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Consolidating patient and clinical data to support better-informed clinical decisions remains a primary function of electronic health records (EHRs). In the United States, nearly 6 million patients receive care from an accountable care organization (ACO). Knowledge of clinical decision support (CDS) tool design for use by physicians participating in ACOs remains limited. The purpose of this quantitative study was to examine whether a significant correlation exists between characteristics of alert content and alert timing (the independent variables) and physician perceptions of improved ACO quality measure adherence during electronic ordering (the dependent variable). Sociotechnical theory supported the theoretical framework for this research. Sixty-nine physician executives using either a Cerner Incorporated or Epic Systems EHR in a hospital or health system affiliated ACO participated in the online survey. The results of the regression analysis were statistically significant, R2 = .108, F(2,66) = 3.99, p = .023, indicating that characteristics of alert content and timing affect physician perceptions for improving their adherence to ACO quality measures. However, analysis of each independent variable showed alert content highly correlated with the dependent variable (p = .007) with no significant correlation found between workflow timing and the dependent variable (p = .724). Understanding the factors that support physician acceptance of alerts is essential to third-party software developers and health care organizations designing CDS tools. Providing physicians with improved EHR-integrated CDS tools supports the population health goal of ACOs in delivering better patient care.

The Patient Protection and Affordable Care Act (PPACA) represents one of the most significant pieces of legislation in the history of United States healthcare. The PPACA has two main goals: to increase the insured patient population in the US and to reduce the overall cost while improving the quality of healthcare in the US. To accomplish the latter goal, healthcare providers are experiencing a movement toward integrated, team-oriented models that place increasing accountability on the providers and institutions. At the same time, these integrative models emphasize effective preventive care, which is critical in reducing the country’s overall healthcare costs. As more health care institutions and providers across the country adopt the healthcare reform models of the Patient-Centered Medical Homes (PCMH) and Accountable Care Organizations (ACOs) directly under the PPACA, the demand for pharmacists is increasing. In addition, the role of the pharmacist through Medication Therapy Management (MTM) is growing as more public and private sectors adopt MTM and its standards are being used as the medication-related cornerstone for the ACOs. There is a call for lower costs and higher quality outcomes in healthcare, and the pharmacists are increasingly integrated into direct patient care and medication management. The newly integrated responsibilities of the pharmacist are numerous and almost limitless. The roleof pharmacists is expanding, and as many studies suggest, their contributions produce auspicious results.

Health policy makers are struggling to manage health care and spending. To identify strategies for improving health quality and reducing health spending, policy makers need to first understand health risks and outcomes. Despite lacking some desirable clinical detail, existing health care databases, such as national health surveys and claims and enrollment data for insured populations, are often rich in information relating patient characteristics to heath risks and outcomes. They typically encompass more inclusive populations than can feasibly be achieved with new data collection and are valuable resources for informing health policy. This dissertation illustrates how the Medicare Current Beneficiary Survey (MCBS) and MassHealth data can be used to develop models that provide useful estimates of risks and health quality measures. It provides insights into: 1) the benefits of a proxy for the Framingham cardiovascular disease (CVD) risk score, that relies only on variables available in the MCBS, to target health interventions to policy-relevant subgroups, such as elderly Medicare beneficiaries, based on their risk of developing CVD, 2) the importance of setting appropriate risk-adjusted quality of care standards for accountable care organizations (ACOs) based on the characteristics of their enrolled members, and 3) the outsized effect of high- frequency hospital users on re-admission measures and possibly other quality measures. This work develops tools that can be used to identify and support care of vulnerable patients to both improve their health outcomes and reduce spending – an important step on the road to health equity.

Background: While value-based payment models emphasizing care coordination have been widely implemented to improve quality and lower expenditures, supporting empirical evidence is sparse. Our objective was to quantify the impact of specialist-to-primary care physician involvement within accountable care organization (ACO) and its association with lower spending. Methods: We conducted a retrospective cohort study of Medicare Shared Savings Program ACOs from 2012-2016 using publicly available data provided by the Centers for Medicare and Medicaid Services at the ACO level. We examined the association between the proportion of primary care services delivered by specialists versus other types of care providers and ACO spending using a generalized estimating equation model. Results: The analytic dataset included 1381 MSSP-years. When compared to ACOs at the lowest (60) levels of providing primary care services through specialists, ACOs who had 35% to 40% of primary care services delivered by specialists spent $1,124 (95% CI, $358 to $1,891) and $969 (95% CI, $250 to $1,688) less per capita, respectively. When stratified at varying levels of specialists providing primary care services, having four years of experience in the Medicare Shared Savings Program was consistently associated with lower spending when compared to having one to three years of experience. Conclusions and Relevance: The optimal portion of specialists providing primary care services - to reduce spending - was found to be 35% to 40%. These findings suggest that integrating specialists in to the activities and objectives of MSSP ACOs could lead to lower spending and better performance.

<div>This dissertation consists of three chapters. The first chapter, Inertia and Switching in Health Insurance Plans, seeks to examine health insurance choice of families and individuals employed by a large Midwestern public university during the years 2012-2016. A growing number of studies indicate that consumers do not understand the basics of health insurance, make inefficient plan choices, and may hesitate to switch plans even when it is optimal to do so. In this study, I identify what are later defined as unanticipated, exogenous health shocks in the health insurance claims data, in order to examine their effect on families' plan choice and switching behavior. Observing switches into relatively generous plans after a shock is indicative of adverse selection. Adverse retention and inertia, on the other hand, may be present if people remain in the relatively less generous plans after experiencing a shock. The results could help inform the policy-makers about consumer cost-effectiveness in plan choice over time.</div><div> Physicians’ relationships with the pharmaceutical industry have recently come under public scrutiny, particularly in the context of opioid drug prescribing. The second chapter, Pharmaceutical Opioid Marketing and Physician Prescribing Behavior, examines the effect of doctor-industry marketing interactions on subsequent prescribing patterns of opioids using linked Medicare Part D and Open Payments data for the years 2014-2017. Results indicate that both the number and the dollar value of marketing visits increase physicians’ patented opioid claims. Furthermore, direct-to-physician marketing of safer abuse-deterrent formulations of opioids is the primary driver of positive and persistent spillovers on the prescribing of less safe generic opioids - a result that may be driven by insurance coverage policies. These findings suggest that pharmaceutical marketing efforts may have unintended public health implications.</div><div> The third chapter, Accountable Care Organizations and Physician Antibiotic Prescribing Behavior, examines the effects of Accountable Care Organizations (ACOs). Physician accountable care organization affiliation has been found to reduce cost and improve quality across metrics that are directly measured by the ACO shared savings program. However, little is known about potential spillover effects from this program onto non-measured physician behavior such as antibiotic over-prescribing. Using a two-part structural selection model that accounts for selection into treatment (ACO group), and non-treatment (control group), this chapter compares physician/nurse antibiotic prescribing across these groups with adjustment for geographic, physician, patient and institutional characteristics. Heterogeneous treatment responses across specialties are also estimated. The findings indicate that ACO affiliation helps reduce antibiotic prescribing by 23.9 prescriptions (about 19.4 percent) per year. The treatment effects are found to vary with specialty with internal medicine physicians experiencing an average decrease of 19 percent, family and general practice physicians a decrease of 16 percent, and nurse practitioners a reduction of 12.5 percent in their antibiotic prescribing per year. In terms of selection into treatment, the failure to account for selection on physician unobservable characteristics results in an understating of the average treatment effects. In assessing the impact of programs, such as the ACO Shared Savings Program, which act to augment how physicians interact with each other and their patients, it is important to account for spillover effects. As an example of such spillover effect - this study finds that ACO affiliation has had a measurable impact on physician antibiotic prescribing.</div>