of spending in Medicare. We show in this article that when considering each state as a whole, there is almost no relationship between the level of spending for Medicare beneficiaries and that for other populations. In sharp contrast to these state-level results, there is a strong relationship between Medicare and Medicaid spending in comparing Hospital Referral Regions within each state. We suggest that the strong intrastate regional correlations demonstrate the importance of the supply of hospital beds, specialists, and other health care resources as determinants of use and spending. In contrast, the lack of correlation at the state level suggests that other factors, such as state-level poverty rates, influence use and spending at the state level, and that these other factors influence Medicare and non-Medicare use and spending differently. These findings demonstrate that it is important to broaden our analytic focus from Medicare beneficiaries to the larger population, and to consider the likely effects of changes in Medicare payment policy on the care received by other state residents.
    Health Affairs 05/2012; 31(5):948-55. DOI:10.1377/hlthaff.2009.1065 · 4.64 Impact Factor
  • Marisa Sklar · Andrew Sarkin · Todd Gilmer · Erik Groessl
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    ABSTRACT: The Illness Management and Recovery (IMR) scale was created to measure recovery outcomes produced by the IMR program. However, many other mental health care programs are now designed to impact recovery-oriented outcomes, and the IMR has been identified as a potentially valuable measure of recovery-oriented mental health outcomes. The purpose of this study was to examine the psychometric properties and structural validity of the IMR clinician scale within a variety of therapeutic modalities other than IMR in a large multiethnic sample (N=10,659) of clients with mental illness from a large U.S. county mental health system. Clients completed the IMR on a single occasion. Our estimates of internal consistency were stronger than those found in previous studies (α=0.82). The scale also related to other measures of theoretically similar constructs, supporting construct and criterion validity claims. Additionally, confirmatory factor analyses supported the multidimensional representation of the IMR clinician scale. The three-factor model of illness self-management and recovery was represented by dimensions of recovery, management, and substance use. These reliable psychometric properties support the use of both the original one-factor and revised three-factor models to assess illness self-management and recovery among a broad spectrum of clients with mental illness.
    Psychiatry Research 04/2012; 199(3). DOI:10.1016/j.psychres.2012.03.013 · 2.68 Impact Factor
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    ABSTRACT: This study examined changes in service use associated with providing age-specific services for youths in their transitional years, ages 18–24. A quasi-experimental, difference-in-difference design with propensity score weighting was used to compare mental health service utilization (use of outpatient, inpatient, emergency, and justice system services) among 931 youths enrolled in outpatient programs specifically for transition-age youths and 1,574 youths enrolled in standard adult outpatient programs in San Diego County, California, from July 2004 through December 2009. Among youths enrolled in outpatient programs geared toward youths of transitional age, the mean number of annual outpatient mental health visits increased by 12.2 (p<.001) compared with youths enrolled in standard adult outpatient programs. Compared with traditional adult outpatient mental health programs, age-specific programs were associated with an increased use of outpatient mental health services. Future research is needed to assess the effectiveness of age-specific programs for transition-age youths and how use of these programs relates to improved clinical, educational, and vocational outcomes over time.
    Psychiatric services (Washington, D.C.) 03/2012; 63(6):592-6. DOI:10.1176/ · 1.99 Impact Factor
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    ABSTRACT: This qualitative study assessed the needs for mental health and other services among transition-age youths who were receiving services in youth-specific programs. Thirteen focus groups were conducted between June 2008 and January 2009. The purposefully sampled participants included transition-age youths age 18 to 24 who were receiving services in youth-specific programs (N=75, eight groups), parents of transition-age youths (N=14, two groups), and providers in the youth-specific programs (N=14, three groups). The qualitative analysis used an inductive approach in which investigators focused on generating themes and identifying relationships between themes. Through a process of repeated comparisons, the categories were further condensed into broad themes illustrating service needs. Youths expressed needs for improved scheduling of services, stronger patient-provider relationships, and group therapies that address past experiences of violence, loss, and sexual abuse and that provide skills for developing and nurturing healthy relationships. Parents and providers expressed needs for increased community-based and peer-led services. Youths, parents, and providers all expressed needs for more housing options and for mentors with similar life experiences who could serve as role models, information brokers, and sources of social support for youths who were pursuing education and employment goals. Findings from the focus groups suggest that there is room for improvement in the provision of services that are relevant to the current needs and life experiences of transition-age youths. Even within age-specific programs, improvements in services are needed to foster transitions to independence.
    Psychiatric services (Washington, D.C.) 02/2012; 63(4):338-42. DOI:10.1176/ · 1.99 Impact Factor
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    Todd P Gilmer · Patrick J O'Connor
    Diabetes care 11/2011; 34(11):2486-7. DOI:10.2337/dc11-1335 · 8.57 Impact Factor
  • Todd P Gilmer · Richard G Kronick
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    ABSTRACT: It is well known that Medicaid spending per beneficiary varies widely across states. However, less is known about the cause of this variation, or about whether increased spending is associated with better outcomes. In this article we describe and analyze sources of interstate variation in Medicaid spending over several years. We find substantial variations both in the volume of services and in prices. Overall, per capita spending in the ten highest-spending states was $1,650 above the average national per capita spending, of which $1,186, or 72 percent, was due to the volume of services delivered. Spending in the ten lowest-spending states was $1,161 below the national average, of which $672, or 58 percent, was due to volume. In the mid-Atlantic region, increased price and volume resulted in the most expensive care among regions, whereas reduced price and volume in the South Central region resulted in the least expensive care among regions. Understanding these variations in greater detail should help improve the quality and efficiency of care-a task that will become more important as Medicaid is greatly expanded under the Affordable Care Act of 2010.
    Health Affairs 07/2011; 30(7):1316-24. DOI:10.1377/hlthaff.2011.0106 · 4.64 Impact Factor

Publication Stats

3k Citations
350.31 Total Impact Points


  • 2001–2014
    • University of California, San Diego
      • Department of Family and Preventive Medicine
      San Diego, California, United States
  • 2005
    • VA San Diego Healthcare System
      San Diego, California, United States
  • 2003
    • San Diego State University
      San Diego, California, United States
  • 1997
    • University of Minnesota Duluth
      Duluth, Minnesota, United States