Penn LDI Small Grants Program
Penn LDI has annually provided small grant funding for early-stage investigations that would otherwise not qualify for larger NIH or other institutional grants. In 2022, seven Senior Fellows and three Associate Fellows have been awarded pilot grants for research projects across a range of topics involving the cost, quality, and equity of health care. Below are the researchers and their projects.
The Effects of Prior Authorization on Medicaid Prescription Drug Access
Principal Investigator: Abby Alpert, PhD | The Wharton School
Prescription drug spending has increased rapidly over the last two decades. In response, state Medicaid programs have implemented prior authorization policies to reduce drug spending and improve the targeting of treatment. Despite the prevalence and importance of these policies in state Medicaid programs, there is limited evidence of their impact on prescription drug access and patient outcomes. In this project, we will use a regression-discontinuity design to study the consequences of prior authorization policies on prescription drug access as well as heterogeneous impacts across geographic areas and socio-demographic characteristics. We will also assess the role of different design features of these policies and their impact on inappropriate and appropriate prescribing.
Implementation of Warmline+bridge: An Innovative Approach to Address Opioid Use Disorder Treatment Gaps in Philadelphia
Principal Investigator: Shoshana Aronowitz, PhD, FNP-BC, MSHP | School of Nursing
More than 100,000 people in the U.S. died of a drug overdose during the one-year period ending in April 2021. This study will assess and improve the implementation and sustainability of Warmline+bridge, an innovative program at Penn Medicine on Demand (PMOD). The purpose of Warmline+bridge, established in October 2021, is to connect Philadelphians with opioid use disorder (OUD) to treatment programs across the city and to provide same-day “bridge prescriptions” of buprenorphine via telehealth. Philadelphia urgently needs this intervention as the city experienced the second highest overdose death rate of any U.S. metro area in 2020 with over 1,200 fatalities, and most individuals with OUD lack access to evidence-based treatment with medications like buprenorphine. Findings from this study will inform actionable ways to successfully implement, sustain, and scale this care delivery model at PMOD and beyond.
Knowledge and Perspectives of Low-Income Caregivers on a New Statewide Children’s Savings Account Initiative
Principal Investigator: Zoe Bouchelle, MD | Perelman School of Medicine
Statewide Children’s Savings Account (CSA) initiatives have gained traction as a policy lever to address disparities in wealth, health, and educational opportunity. Increasingly, states are investing funds in interest-earning accounts for newborns in order to generate assets for higher education. In 2019, Pennsylvania launched a statewide CSA that invests $100 in an account for every newborn, yet in 2020 only 10% of eligible families claimed the money. Despite low uptake of this historic investment, there has been little investigation of families’ knowledge and perceptions of CSA programs, particularly among low-income families whose children stand to benefit most. In this mixed-methods study, we will utilize a point of care survey and semi-structured interviews with low-income, urban caregivers in Philadelphia primary care practices to examine knowledge, perceptions, and factors associated with participation. Findings will be directly applied through a Medical Financial Partnership and will help inform policy interventions to promote meaningful uptake.
The Impact of Medicaid Policies on Long-Term Care Workers’ Economic Outcomes
Principal Investigator: Pilar Gonalons-Pons, PhD | School of Arts & Sciences
The long-term care industry is one of the fastest growing sectors of the economy, but also creates some of the lowest-paid and lowest-quality jobs. The precarious working conditions of long-term care workers—who are disproportionately women and women of color—are costly for both the workers and the patients they care for. This study will examine the role of government policy in shaping the economic conditions of this critical workforce by analyzing whether and how Medicaid long-term care policies shape care workers’ economic outcomes and job characteristics, in particular wages, access to benefits, schedule predictability, and union membership.
Improving Early-Stage OUD Treatment in Primary Care
Principal Investigator: Rebecca (Arden) Harris, MD, MSc | Perelman School of Medicine
About two-thirds of all patients with opioid use disorder who begin outpatient buprenorphine treatment discontinue within the first six months, with nearly half of the attrition occurring in the first 30 days. Treatment dropout is concerning as it elevates the risks of relapse, infections, justice system involvement, and overdose deaths. This study will use a combination of quantitative and qualitative methods to investigate the patient experience in the first days of treatment. The findings will be used to design a clinic-based intervention to lower the barriers to treatment engagement.
A Proactive, Tailored, Population Health Approach for Tobacco Treatment for Parent Smokers through a Pediatric Care Network
Principal Investigator: Brian Jenssen, MD, MSHP | Perelman School of Medicine
Routinely delivered tobacco treatment to parents who smoke would provide a major health benefit in the U.S., as tobacco use leads to 480,000 preventable deaths, $300 billion in tobacco attributable costs, and secondhand smoke (SHS) exposure that affects more than 40% of children each year. Pediatricians are uniquely positioned to protect children from SHS exposure by helping medically underserved parents quit smoking. However, appropriate treatments are rarely provided to parents/caregivers who smoke and strategies are needed to engage household members who smoke and are not present at the child’s health care visit. Our team has created a clinical decision support (CDS) system deployed within the Children’s Hospital of Philadelphia (CHOP) Primary Care Network that captures when there are household members not at the visit who smoke and gets permission to contact them. Funding from this grant will be used to test how best to engage these parents in treatment.
Trends and Factors Associated with Hospital and Pharmacy Contracting in the 340B Drug Pricing Program
Principal Investigator: John Lin, MD | Perelman School of Medicine
Through the Federal 340B Drug Pricing Program, providers may purchase drugs at substantial discounts and contract with pharmacies to dispense them. The Program has two goals: (1) to financially support safety net clinics and hospitals and (2) to improve access to medications for vulnerable patients.
Under the Affordable Care Act, the 340B Program was expanded, allowing its providers to contract with an unlimited number of pharmacies. Although the intent was to provide vulnerable patients better access to medications, it is unclear whether the expansion has occurred with the providers and pharmacies serving the largest shares of vulnerable patients.
The investigators will analyze trends and factors associated with provider and pharmacy contracting under the 340B Program. This work will generate some of the first evidence to date on the scale and scope of provider and pharmacy contracting under the 340B Program and inform the extent to which growth has served the vulnerable communities it was intended to benefit.
FQHC Based Integrated Care for Serious Mental Illness
Principal Investigator: Steven Marcus, PhD | School of Social Policy & Practice
Access to quality integrated primary care and behavioral health services is critical to addressing disparate health outcomes among individuals with serious mental illness (SMI) and chronic health conditions. Many individuals with SMI and chronic disease rely on federally qualified health centers (FQHCs) to receive care, though research examining how FQHCs can best deliver integrated behavioral health (IBH) to this group is lacking. This study will examine how individuals with SMI and chronic disease utilize IBH services within FQHCs, and what type of IBH leads to best outcomes for this group. The study will identify patient, organizational, and community-level factors affecting patterns of IBH utilization among individuals with SMI and chronic disease, examine how patterns of IBH utilization affects service quality and clinical outcomes among this group, and explore factors moderating this relationship.
Understanding Prognostic Communication Between Clinicians and Surrogates of Older Adults with Moderate to Severe Traumatic Brain Injury: A Qualitative Study
Principal Investigator: Stephen Miranda, MD | Perelman School of Medicine
Older adults account for a disproportionate number of deaths after traumatic brain injury (TBI), often necessitating urgent, value-laden conversations about life-saving surgery. Because an acceptable neurological status or functional outcome is not guaranteed post-operatively, it is critical to understand how clinicians and patient surrogates communicate about the future. This project will yield essential information about how prognosis is disclosed and perceived after TBI, using qualitative methods to: (a) describe the content of care-planning discussions between clinicians and surrogates, and (b) explore surrogate perceptions about prognostic communication. Such evidence will inform the development of behavioral interventions to improve shared decision-making after these injuries so that surrogate expectations are better aligned with realistic outcomes, and that recommended treatments are more concordant with patient values.
Evaluating the Early Impact of the End-Stage Renal Disease Treatment Choices Model on Health Equity
Principal Investigator: Amol Navathe, MD, PhD | Perelman School of Medicine
Patients with end-stage renal disease (ESRD) suffer from limited and inequitable access to cost-effective therapies such as home dialysis or kidney transplantation (compared to in-center hemodialysis). To improve access to these therapies, the Centers for Medicare and Medicaid Services implemented a new mandatory payment model in 2021—the ESRD treatment choices (ETC) model—which randomized 30% of all hospital referral regions in the country to receive payment adjustments that incentivize home dialysis and kidney transplantation. Unfortunately, there is growing concern that the randomization design may unintendedly worsen access to these therapies for minority populations. In this proposal, we will leverage data from Medicare and transplant registries to evaluate the impact of the ETC model on health equity. Specifically, we aim to establish whether the ETC model 1) appropriately randomized participants to account for equity, and 2) had an early impact on home dialysis and kidney transplant waitlisting for minority populations.