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While it has often been said that the most frequent users of overburdened hospital emergency departments are mentally ill substance abusers, a study out today (Dec. 3) by researchers from NYU Wagner and the University of California, San Francisco, has found that this belief is unfounded – an “urban legend.”
Co-authored by John Billings of NYU’s Robert F. Wagner Graduate School of Public Service and Maria C. Raven of the University of California and published in the December issue of Health Affairs, the new analysis of hospital emergency department (ED) use in New York City by Medicaid patients reveals that conditions related to substance abuse and mental illness are responsible for a small share of the emergency department visits by frequent ED users, and that ED use accounts for a small portion of these patients’ total Medicaid expenditures. However, according to the study, frequent emergency department users have a substantial burden of disease, often having multiple chronic conditions and many hospitalizations.
The article, “Dispelling an Urban Legend: Frequent Emergency Department Users Have Substantial Burden of Disease,” analyzes data on emergency department visits by 212,259 New York City residents who received their first emergency department care in 2007. The researchers reviewed each patient’s eligibility, ED use, Medicaid fee-for-service spending, and diagnostic history. The main part of the analysis covers the three years before each patient’s first visit to a hospital emergency department, the 12 months after the initial visit, and the subsequent two years. As the authors write, “contrary to urban legend, most repeat users in the study did appear to have relatively strong linkage to ambulatory care, at least as evidenced by their high rates of primary and specialty care visits. Except for ED users with ten or more visits in the index [initial] year, ambulatory care visit rates actually exceeded ED visit rates.”
While hospital emergency department use is not a major cost driver for the Medicaid program, an improved understanding of Medicaid beneficiaries who frequently obtain ED care could help inform the current policy debate over how to meet the significant needs of this population and how to contain Medicaid expenditures, according to the researchers.
Importantly, the analysis indicates that “predictive modeling” based on information provided at a patient’s initial ED visit could be used to identify individuals likely to return to theemergency department frequently. Billings and Raven write that the predictive modeling approach, coupled with an understanding of the characteristics of frequent ED users, offers health care institutions an opportunity to design targeted, cross-system health care interventions to keep future high users from having to return to the hospital for emergency care.
“It is also important to note that only a small number of ‘frequent fliers’ are ultra-high ED users or serial high ED users, with frequent ED use year after year,” Billings and Raven assert. “To date, most thinking by providers and policy makers about the problem of frequent ED users has focused on these serial users, but the overwhelming majority of frequent users have only episodic periods of high ED use, instead of consistent use over multiple years. More needs to be learned about these patients (they, too, could be interviewed in the ED), and predictive modeling and quick intervention will probably be critical since their repeat ED use is unlikely to continue over time.”
Half of the adults in the world (about 2.5 billion people) are “unbanked”—meaning their money is not housed in a secure institution. That’s the central concern of a new book, Banking the World: Empirical Foundations of Financial Inclusion, co-edited by Jonathan Morduch, a professor in the Robert F. Wagner Graduate School of Public Service.
To reach those billions of people, Morduch argues that we need to think about banking in radically different ways. Promising solutions involve using new technologies like mobile phones, as well as re-imagining ideas such as self-governing, village-based saving groups. Understanding those possibilities is a focus of the Financial Access Initiative (FAI), the NYU center that Morduch, an expert in public policy and economics, founded with colleagues at Yale and Harvard.
NYU Research Digest recently sat down with him to discuss old perspectives and new ideas.
How does your research connect two typically incongruent issues like banking and poverty?
Let’s start with poverty, rather than banking. If you’re reading this, you’re probably not poor, but you may have ideas about what it’s like to be poor. Over the past decade, I’ve come to see that my own ideas about poverty were wrong. Elements that I had thought were very important, I now believe are much less important. I had been locked into a logic that was shaped by the available data—large surveys designed to test formal hypotheses, but that turn out to give a very blurry sense of how people actually live their lives.
Rather than surveying thousands of households, a group of researchers started with just a few dozen. Rather than collecting data only once, the researchers visited and revisited the same households many times over a year. Everything bought and sold was noted—all financial transactions, whether at a bank or with family and friends. The intensity of the engagement allowed us to see and understand activities that had been out of view.
This is the data from India, Bangladesh, and South Africa described in your previous book, Portfolios of the Poor: How the World’s Poor Live on $2 a Day. What did it tell you?
The evidence showed that a vast problem for many poor families is not low incomes per se, but the fact that incomes are unreliable and often unpredictable. We often talk about the 40 percent of the world living on under $2 a day per person, but we lose sight of the fact that people don’t literally earn $2 a day. They earn $10 one day, for example, and then very little for a few weeks. Those ups and downs mean that families spend a lot of time figuring out how to borrow and save and deal with risk. We also see people often borrowing to pay for health emergencies, school fees, and simply getting food on the table. But their financial tools are often expensive and unreliable—if they even exist.
You’ve written a lot about microfinance over the years. Is that the solution to “banking the world”?
Microfinance centers on small loans for small-scale entrepreneurs, mostly poor women, who seek capital to grow their businesses. The idea is associated with Grameen Bank of Bangladesh, but the sector has grown quickly, now serving 200 million customers globally, including some here in New York.
Microfinance is an inspiration, but it can also box us in. The starting point of Banking the World is that we need to go beyond the kind of entrepreneurial finance celebrated by microfinance. More fundamental is access to basic money management tools. A huge group of the 2.5 billion unbanked adults are not entrepreneurs. They have jobs, but they still need financial tools—a safe place to save, a convenient way to make payments, short-term loans for general purposes. Entrepreneurs too have needs beyond business. In these ways, the poor are not so different from the rich. It’s been a hard message for some people to hear, but conversations are shifting.
Banking the World collects empirical studies that point to viable solutions, and push us to take a critical look at popular ideas like financial literacy. The chapters also draw new links, like those between finance and under-nutrition. All that, I hope, takes us another step toward solving a problem that is huge—but solvable.
In 2010, nonprofits in the U.S. numbered 1.5 million, with $1.51 trillion in revenues, and to find particulars or overall trends about this vast and growing sector of the economy, many people use the Form 990. This is the financial and organizational report that every tax-exempt organization submits annually to the Internal Revenue Service.
Yet, like many public documents, the forms are not so easy for researchers, practitioners, and others to access and analyze.
Writing in a recent paper, Beth Noveck, a visiting professor at the Robert F. Wagner Graduate School of Public Service, along with co-author Daniel L. Goroff, a program director at the Alfred P. Sloan Foundation, asked whether government transparency could be enhanced with technology to better support innovation, engagement, and outcomes in the nonprofit sector.
Noveck, who formerly led President Barack Obama’s Open Government Initiative, is immersed in studying the broad, important issue of how governments can better use tech-enabled platforms to engage the citizenry. In her Aspen Institute paper with Goroff, entitled “Information for Impact: Liberating Nonprofit Sector Data,” she finds that, like other data collected by the U.S. government, the information in the Form 990s could be far more beneficial “if it were not only ‘public’ but ‘open’ data.” That is: “Available to all, free of charge, in a standard format, published without proprietary conditions, and available online as a bulk download rather than through single-entry lookup.
“Making the 990 data truly open… would not only make it easier to use for the organizations that already process it,” the authors write, “but would also make it useful to researchers, advocates, entrepreneurs, technologists, and nonprofits that do not have the resources to use the data in its current form.”
The move would also encourage greater transparency by nonprofits, spur innovation in the sector, and “above all, help us to understand the potential value of the 990 data,” note the authors.
At present, the IRS creates Form 990 image files and sells DVD compilations to subscribers.
“Just as most people have gotten accustomed to sharing large files via a service like Dropbox, it would be simple for the IRS to publish the returns online for anyone to download in bulk for free,” Noveck wrote in a recent blog post about the paper.
But if converting the Form 990 into an open-data government document sounds straightforward, the co-authors find that it isn’t a simple delivery. Liberating government data of all kinds, they write, typically requires overcoming technological, political, and cultural barriers to change.
[Originally appeared in NYU Research Digest, Spring 2013].
The Aspen Insitute today released a new report in Washington, D.C., by NYU Wagner Visiting Professor Beth Noveck and Daniel L. Goroff. The report, "Information for Impact: Liberating Nonprofit Sector Data," shows how new technology designed to improve data on the nonprofit sector can prompt greater innovation and effectiveness.
Noveck is former director of the White House Open Government Initiative. Goroff, while at the Office of Science and Technology Policy, helped establish the new Interagency Task Force on Smart Disclosure. He is a program director with the Alfred P. Sloan Foundation.
In a nationally representative sample of nearly 3,000 children and adolescents, those who had higher concentrations of urinary bisphenol A (BPA), a manufactured chemical found in consumer products, had significantly increased odds of being obese, according to a groundbreaking study in the September 19 issue of Journal of the American Medical Association (JAMA) by NYU Wagner professors Leonardo Trasande and Jan Blustein.
Leonardo Trasande, M.D., M.P.P., who is co-affiliated with the NYU School of Medicine, presented the findings of the study at a JAMA media briefing announcing the Journal's new issue devoted to the question of obesity. The research, which has drawn national media coverage, is co-authored by Dr. Jan Blustein, M.D., P.h.D, professor of health policy and professor of medicine at Wagner and the School of Medicine. A third author, Teresa M. Attina, is affiliated with the School of Medicine, Department of Pediatrics.