Transit and treatment: Aligning systems to address substance use in Connecticut.

OBJECTIVE: Test hypotheses that proximity to new transit improves substance use disorder treatment provider cost efficiency (i.e., economies of scale and scope). DATA SOURCES AND STUDY SETTING: Connecticut substance uses disorder treatment providers/programs. A 2015 rapid transit line opening with 10 stations, near some providers/programs. Providers' annual operating costs from publicly available federal tax forms (2013-2018). Annual client counts, service-type (including substance use disorder and/or mental health, among others), and location data, for 50 providers and their programs, from Department of Mental Health and Addiction Services, with an unbalanced panel of 285 provider-years. STUDY DESIGN: Economies of scale occur when the percent change in operating costs is less than the percentage change in clients. Economies of scope occur when operating costs fall as providers treat clients with multiple service needs. With our quasi-experimental, multivariate regressions approach, we test hypotheses that proximity to a new transit line enhances economies of scale and scope (i.e., lowers unit operating costs). DATA COLLECTION/EXTRACTION METHODS: Annual provider-level operating costs merged with new transit station locations and Department of Mental Health and Addiction Services program/provider-level secondary data (locations, client counts/completions/dates, service types, and average demographics). PRINCIPAL FINDINGS: For providers with programs within 1-mile of new transit (compared with a "control" sample beyond 1-mile of new transit), (i) a 10% increase in clients leads to a 0.12% lower operating costs per client; (ii) a 10% increase in clients completing treatment results in a 1.5% decrease in operating costs per client; (iii) a 10% increase in clients receiving treatment for multiple services causes a 0.81% lower operating costs per client; (iv) offering multiple services leads to 6.3% lower operating costs. CONCLUSIONS: New transit proximity causes operating cost savings for substance use disorder/mental health treatment providers. System alignment may benefit transit and health care sectors.

The impact of the Coronavirus pandemic on New York City real estate: First evidence.

We investigate whether pandemic-induced contagion disamenities and income effects arising due to COVID-related unemployment adversely affected real estate prices of one- or two-family owner-occupied properties across New York City (NYC). First, ordinary least squares hedonic results indicate that greater COVID case numbers are concentrated in neighborhoods with lower-valued properties. Second, we use a repeat-sales approach for the period 2003-2020, and we find that both the possibility of contagion and pandemic-induced income effects adversely impacted home sale prices. Estimates suggest sale prices fell by roughly $60,000 or around 8% in response to both of the following: 1000 additional infections per 100,000 residents and a 10-percentage point increase in unemployment in a given Modified Zip Code Tabulation Area (MODZCTA). These price effects were more pronounced during the second wave of infections. On the basis of cumulative MODZCTA infection rates through 2020, the estimated COVID-19 price discount ranged from approximately 1% to 50% in the most affected neighborhoods, and averaged 14%. The contagion effect intensified in the more affluent, but less densely populated NYC neighborhoods, while the income effect was more pronounced in the most densely populated neighborhoods with more rental properties and greater population shares of foreign-born residents. This disparity implies the pandemic may have been correlated with a wider gap in housing wealth in NYC between homeowners in lower-priced and higher-priced neighborhoods.

Too Big, Too Small, or Just Right? Cost-Efficiency of Environmental Inspection Services in Connecticut.

OBJECTIVE: To assess optimal activity size/mix of Connecticut local public health jurisdictions, through estimating economies of scale/scope/specialization for environmental inspections/services. DATA SOURCES/STUDY SETTING: Connecticut's 74 local health jurisdictions (LHJs) must provide environmental health services, but their efficiency or reasons for wide cost variation are unknown. The public health system is decentralized, with variation in organizational structure/size. We develop/compile a longitudinal dataset covering all 74 LHJs, annually from 2005 to 2012. STUDY DESIGN: We estimate a public health services/inspections cost function, where inputs are translated into outputs. We consider separate estimates of economies of scale/scope/specialization for four mandated inspection types. DATA COLLECTION/EXTRACTION METHODS: We obtain data from Connecticut Department of Public Health databases, reports, and other publicly available sources. There has been no known previous utilization of this combined dataset. PRINCIPAL FINDINGS: On average, regional districts, municipal departments, and part-time LHJs are performing fewer than the efficient number of inspections. The full-time municipal departments and regional districts are more efficient but still not at the minimum efficient scale. The regional districts' elasticities of scale are larger, implying they are more efficient than municipal health departments. CONCLUSIONS: Local health jurisdictions may enhance efficiency by increasing inspections and/or sharing some services.

Dynamics of the mental health workforce: investigating the composition of physicians and other health providers.

We evaluate how changes to mental health workforce levels, composition, and degree of labor substitution, may impact typical practice output. Using a generalized Leontief production function and data from 134 U.S. Department of Veterans Affairs (VA) mental health practices, we estimate the q-complementarity/q-substitutability of mental health workers. We look at the entire spectrum of mental health services rather than just outpatient or physician office services. We also examine more labor types, including residents, than previous studies. The marginal patient care output contribution is estimated for each labor type as well as the degree to which physicians and other mental health workers may be substitutes or complements. Results indicate that numerous channels exist through which input substitution can improve productivity. Seven of eight labor and capital inputs have positive estimated marginal products. Most factor inputs exhibit diminishing marginal productivity. Of 28 unique labor-capital pairs, 17 are q-complements and 11 are q-substitutes. Complementarity among several labor types provides evidence of a team approach to mental health service provision. Our approach may serve to better inform healthcare providers regarding more productive mental health workforce composition both in and outside of VA.

Health-care service utilization in substance abusers receiving contingency management and standard care treatments.

AIM: To determine the impact of standard care and contingency management treatments on the utilization of general health-care services by substance abusers. PARTICIPANTS, DESIGN AND MEASUREMENTS: This secondary analysis pooled 1028 treatment-seeking substance abusers from five randomized clinical trials that compared the effects of standard care (SC, n = 362) to standard care plus contingency management (CM, n = 666). In each trial, subjects in the CM condition showed significantly greater reductions in substance use than their SC counterparts. For each subject, utilization of 15 general health-care services was measured 1 year prior to treatment intake and up to 9 months following treatment intake. Post-intake utilization data were pro-rated to be comparable to the 1-year pre-intake data. Paired t-tests evaluated changes in service utilization pre- and post-intake, and difference-in-differences regression models were used to estimate the impact of CM, compared to SC, on changes in the utilization of each of the 15 health services. SETTING: Out-patient community substance abuse clinics in Connecticut and Massachusetts, USA. FINDINGS: Utilization of several types of out-patient services increased significantly between the pre- and post-intake periods [e.g. dental visits (0.47, P < 0.001), community health center visits (0.50, P < 0.001), visits to a mental health professional office (1.03, P = 0.001)], while in-patient hospital care for mental health problems decreased significantly (-3.50 nights, P < 0.001). A substantial portion of these changes occurred during the treatment period. No significant differences were found between the two treatment conditions. CONCLUSIONS: Initiating out-patient substance abuse treatment is associated with changes in general health-care service utilization, independent of the type of treatment offered.