NYMC Student Theses and Dissertations

Date of Award

3-26-2026

Document Type

Doctoral Dissertation - Open Access

Degree Name

Doctor of Public Health

Department

Public Health

First Advisor

Adam Block, PhD

Second Advisor

Kenneth Knapp, PhD

Third Advisor

Michael Gusmano, PhD

Abstract

Abstract

Background: U.S. health policy relies on multiple levers to influence system performance, financial stability, and population health. This dissertation uses a three-paper portfolio to evaluate organizational change (hospital acquisitions), payment reform (Maryland all-payer global budgets), and income-related state policies, applying difference-in-differences (DiD) designs with prespecified diagnostics to support causal interpretation.

Methods: Study 1 examined hospital change-of-ownership (CHOW) acquisitions using a national hospital-year panel from RAND HCRIS (2014–2023), linked to CHOW timing data from 2016–2023. Effects on revenue outcomes were estimated using a staggered difference-in-differences design implemented with the Callaway and Sant’Anna estimator, using doubly robust inverse probability weighting, hospital-level clustered inference, event-study analyses, placebo tests, and wild-bootstrap inference (999 replications) for preferred specifications. Study 2 evaluated Maryland’s 2014 all-payer global budget revenue (GBR) model using a matched Maryland–Massachusetts hospital-year panel (2010–2023; 2,261 matched observations) constructed by merging RAND HCRIS financial measures with CMS certification–based provider characteristics. Two-way fixed-effects DiD models with hospital and year fixed effects, event-study diagnostics, and a pre-period placebo test were used to assess changes in margins, inpatient revenue per discharge (log), and COVID-period margin volatility (2020–2022). Study 3 assessed income-related policy adoption (minimum wage increases, Earned Income Tax Credit adjustments, Medicaid expansion) using CDC BRFSS state-year-subgroup prevalence data (2018–2023; 15,154 observations across 55 states/territories) with ACS/IPUMS covariates. Two-way fixed-effects DiD models with event studies, placebo tests, and trend-adjusted specifications were used to evaluate changes in fair/poor self-rated health.

Results: Study 1 found small, statistically null average effects of CHOW acquisitions on revenues per discharge in the preferred specification (net revenue per discharge −1.7%, p=0.477; operating revenue per discharge −3.5%, p=0.164), with supportive pre-trend evidence for net revenue and attenuating post-acquisition patterns amid increasing long-horizon uncertainty. Study 2 found that GBR was associated with higher inpatient revenue per discharge in Maryland relative to Massachusetts after 2014 (β=0.287, p=0.003; ≈33% increase), while total margins showed no statistically detectable change (β=0.021, p=0.232) and COVID-period margin volatility did not differ significantly (β=−0.018, p=0.161); the pre-period placebo estimate was null (β=−0.008, p=0.801). Study 3 showed a small baseline reduction in fair/poor self-rated health following income-policy adoption (−0.00403, SE=0.00141, p≈0.006), but event-study diagnostics indicated a pre-policy trend violation, and state-specific trend-adjusted specifications were statistically and practically null; randomized-date placebo estimates were null (β=0.0007, p=0.59).

Conclusions: Effects differed across three policy domains by lever and outcome. Hospital acquisitions were not associated with detectable average revenue changes in this national cost-report panel; Maryland’s global budgets were associated with higher revenue intensity per inpatient discharge without clear evidence of improved profitability or reduced margin volatility during COVID; and apparent short-run health improvements following income-policy adoption were not robust to trend-adjusted specifications. Collectively, the dissertation underscores the importance of rigorous DiD diagnostics for disciplined interpretation and for distinguishing changes in revenue intensity from profitability and near-term population health effects.

Comments

This dissertation includes manuscripts prepared for publication. Copyright for any third-party material remains with the respective rights holders.

Keywords

difference-in-differences; hospital acquisitions; global budgets; income-related policies; hospital finance; population health; Maryland; BRFSS

Disciplines

Health and Medical Administration | Medical Specialties | Medicine and Health Sciences | Population Health | Public Health | Social and Behavioral Sciences

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