Megdalynn Fisher, MPA

Megdalynn Fisher, MPA

she/her

PhD Candidate

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Adobe-based newsletter created to promote the Health Policy Workshop’s Spring semester

publications

The Hope of Mankind

Published in The Journal of Student Leadership, 2017

In the inaugural edition of the Journal of Student Leadership we pause to ponder what student leadership is and what students can contribute toward the future of leadership and leadership studies.

Recommended citation: Fisher, Megdalynn. (2017). "The Hope of Mankind." The Journal of Student Leadership. 1(1).
Download Paper

talks

The Hope of Mankind

Published:

Fisher, Megdalynn. “The Hope of Mankind,” Oral recitation at the celebration of the inaugural edition of The Journal of Student Leadership, Orem, Utah, April 20, 2017.

An Advocacy Coalition Framework Approach to Section 340B

Published:

The Section 340B Drug Pricing program is often criticized and defended by various stakeholders. As a program with a nuanced history, growing footprint, poor targeting, and unintended consequences, I explore the program’s development, implementation, and evaluation using an Advocacy Coalition Framework to conceptualize the public policy process.

Tribal Self-Governance and COVID-19 Outcomes

Published:

Does tribal self governance improve COVID-19 outcomes among Native American and Indigenous American populations? I present early findings on collaborative work with Patrick Carlin.

Hospital Competition, Quality, and Municipal Debt: Do Non-Profit Hospitals Utilize Municipal Market Credit Access to Fund Competition on Quality

Published:

Using the variation of municipal governments’ credit ratings, I examine associations between Hospital Compare quality ratings, market concentration, and nonprofit hospital municipal market bond issuance to identify the effects of hospital quality measures on bond issuance. Findings include higher bond issuance in counties with lower reported hospital quality.

Public Reporting of Nursing Home Antipsychotic Use: Changes in the Reporting of Exclusionary Diagnoses?

Published:

Following the public reporting of Antipsychotic Medication (APM) use in nursing homes, we document an increase in prevalence of schizophrenia diagnos, a diagnosis which excludes facilities from the public reporting requirement for these residents. Public reporting is designed to reduce off-label use of APMs, increases in schizophrenia diagnosis are an unintended consequence of the policy that may be attributed to either more accurate diagnosis or upcoding.

Racial and Ethnic Segregation in Nursing Homes

Published:

In this presentation, we discuss our upcoming contribution to the literature measuring and understanding drivers of racial and ethnic sorting (segregation) in the health care setting by constructing dissimilarity indices (DI) for nursing homes. The dissimilarity index, a commonly used measure in residential segregation studies, ranges from 0 to 1 and in our context describes the share of patients in a health care market who would have to switch homes in order for there to be evenness (no segregation) across the providers in that market. Prior work has computed the DI in healthcare settings but provides limited evidence on how the DI varies across geographic areas and/or is based on data more than a decade old. We combine administrative data on all certified nursing homes in the U.S. with health assessments of long-term stay patients residing in those homes for the years 2011 and 2017. Geographically, we define a nursing home market to be a county.

Does Public Quality Reporting Improve Quality? The Case of Nursing Home Prescribing of Antipsychotics

Published:

The quality of services provided in nursing homes and other healthcare settings is a high societal concern. Public reporting of provider quality is an important part of the policy making toolkit, to incentivize providers to improve quality, to alleviate information problems in healthcare markets, and enable greater competition. Starting in 2012, nursing homes were required to publicly report the share of residents who received potentially inappropriate antipsychotic medications (APMs) on the popular CMS “Nursing Home Compare” website. This requirement was driven by concern regarding over-medication with APMs (“chemically restraining” to alleviate staff burdens) of NH residents. Policy makers recognized that the addition of this measure to the Compare website might instigate “cream skimming” if nursing homes avoid patients for whom APMs may be appropriate care, thus the policy exempted patients with certain diagnoses considered appropriate for treatment with antipsychotics (schizophrenia, Tourette Syndrome and Huntington’s disease) from the measure’s calculation. Reporting requirements may also prove unwieldy for small nursing homes, so only ones with 30 (or later 20) and more residents were required to report. Prior work has shown that new patient flows are influenced by reported quality, thus there may be strategic responses by nursing homes to public reporting requirements: to medically upcode residents at the margin of an exclusionary diagnosis. There may also be incentives to cream skim patients who are not at high likelihood of needing APMs, and, to prescribe medications that are a partial substitute for APMs (such as antidepressants) but are not included in public reporting. We test the hypothesis that nursing homes responses align with these incentives, using data from individual and administrative records from the nursing home sector. We use a DD design, pre- and post-policy, comparing responses among smaller facilities as a control group to larger facilities who were affected by the policy. More specifically, we use data from three Centers for Medicare and Medicaid Services (CMS) sources: 1) the Minimum Data Set (MDS) which contains an administrative record each year 2011-2017 for individual residents in all certified NHs in the U.S., recording their clinical diagnoses, as well as medications received; 2) 2011-2017 data from the Certification and Survey Provider Enhanced Reports (CASPER) which contains a facility record for each NH; 3) 2011-2017 data from Nursing Home Compare, a publicly available record on every NH containing quality measures relevant to this research. We verify prior findings that overall APM medication of long-term stay residents has been declining over time, especially in homes subject to public reporting. However, we find novel evidence from regression and event study analysis that there was also systematic upcoding: we find that diagnosis of schizophrenia, an exclusionary diagnosis, is increasing in nursing homes subject to public reporting, after the policy, by 3.2% (95%CI: 1.5 to 4.9) among residents with APM prescriptions. We find no evidence consistent with cream skimming. We do find evidence of increased prescribing of anti-anxiety medications, potential substitutes for APMs. We also find disparities in the increasing diagnosis of schizophrenia by marital status and in homes most reliant on Medicaid. Taken together, this evidence suggests that policy makers intending to improve quality in nursing homes through transparency of quality metrics should be aware of possible unintended consequences.

teaching

Public Management Economics, MPA-612

Graduate Teaching Assistant, Brigham Young University, Romney Institute of Public Service and Ethics, 2018

Course support, lab direction and tutoring, assignment grading for Dr. Andrew Heiss. By the end of this course, you will (1) be literate in fundamental economic principles, (2) understand the limits of economic theory and free markets, (3) justify government and nonprofit intervention in the economy, and (4) make informed policy recommendations by analyzing and evaluating public sector policies.
MPA-612

Contemporary Economic Issues in Public Affairs, SPEA-V202

Associate Instructor (Instructor of Record), Indiana University, O'Neill School of Public and Environmental Affairs, 2021

Fall Semester (3 cr.)
This course reinforces and deepens economic skills by applying basic microeconomic concepts and models to a variety of policy areas. Using economic models, students in the course will examine the motivation for intervention in the economy, the types of intervention, and the predicted effects of policies.
Policy areas covered will include tax, social, health, regulatory, environmental, and trade policy, among others. To better understand these issues, the course will first briefly discuss some of the institutional details of the policy area, and then use economic models to examine impact of policy on behavior and market outcomes.

Contemporary Economic Issues in Public Affairs, SPEA-V202

Associate Instructor (Instructor of Record), Indiana University, O'Neill School of Public and Environmental Affairs, 2022

Spring Semester (3 cr.)
This course reinforces and deepens economic skills by applying basic microeconomic concepts and models to a variety of policy areas. Using economic models, students in the course will examine the motivation for intervention in the economy, the types of intervention, and the predicted effects of policies.
Policy areas covered will include tax, social, health, regulatory, environmental, and trade policy, among others. To better understand these issues, the course will first briefly discuss some of the institutional details of the policy area, and then use economic models to examine impact of policy on behavior and market outcomes.

wip

Government Intervention in Nursing Homes: Assessing Ownership Dynamics and Quality of Care Under Non-State Government Owned Supplemental Payment Programs

Work in Progress: job market paper

Do subsidies through Non-State Government Owned nursing facility supplemental payment programs spur government acquisitions and do the subsidies translate to fewer deficiencies and better quality?

Recommended citation: Fisher, Megdalynn. "Government Intervention in Nursing Homes: Assessing Ownership Dynamics and Quality of Care Under Non-State Government Owned Supplemental Payment Programs" work in progress.

End of Life Inpatient Spending and Hospital Advertising

Work in Progress: under review

Does hospital advertising inform patient choice or represent ‘cheap talk’? We investigate the hospital advertising at the market level, establishing a correlation with end-of-life inpatient spending, a proxy for geographical differences in hospital spending on care with a uniform outcome.

Recommended citation: Freedman, Seth, Victoria Perez, Megdalynn Fisher. "End of Life Inpatient Spending and Hospital Advertising" under review.

Nursing Home Use of Antipsychotics: Does Public Reporting Incentivize Gaming?

Work in Progress: working paper

The number of nursing home residents with schizophrenia has increased due to their exemption from the requirement for antipsychotic medication quality reporting. Since public reporting incentivizes either more accurate diagnosis or upcoding, we examine these effects at the reporting threshold based on number of residents in the facility.

Recommended citation: Bowblis, John, Megdalynn Fisher, Kosali Simon. "Nursing Home Use of Antipsychotics: Does Public Reporting Incentivize Gaming?" work in progress.

Racial, Demographic and Health Sorting Among Nursing Home Residents

Work in Progress: submitted

We contribute to the literature measuring segregation in the health care setting by constructing dissimilarity indices (DI) for nursing homes and counties to examine relationships with income inequality, reliance on Medicaid, urbanicity, and quality.

Recommended citation: Fisher, Megdalynn, Madeline Mustaine, Kosali Simon, John R. Bowblis. "Racial, Demographic and Health Sorting Among Nursing Home Residents" work in progress.

Antipsychotic Medication Use Among Nursing Home Residents with Alzheimer’s Disease and Related Dementias: Ownership Structures

Work in Progress: working paper

Do nursing home residents with Alzheimer’s disease and related dementias (ADRD) receiving antipyschotic medications more often based on ownership structures, and do rates of diagnosis excluding public reporting requirements of antipsychotic medication use differ by these ownership structures?

Recommended citation: Bowblis, John, Megdalynn Fisher, Judith Lucas, Kosali Simon. "Antipsychotic Medication Use Among Nursing Home Residents with Alzheimer's Disease and Related Dementias: Ownership Structures and Racial Disparities." work in progress.

Medicaid Expansion and Nursing Home Outcomes

Work in Progress: working paper

Medicaid expansion has increased the number of nursing home (NH) residents (Ritter et al, Van Houtven et al) but there is a lack of research on individual level decisions and facilty level reactions. To expand this research base, we examine resident level data to determine how quickly Medicaid expansion leads to changes in the type of long-stay patients in NHs, and how that translates into changes in the characteristics of long-stay residents and NHs over time. We hypothesize that SMI populations under 65 will be the group that experiences the largest increase.

Recommended citation: Bowblis, John, Megdalynn Fisher, Madeline Mustaine, and Kosali Simon. "Medicaid Expansion and Nursing Home Outcomes" work in progress.