Caroline Carlin

• PhD
• Professor (Associate) at University of Minnesota

When a clinic system is acquired by an integrated delivery system (IDS), the ownership change includes both vertical integration with the hospital(s), and horizontal integration with the IDS's previously owned or “legacy” clinics, causing increased market concentration in physician services. Although there is a robust literature on the impact of ho...

We compared new Medicaid enrollees with similar ongoing enrollees for evidence of pent-up demand using claims data following Minnesota’s 2014 Medicaid expansion. We hypothesized that if new enrollees had pent-up demand, utilization would decline over time as testing and disease management plans are put in place. Consistent with pent-up demand among...

Purpose: To learn how the highest-performing primary care practices manage change when implementing improvements to diabetes care delivery. Methods: We ranked a total of 330 primary care practices submitting practice management assessments and diabetes reports to the Understanding Infrastructure Transformation Effects on Diabetes study in 2017 a...

Objective: Identify the improvement in diabetes performance measures and population-based clinical outcomes resulting from changes in care management processes (CMP) in primary care practices over 3 years. Research design and methods: This repeated cross-sectional study tracked clinical performance measures for all diabetes patients seen in a co...

Purpose: To learn whether the COVID-19 pandemic's disruptions and associated reduced health outcomes for people with chronic conditions might have been caused by a decrease in care management processes (CMPs) in primary care clinics METHODS: Longitudinal cohort design with repeated survey-based measures of CMPs from 2017, 2019, and 2021 in 269 pri...

Background: Diabetes outcomes in primary care settings depend on specific care management processes (CMPs) provided by practices. CMPs have been tracked in Minnesota since 2017 using a practice survey that measures the presence of 1CMPs in primary care, including CMPs focused on patients with diabetes. Method: Secondary data analysis of CMP data co...

Objectives: To compare primary care management processes (CMPs) and outcome measures for diabetes quality among large, medium, and small medical groups. Study design: Observational comparison of differences in processes and outcomes over time among 329 primary care practices that agreed to participate and returned completed surveys in both 2017...

A popular method for estimating a causal treatment effect with observational data is the difference-in-differences model. In this work, we consider an extension of the classical difference-in-differences setting to the hierarchical context in which data cannot be matched at the most granular level. Our motivating example is an application to assess...

Although previous work suggests that high performing practices focus on proactive patient outreach, the specific care management processes (CMP) that improve diabetes outcomes remain unclear. We evaluated 60 CMP from a state-wide practice survey in 2017 and 2019. Previously validated, the survey included 586 practices in 2017 (71% response, N=415)...

Purpose: The aim of this study was to determine what strategies and factors are most important for high performance in the primary care of patients with diabetes. Methods: We performed a mixed-methods, cross-sectional, observational analysis of interviews and characteristics of primary care clinics in Minnesota and bordering areas. We compared s...

Background: Having depression and living in a rural environment have separately been associated with poor diabetes outcomes, but there little is known about the interaction between the 2 risk factors. This study investigates the association of depression and rurality with glycemic control in adults, as well as their interaction. Methods: This is...

Purpose: The purpose of this study was to assess whether primary care practices certified as medical homes differ in having the practice systems required for that designation and in attaining favorable outcomes for their patients with diabetes, and whether those systems are associated with better diabetes outcomes. Methods: We undertook a cross-...

Objective: The effective redesign of primary care delivery systems to improve diabetes care requires an understanding of which particular components of delivery consistently lead to better clinical outcomes. We identified associations between common systems of care management (SysCMs) and the frequency of meeting standardized performance targets f...

A popular method for estimating a causal treatment effect with observational data is the difference-in-differences (DiD) model. In this work, we consider an extension of the classical DiD setting to the hierarchical context in which data cannot be matched at the most granular level (e.g., individual-level differences are unobservable). We propose a...

Patients with diabetes and comorbid depression have an increased risk of complications. In a repeated panel cross-sectional study, we investigated the effect of depression care on glycemic control for adults with diabetes. Local health plan provided secondary data (N=29,227) that contained depression information and overall health risk calculated b...

Although national measures of the quality of diabetes care delivery demonstrate improvement, progress has been slow. In 2008, the Minnesota legislature endorsed the patient-centered medical home (PCMH) as the preferred model for primary care redesign. In this work, we investigate the effect of PCMH-related clinic redesign and resources on diabetes...

Objectives To examine the association between having a patient-centered medical home (PCMH) and healthcare expenditures and quality of care for children with special health care needs (CSHCN). Methods We conducted a cross-sectional analysis of 8802 CSHCN using the 2008-2012 Medical Expenditure Panel Survey. A PCMH indicator was constructed from sur...

State child care subsidy programs are intended to support the employment of low-income parents, particularly for families receiving or likely to receive Temporary Assistance for Needy Families. To study the impact of child care subsidies on employment, this study used detailed data from a survey of low-income parents in Minnesota, linked with admin...

Introduction: Of more than 300,000 adult Minnesotans who have received a diagnosis of diabetes, 16% are younger than 45 years; however, state diabetes surveillance data primarily describe older adults. National reports suggest adults younger than 45 years are less likely than older adults with diabetes to meet blood glucose (hemoglobin A1c [HbA1c]...

Context Long-term adherence to pharmaceutical treatment for multiple sclerosis (MS) is poor. A focus on patient preferences when determining the patient’s therapeutic plan may improve this experience. Objective To identify factors important to patients with MS when evaluating their options for pharmaceutical agents that deliver disease-modifying t...

Background: Multiple sclerosis (MS) is a neurological degenerative chronic condition without cure. However, long-term disease-modifying therapies (DMTs) help reduce the severity of MS symptoms. Adherence to DMTs is key to their success. Several studies have analyzed what makes patients adherent to their DMTs. As new DMTs have entered the market, f...

Patient cost sharing for contraceptive prescriptions was eliminated for certain insurance plans as part of the Affordable Care Act. We examined the impact of this change on women's patterns of choosing prescription contraceptive methods. Using claims data for a sample of midwestern women ages 18-46 with employer-sponsored coverage, we examined the...

Background/Aims: The Affordable Care Act (ACA) mandated that, starting in late 2012, private health insurance plans that are not exempt or grandfathered were required to cover all contraceptive methods approved by the U.S. Food and Drug Administration as prescribed for women without a patient copayment. This policy has the potential to save billion...

Background/Aims: Our objective is to determine factors affecting choice of narrow provider network plans, and whether care covered by a narrow network preferred provider organization (PPO) plan differs from care provided in a plan with a broader PPO network. Narrow provider networks, when built around a single vertically integrated system, hold the...

Background/Aims: The objective was to understand patient loyalty to providers over time in order to inform effective population health management. We studied patient care-seeking patterns over a 6-year timeframe in Minnesota, an environment where care systems are motivated to practice population health management through shared-saving contracts wit...

Background/Aims: Many state agencies, insurers and providers expected newly insured individuals under the Affordable Care Act (ACA) to inundate the health care market with high demand for health care. High health care utilization among newly insured individuals could indicate higher health risk and/or pent-up demand, defined as initial utilization...

Background: Research connecting patient-centered medical homes (PCMHs) with improved quality and reduced utilization is inconsistent, possibly because individual domains of change, and the stage of change, are not incorporated in the research design. The objective of this study was to examine the association between stage and domain of change and...

Multiple parties influence the choice of facility for hospital-based inpatient and outpatient services. The patient is the central figure, but their choice of facility is guided by their physician and influenced by hospital characteristics. This study estimated changes in referral patterns for inpatient admissions and outpatient diagnostic imaging...

To fill an empirical gap in the literature by examining changes in quality of care measures occurring when multispecialty clinic systems were acquired by hospital-owned, vertically integrated health care delivery systems in the Twin Cities area. Administrative data for health plan enrollees attributed to treatment and control clinic systems, merged...

This work proposes a frailty model that accounts for non-random treatment assignment in survival analysis. Using Monte Carlo simulation, we found that estimated treatment parameters from our proposed endogenous selection survival model (esSurv) closely parallel the consistent two-stage residual inclusion (2SRI) results, while offering computational...

Context: Health care delivery systems are becoming increasingly consolidated in urban areas of the United States. While this consolidation could increase efficiency and improve quality, it also could raise the cost of health care for payers. This article traces the consolidation trajectory in a single community, focusing on factors influencing rec...

To understand patient loyalty to providers over time, informing effective population health management. Patient care-seeking patterns over a 6-year timeframe in Minnesota, where care systems have a significant portion of their revenue generated by shared-saving contracts with public and private payers. Weibull duration and probit models were used t...

Objectives: We explored the process of physician selection, focusing on selection of surgeons for knee and hip replacement to increase the probability of a new relationship, making cost and quality scorecard information more relevant. Study design: We collected data using a mailed survey sent to patients with knee or hip replacement surgery shor...

Arteriovenous fistulas (AVFs) appear to be clinically superior to catheters as vascular access for maintenance hemodialysis, but higher insertion costs and high disease burden and mortality obscure the issue of whether AVF placement before hemodialysis initiation represents a net cost savings. We aimed to investigate Medicare costs for patients beg...

To examine how the relationship between patient characteristics, patient experience with the health care system, and overall satisfaction with care varies with illness complexity. Telephone survey in 14 U.S. geographical areas. Structural equation modeling was used to examine how relationships among patient characteristics, three constructs represe...

Understanding angler site choice preferences is important in the management of recreational fisheries to forecast angling demand and effort. This study investigated lake choice by recreational anglers fishing for walleye Sander vitreus in Minnesota and examined how choices were influenced by lake characteristics, angler demographics, and angler cat...

We assess the welfare impact of adverse selection in health insurance choices using detailed panel data on health plan choices and complete health care utilization. Our estimates suggest that adverse selection plays an important role in explaining cost differentials across plans and much of the selection occurs along difficult to contract upon dime...

Much of the health care insurance coverage available in the United States is offered in the context of plan choice. An understanding of how to predict individuals' choice of health plans is instrumental in understanding and managing these markets. In addition, choice of plans is a key component in many proposals for national health coverage in the...

We examine the factors that lead employees to search for health plan quality information and the effect of such information on the decision to switch plans. Extending Hirshleifer and Riley's model [Hirshleifer, J., Riley, J.G., 1979. The analytics of uncertainty and information--an expositional survey. Journal of Economic Literature 17 (December (4...

At the beginning of the 21st century, employer-provided insurance benefits have become a major component of employment compensation in the United States, with a compensating differential estimated by Miller (2004) of 10-11% of wages. In addition to being a substantive component of compensation, the cost of insurance has been increasing rapidly. Fro...

Background Many employers are changing their pharmacy benefit designs to contain cost increases. The objective of this study was to evaluate employee awareness of the cost-saving potential of these changes in the context of one such employer initiative. Methods We analyzed data from a survey of employees in 16 firms in Minneapolis, MN, USA. All of...

More than half of all Americans receive health insurance coverage through an employer. The rising costs and escalating complexity of health insurance has led many employers to embark on extensive employee education campaigns. In 2002, 1,365 randomly selected employees from 16 Buyers Health Care Action Group firms in the Minneapolis region were surv...

To analyze the factors associated with employee awareness of employer-disseminated quality information on providers. Primary data were collected in 2002 on a stratified, random sample of 1,365 employees in 16 firms that are members of the Buyers Health Care Action Group (BHCAG) located in the Minneapolis-St. Paul region. An employer survey was also...