Jose Pagan
Jose Pagan
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Chair and Professor of the Department of Public Health Policy and Management
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Professional overview
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Dr. Pagán received his PhD in economics from the University of New Mexico and is a former Robert Wood Johnson Foundation Health & Society Scholar with expertise in health economics and population health. He has led research, implementation, and evaluation projects on the redesign of health care delivery and payment systems. He is interested in population health management, health care payment and delivery system reform, and the social determinants of health. Over the years his research has been funded through grants and contracts from the Department of Defense, the Agency for Healthcare Research and Quality, the National Institutes of Health, the Centers for Medicare & Medicaid Services, the European Commission, and the Robert Wood Johnson Foundation, among others.
Dr. Pagán is Chair of the Board of Directors of NYC Health + Hospitals, the largest public healthcare system in the United States. He also served as Chair of the National Advisory Committee of the Robert Wood Johnson Foundation’s Health Policy Research Scholars and was a member of the Board of Directors of the Interdisciplinary Association for Population Health Science and the American Society of Health Economists.
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Areas of research and study
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Applied EconomicsHealth EconomicsPopulation HealthPublic Health Policy
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Publications
Publications
Leveraging the Food Environment in Obesity Prevention: the Promise of Systems Science and Agent-Based Modeling
AbstractLi, Y., Berenson, J., Gutiérrez, A., & Pagán, J. A. (n.d.).Publication year
2016Journal title
Current Nutrition ReportsVolume
5Issue
4Page(s)
245-254AbstractUnderstanding (and reshaping) the neighborhood food environment has emerged as an important pathway to change diet and reduce obesity risk. Dietary behaviors and the development of obesity are complex processes which feature interactions among multiple biological, behavioral, environmental, and cultural factors. Systems science, especially agent-based modeling, offers an effective approach to help identify the best strategies to leverage the food environment in ways that can improve dietary behaviors and prevent obesity. With support from existing literature, this study presents a conceptual framework that describes the pathways through which food environment influences dietary behaviors and obesity. The paper articulates the rationale for using systems science to understand the dynamics and interactions of food environment, dietary behaviors, and obesity. Two specific agent-based models depicting the food environment are presented to demonstrate the promise of systems science to inform the design and implementation of public health interventions and policies for improving dietary behaviors and preventing obesity.Patient-Centered Medical Home Features and Health Care Expenditures of Medicare Beneficiaries with Chronic Disease Dyads
AbstractPhilpot, L. M., Stockbridge, E. L., Padrón, N. A., & Pagán, J. A. (n.d.).Publication year
2016Journal title
Population Health ManagementVolume
19Issue
3Page(s)
206-211AbstractThree out of 4 Medicare beneficiaries have multiple chronic conditions, and managing the care of this growing population can be complex and costly because of care coordination challenges. This study assesses how different elements of the patient-centered medical home (PCMH) model may impact the health care expenditures of Medicare beneficiaries with the most prevalent chronic disease dyads (ie, co-occurring high cholesterol and high blood pressure, high cholesterol and heart disease, high cholesterol and diabetes, high cholesterol and arthritis, heart disease and high blood pressure). Data from the 2007-2011 Medical Expenditure Panel Survey suggest that increased access to PCMH features may differentially impact the distribution of health care expenditures across health care service categories depending on the combination of chronic conditions experienced by each beneficiary. For example, having no difficulty contacting a provider after regular hours was associated with significantly lower outpatient expenditures for beneficiaries with high cholesterol and diabetes (n = 635; P = 0.038), but it was associated with significantly higher inpatient expenditures for beneficiaries with high blood pressure and high cholesterol (n = 1599; P = 0.015), and no significant differences in expenditures in any category for beneficiaries with high blood pressure and heart disease (n = 1018; P > 0.05 for all categories). However, average total health care expenditures are largely unaffected by implementing the PCMH features considered. Understanding how the needs of Medicare beneficiaries with multiple chronic conditions can be met through the adoption of the PCMH model is important not only to be able to provide high-quality care but also to control costs.Social Norms and the Consumption of Fruits and Vegetables across New York City Neighborhoods
AbstractLi, Y., Zhang, D., & Pagán, J. A. (n.d.).Publication year
2016Journal title
Journal of Urban HealthVolume
93Issue
2Page(s)
244-255AbstractConsumption of fruits and vegetables is associated with a lower risk of developing many chronic health conditions such as diabetes and cardiovascular disease. While five or more servings of fruits and vegetables per day are recommended, only 50 % of New York City (NYC) residents consume two or more servings per day. In addition, there is wide variation in dietary behaviors across different neighborhoods in NYC. Using a validated agent-based model and data from 34 NYC neighborhoods, we simulate how a mass media and nutrition education campaign strengthening positive social norms about food consumption may potentially increase the proportion of the population who consume two or more servings of fruits and vegetables per day in NYC. We found that the proposed intervention results in substantial increases in daily fruit and vegetable consumption, but the campaign may be less effective in neighborhoods with relatively low education levels or a relatively high proportion of male residents. A well-designed, validated agent-based model has the potential to provide insights on the impact of an intervention targeting social norms before it is implemented and shed light on the important neighborhood factors that may affect the efficacy of the intervention.Advancing the use of evidence-based decision-making in local health departments with systems science methodologies
AbstractLi, Y., Kong, N., Lawley, M., Weiss, L., & PagÁn, J. A. (n.d.).Publication year
2015Journal title
American journal of public healthVolume
105Page(s)
S217-S222AbstractObjectives: We assessed how systems science methodologies might be used to bridge resource gaps at local health departments (LHDs) so that they might better implement evidence-based decision-making (EBDM) to address population health challenges. Methods: We used the New York Academy of Medicine Cardiovascular Health Simulation Model to evaluate the results of a hypothetical program that would reduce the proportion of people smoking, eating fewer than 5 fruits and vegetables per day, being physically active less than 150 minutes per week, and who had a body mass index (BMI) of 25 kg/m2 or greater. We used survey data from the Behavioral Risk Factor Surveillance System to evaluate health outcomes and validate simulation results. Results: Smoking rates and the proportion of the population with a BMI of 25 kg/m2 or greater would have decreased significantly with implementation of the hypothetical program (P < .001). Two areas would have experienced a statistically significant reduction in the local population with diabetes between 2007 and 2027 (P < .05). Conclusions: The use of systems science methodologies might be a novel and efficient way to systematically address a number of EBDM adoption barriers at LHDs.Chronic pain and health care spending: An analysis of longitudinal data from the medical expenditure panel survey
AbstractStockbridge, E. L., Suzuki, S., & Pagán, J. A. (n.d.).Publication year
2015Journal title
Health Services ResearchVolume
50Issue
3Page(s)
847-870AbstractObjective To estimate average incremental health care expenditures associated with chronic pain by health care service category, expanding on prior research that focused on specific pain conditions instead of general pain, excluded low levels of pain, or did not incorporate pain duration. Data Source Medical Expenditure Panel Survey (MEPS) data (2008-2011; N = 26,671). Study Design Differences in annual expenditures for adults at different levels of pain that interferes with normal work, as measured by the SF-12, were estimated using recycled predictions from two-part logit-generalized linear regression models. Principal Findings "A little bit" of chronic pain-related interference was associated with a $2,498 increase in total adjusted expenditures over no pain interference (p <.0001) and a $1,008 increase over nonchronic pain interference (p =.0001). Moderate and severe chronic pain-related interference was associated with a $3,707 and $5,804 increase in expenditures over no pain interference and a $2,218 and $4,315 increase over nonchronic interference, respectively (p <.0001). Expenditure increases were most pronounced for inpatient and hospital outpatient expenditures compared to other types of health care expenditures. Conclusions Chronic pain limitations are associated with higher health care expenditures. Results underscore the substantial cost of pain to the health care system.Cost-Effectiveness Analysis of a Colonoscopy Screening Navigator Program Designed for Hispanic Men
A news media analysis of the economic and reputational penalties of the hospital readmissions reduction program
Alliance for a healthy border
Correlation between Cocaine Prices and Purity with Trends in Emergency Department Visits in a Major Metropolitan Area
AbstractZhu, H., Wilson, F. A., Stimpson, J. P., & Pagán, J. A. (n.d.).Publication year
2014Journal title
Journal of Urban HealthVolume
91Issue
5Page(s)
1009-1018AbstractIllicit drug use not only causes acute and chronic adverse health outcomes but also results in a significant burden to health care providers. The objective of this study is to examine the relationship between cocaine prices and purity with emergency department (ED) visits for the Chicago-Naperville-Joliet metropolitan area. Our primary outcome was number of cocaine-related ED visits per quarter provided by the Drug Abuse Warning Network. The predictor variables of cocaine purity and price were provided by the System to Retrieve Information from Drug Evidence database. Autoregressive integrated moving average (ARIMA) regressions were used to estimate the effects of cocaine price and purity on cocaine-related ED visits. Although cocaine prices did not change substantially over time, cocaine purity decreased by over 30 % between 2006 and 2010. ARIMA regression results suggest that cocaine-related ED visits were not significantly associated with powder or crack cocaine prices; however, a decrease in powder cocaine purity was associated with 2,081 fewer ED visits overall from 2007 to 2010. The cocaine trade continues to be a major public health and law enforcement threat to large metropolitan cities like Chicago. Regular monitoring of cocaine purity levels may provide early warning of impending changes in cocaine-related ED visits for law enforcement and health care providers.Fatal crashes from drivers testing positive for drugs in the U.S., 1993-2010
AbstractWilson, F. A., Stimpson, J. P., & Pagán, J. A. (n.d.).Publication year
2014Journal title
Public Health ReportsVolume
129Issue
4Page(s)
342-350AbstractObjective. Illegal drug use is a persistent problem, prescription drug abuse is on the rise, and there is clinical evidence that drug use reduces driving performance. This study describes trends in characteristics of drivers involved in fatal motor vehicle crashes who test positive for drugs. Methods. We used the Fatality Analysis Reporting System-a census of motor vehicle crashes resulting in at least one fatality on U.S. public roads-to investigate suspected drug use for the period 1993-2010. Results. Drugged drivers who were tested for drug use accounted for 11.4% of all drivers involved in fatal motor vehicle crashes in 2010. Drugged drivers are increasingly likely to be older drivers, and the percentage using multiple drugs increased from 32.6% in 1993 to 45.8% in 2010. About half (52.4%) of all drugged drivers used alcohol, but nearly three-quarters of drivers testing positive for cocaine also used alcohol. Prescription drugs accounted for the highest fraction of drugs used by drugged drivers in fatal crashes in 2010 (46.5%), with much of the increase in prevalence occurring since the mid-2000s. Conclusions. The profile of a drugged driver has changed substantially over time. An increasing share of these drivers is now testing positive for prescription drugs, cannabis, and multiple drugs. These findings have implications for developing interventions to address the changing nature of drug use among drivers in the U.S.Patient-centered medical home features and expenditures by medicare beneficiaries
AbstractStockbridge, E. L., Philpot, L. M., & Paǵan, J. A. (n.d.).Publication year
2014Journal title
American Journal of Managed CareVolume
20Issue
5Page(s)
379-385AbstractObjectives: To determine the impact of individual features of the patientcentered medical home (PCMH) care model on next-year healthcare expenditures including outpatient, inpatient, emergency department, pharmacy, and total healthcare expenditures among Medicare beneficiaries 65 years and older. Study Design: Analysis of retrospective longitudinal survey data. Methods Longitudinal files from the Medical Expenditure Panel Survey were analyzed. Differences in expenditures for individuals whose usual sources of care did or did not have different PCMH features were estimated using recycled predictions from generalized linear regression models. Results: Having little to no difficulty contacting the regular source of care over the telephone during regular business hours was associated with significantly lower total and inpatient expenditures over the next year (differences of $2867 and $3736, respectively). Having a regular source of care with office hours at night or on weekends was associated with significantly lower outpatient, emergency department, and other expenditures (differences of $535, $103, and $328, respectively). Pharmacy expenditures were significantly higher for individuals whose usual source of care inquired about medications and treatments prescribed by other doctors (difference of $362). Conclusions: This study points out the need to identify how individual PCMH features impact healthcare expenditures across different policy-relevant categories. Practices that have not fully adopted a PCMH model can still make progress in improving quality and controlling costs by adopting even some modest features of the PCMH model.Psychological distress and emergency department utilization in the United states: Evidence from the medical expenditure panel survey
AbstractStockbridge, E. L., Wilson, F. A., & Pagán, J. A. (n.d.).Publication year
2014Journal title
Academic Emergency MedicineVolume
21Issue
5Page(s)
510-519AbstractObjectives Psychological distress not only has substantial health and social consequences, but is also associated with emergency department (ED) use. Previous studies have typically used cross-sectional data to focus on the relation between serious psychological distress and dichotomized ED utilization measures, without assessing the volume of ED use or examining nonserious levels of psychological distress. The objective of this study was to explore the association between ED utilization volume and the full spectrum of psychological distress. Methods Data from Panel 14 of the Medical Expenditure Panel Survey (MEPS; 2009-2010, n = 9,743) provided a nationally representative sample of U.S. individuals. ED utilization volume and three specifications of the Kessler Psychological Distress Scale (K6) were analyzed: a dichotomous serious/no serious psychological distress measure, a five-category ordinal measure, and a scale measure with a range of 0 to 24. Negative binomial-logit hurdle regression models were used to analyze how the different specifications of the K6 psychological distress measure were related to ED use. Results Adults with serious psychological distress in 2009 had 1.59 (95% confidence interval [CI] = 1.15 to 2.20) times greater adjusted odds of having one or more ED visits in 2010 than those without serious psychological distress. Nonserious psychological distress levels in 2009 were also associated with increased adjusted odds of having at least one ED visit in 2010. The K6 scores showed a dose-response relationship in terms of the adjusted odds of having one or more ED visits. The adjusted odds ratios (ORs) were 1.86 (95% CI = 1.37 to 2.54) for adults with K6 scores at or above 11, OR 1.76 (95% CI = 1.38 to 2.25) for adults with K6 scores between 6 and 10, OR 1.33 (95% CI = 1.05 to 1.68) for adults with K6 scores between 3 and 5, and OR 1.17 (95% CI = 0.92 to 1.48) for adults with K6 scores of 1 or 2. In addition, the adjusted odds of having one or more ED visits in 2010 significantly increased with increasing psychological distress in 2009 (OR = 1.04, 95% CI = 1.03 to 1.06). Each additional point added to the K6 scale results in an increase in the adjusted odds of an ED visit. Conclusions Even a low level of psychological distress, and not just serious psychological distress, may be an early indicator of future ED use. These results highlight the need to develop novel responses to better manage or avert ED use not only for adults with serious psychological distress but also for those who are experiencing even mild symptoms of psychological distress.Share of Mass Transit Miles Traveled and Reduced Motor Vehicle Fatalities in Major Cities of the United States
The community diabetes education (CoDE) program: Cost-effectiveness and health outcomes
AbstractPrezio, E. A., Pagán, J. A., Shuval, K., & Culica, D. (n.d.).Publication year
2014Journal title
American journal of preventive medicineVolume
47Issue
6Page(s)
771-779AbstractConclusions A simulated clinical trial suggests that a community health worker-led diabetes intervention is a cost-effective way to reduce diabetes-related complications for uninsured Mexican Americans during a 20-year horizon in comparison to usual medical care.Background Limited evidence exists regarding the long-term effects of community health worker-led diabetes management programs on health outcomes and cost-effectiveness, particularly in low-income, ethnic minority populations.Purpose To examine the long-term cost-effectiveness and improvements in diabetes-related complications of a diabetes education and management intervention led by community health workers among uninsured Mexican Americans.Methods Clinical data, changes in hemoglobin A1c over 12 months, and costs from an RCT of 180 uninsured Mexican Americans with type 2 diabetes conducted in 2006 were utilized for secondary analyses in 2012. Simulation modeling was used to estimate long-term cost and health outcomes using the validated Archimedes Model. The absolute differences for the incremental cost-effectiveness ratios and cumulative incidence of diabetes-related complications were derived by comparing intervention and control groups.Results During a 20-year time horizon, participants who received the intervention would be expected to have significantly lower hemoglobin A1c levels (p<0.001), fewer foot ulcers (p<0.001), and a reduced number of foot amputations (p=0.005) in comparison with a control group receiving usual medical care. An incremental cost-effectiveness ratio of $355 per quality-adjusted life year gained was estimated for intervention participants during the same time period.Uninsurance, underinsurance, and health care utilization in Mexico by US border residents
AbstractSu, D., Pratt, W., Stimpson, J. P., Wong, R., & Pagán, J. A. (n.d.).Publication year
2014Journal title
Journal of Immigrant and Minority HealthVolume
16Issue
4Page(s)
607-612AbstractUsing data from the 2008 Cross-Border Utilization of Health Care Survey, we examined the relationship between United States (US) health insurance coverage plans and the use of health care services in Mexico by US residents of the US-Mexico border region. We found immigrants were far more likely to be uninsured than their native-born counterparts (63 vs. 27.8 %). Adults without health insurance coverage were more likely to purchase medications or visit physicians in Mexico compared to insured adults. However, adults with Medicaid coverage were more likely to visit dentists in Mexico compared to uninsured adults. Improving health care access for US residents in the southwestern border region of the country will require initiatives that target not only providing coverage to the large uninsured population but also improving access to health care services for the large underinsured population.Using systems science for population health management in primary care
AbstractLi, Y., Kong, N., Lawley, M. A., & Pagán, J. A. (n.d.).Publication year
2014Journal title
Journal of Primary Care and Community HealthVolume
5Issue
4Page(s)
242-246AbstractObjectives: Population health management is becoming increasingly important to organizations managing and providing primary care services given ongoing changes in health care delivery and payment systems. The objective of this study is to show how systems science methodologies could be incorporated into population health management to compare different interventions and improve health outcomes. Methods: The New York Academy of Medicine Cardiovascular Health Simulation model (an agent-based model) and data from the Behavioral Risk Factor Surveillance System were used to evaluate a lifestyle program that could be implemented in primary care practice settings. The program targeted Medicare-age adults and focused on improving diet and exercise and reducing weight. Results: The simulation results suggest that there would be significant reductions projected in the proportion of the Medicare-age population with diabetes after the implementation of the proposed lifestyle program for a relatively long term (3 and 5 years). Similar results were found for the subpopulations with high cholesterol, but the proposed intervention would not have a significant effect in the proportion of the population with hypertension over a time period of <5 years. Conclusions: Systems science methodologies can be useful to compare the health outcomes of different interventions. These tools can become an important component of population health management because they can help managers and other decision makers evaluate alternative programs in primary care settings.Assessing long-term health and cost outcomes of patient-centered medical homes serving adults with poor diabetes control
Health insurance coverage, income distribution and healthcare quality in local healthcare markets
AbstractDamianov, D. S., & Pagán, J. A. (n.d.).Publication year
2013Journal title
Health Economics (United Kingdom)Volume
22Issue
8Page(s)
987-1002AbstractWe develop a theoretical model of a local healthcare system in which consumers, health insurance companies, and healthcare providers interact with each other in markets for health insurance and healthcare services. When income and health status are heterogeneous, and healthcare quality is associated with fixed costs, the market equilibrium level of healthcare quality will be underprovided. Thus, healthcare reform provisions and proposals to cover the uninsured can be interpreted as an attempt to correct this market failure. We illustrate with a numerical example that if consumers at the local level clearly understand the linkages between health insurance coverage and the quality of local healthcare services, health insurance coverage proposals are more likely to enjoy public support.Rural-Urban Differences in Health Services Utilization in the US-Mexico Border Region
Alliance for a healthy border: Factors related to weight reduction and glycemic success
AbstractWang, X., Ghaddar, S., Brown, C., Pagán, J. A., & Balboa, M. (n.d.).Publication year
2012Journal title
Population Health ManagementVolume
15Issue
2Page(s)
90-100AbstractWe examined the factors related to success in achieving weight reduction and glycemic control in Alliance for a Healthy Border (AHB), a chronic disease prevention program implemented from 2006 to 2009 through 12 federally qualified community health centers serving primarily Hispanics in communities located along the US-Mexico border region. We analyzed data from Phase I of AHB using logistic regression to examine the determinants of success in achieving weight reduction and glycemic control among the participants in AHB programs. Factors affecting weight reduction success were sex, age, employment status, income, insurance, diabetes, baseline body mass index (BMI), smoking status, family history of diabetes, session type, program duration, and physical activity changes. Factors affecting achievement of glycemic success included sex, age, employment status, diabetes, baseline BMI, family history of diabetes, program duration, and physical activity changes. We found that the AHB interventions were more successful in reducing participants' HbA1c level than BMI. In addition to sociodemographic factors, participants with better baseline health conditions (ie, participants without diabetes or family history of diabetes, normal BMI, former smokers) were more likely to achieve success after the interventions. Of the 4 key features defining each of the 12 interventions, session type and program duration were associated with success. Within a relatively short time period, physical activity improvements had a stronger effect on weight reduction and glycemic success than improvements in dietary habits. The effectiveness of diabetes and cardiovascular disease prevention programs can be improved substantially by considering these factors during program design and structure.Breast cancer genetic testing awareness, attitudes and intentions of Latinas living along the US-Mexico border: a qualitative study
Cost-effectiveness analysis of a community health worker intervention for low-income hispanic adults with diabetes
AbstractShelton Brown, H., Wilson, K. J., Pagán, J. A., Arcari, C. M., Martinez, M., Smith, K., & Reininger, B. (n.d.).Publication year
2012Journal title
Preventing Chronic DiseaseVolume
9Issue
8AbstractIntroduction: The objective of our study was to estimate the long-term cost-effectiveness of a lifestyle modification program led by community health workers (CHWs) for low-income Hispanic adults with type 2 diabetes. Methods: We forecasted disease outcomes, quality-adjusted life years (QALYs) gained, and lifetime costs associated with attaining different hemoglobin A1c (A1c) levels. Outcomes were projected 20 years into the future and discounted at a 3.0% rate. Sensitivity analyses were conducted to assess the extent to which our results were dependent on assumptions related to program effectiveness, projected years, discount rates, and costs. Results: The incremental cost-effectiveness ratio of the intervention ranged from $10,995 to $33,319 per QALY gained when compared with usual care. The intervention was particularly cost-effective for adults with high glycemic levels (A1c > 9%). The results are robust to changes in multiple parameters. Conclusion: The CHW program was cost-effective. This study adds to the evidence that culturally sensitive lifestyle modification programs to control diabetes can be a cost-effective way to improve health among Hispanics with diabetes, particularly among those with high A1c levels.Health literacy and breast cancer screening among Mexican American women in South Texas
Housing strain, mortgage foreclosure, and health
AbstractCannuscio, C. C., Alley, D. E., Pagán, J. A., Soldo, B., Krasny, S., Shardell, M., Asch, D. A., & Lipman, T. H. (n.d.).Publication year
2012Journal title
Nursing outlookVolume
60Issue
3Page(s)
134-142.e1AbstractBackground: Foreclosure rates have risen rapidly since 2005, reaching historically high levels. The purpose of this study was to examine the health implications of the current housing crisis. Methods: We conducted a cross-sectional online consumer panel survey including residents of California, Arizona, Nevada, and Florida (n = 798) to determine the feasibility of contacting distressed homeowners via the Internet and to assess mental and physical health among respondents across the spectrum from those having no housing strain to those in loan default or home foreclosure. Results: Homeowners in default or foreclosure exhibited poorer mental health and more physical symptoms than renters, homeowners with moderate strain, and homeowners with no strainöfollowing a gradient that was consistent across multiple health indicators. Conclusions: Internet panel sampling was an efficient method of contacting distressed homeowners. Record-high foreclosure rates may have broad implications for nursing and public health. Homeowners in default or foreclosure represent an identifiable high-risk group that may benefit from coordinated, affordable health and social services.Income inequality and obesity prevalence among oecd countries