Thesis (M.H.A.)--University of Michigan, 1971.

Thesis (Ph. D.)--University of Chicago, Dept. of Economics, August 2002 / Includes bibliographical references. Also available on the Internet.

Dissertation (D.P.H.)--University of Michigan, 2004. / Includes bibliographical references.

There is some controversy which centers around the question of whether a particular government policy or program may be Judged successful. This dissertation takes the position, with due respect to the difficulties of such a task, that policy success can be evaluated and that it is important that such evaluations be made. Traditionally, health care in the United States has been delivered by the solo medical practitioner on a fee-for-service basis. A relatively new concept in the health care delivery system combines group practice with prepayment for services. These types of practices were designated as Health Maintenance Organizations in 1970 by the Nixon Administration.The major question of this dissertation is whether or not the HMO policy of the federal government has been a success. Along with this question the primary focus of this dissertation is upon the development and evolution of the federal HMO program.

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Introduction and Background: Burnout is a syndrome that many health professionals are experiencing. It involves a state of emotional and mental exhaustion and professional fatigue that can impact the personal lives of these individuals leading to anxiety, depression, and discontentment. The impact may go further in the healthcare setting and lead to a decrease in patient safety and diminished quality of care for patients. Purpose: The purpose of this literature review is to systematically and critically appraise current literature to examine the associations between nurse burnout rates and poor patient outcomes. Literature Review: A total of thirteen articles, one literature review, and one meta-analysis were included in this review. Databases that were used to obtain these articles included PubMed, ScienceDirect, Scopus, and CINAHL. Findings: The related factors that were associated with nurse burnout included a high-stress work environment, lack of support, emotional exhaustion, depersonalization, and inadequate staffing. In situations where the staff was experiencing high levels of burnout, there was a correlation with decreased patient and family satisfaction and an increase in adverse events such as medication errors and missed care. Conclusion: Due to the COVID-19 pandemic, articles published within the past years have consisted of data collection through questionnaires and online surveys to limit the transmission of the virus. This technique could have led to a bias gap within the literature collected considering the lack of validity questionnaires yield due to the collection of information without further explanation. Despite this limitation, the data results still exposed that the presence of burnout among health professionals is associated with worsening patient safety. High levels of burnout are related to external factors, such as high workload, long hours, and interpersonal relationships. Avoiding professional exhaustion is an important strategy for improving patient safety.

In today's health care environment tremendous efforts are being made by Health Maintenance Organizations (HMOs) to deliver appropriate patient care while controlling utilization of services and costs. One area of concern over the past two years has been the apparent over-utilization of spinal surgeries within a local Senior HMO. This HMO has no specific plan or physician guidelines for the management of low back pain. Utilization of spinal surgeries is measured in incidence of admissions per thousand members of the Senior HMO. Over the past two years the incidence of spinal surgeries per thousand has grown from 2.4 in 1995, 4.1 in 1996 and 7.4 during the first quarter of 1997. This is compared to a suggested rate of 1.5 per thousand for similar HMO populations around the country. The purpose of this study was to determine the effectiveness of the presentation of a treatment algorithm and physician guidelines for the management of low back pain (LBP). In order to determine the effectiveness of the presentation of the algorithm, the incidence of spinal surgeries per thousand for nine quarters prior to the presentation was compared to the incidence per thousand for the three quarters following the presentation. Results of this comparison showed a slight drop, but statistically insignificant (P = .62), in the rate of surgeries compared to the previous year. When compared to the previous two years the rate was actually slightly higher, but statistically insignificant (P = .57) after the presentation. Although the comparisons were determined to be insignificant, trend analysis indicated a gradual rise in the incidence during the initial five quarters, a plateau during the next four quarters, and a slight decrease in the rate of surgeries during the last three quarters which followed the introduction of the treatment algorithm. At this time it would be appropriate to continue the analysis of quarterly data and continue feedback and education to the primary care physicians in an attempt to promote proper utilization of spinal surgeries and overall management of LBP.

The utilization of ambulatory services by the health maintenance organization of Florida (HMO), independent practice association (IPA) model, was compared to a fee-for-service population. Each randomly selected group consisted of 250 patients being cared for by the same providers, at the same clinic, during the calendar year 1986. Demographic and clinical data was gathered from the office charts. Frequencies were evaluated by the Statistical Package for the Social Sciences and t-tests were run to substantiate variance at the 0.05 level of confidence. The HMO group is a younger population (t = 0.017), and the males are responsible for the increased utilization of ambulatory services (t = 0.001). Trends of increased utilization are noted across the age groups and the variables. The rate of hospitalization is insignificantly higher for the HMO population and covers a broader range of age groups. Consequently, this HMO IPA model increases the rate of ambulatory service utilization in a younger population without reducing the rate of hospitalization. Cost effectiveness studies and organizational management evaluations are needed.

This thesis examines several recent transformations in the United States health care system and their effects on the role of physicians. Technology, specialization, ancillary health care workers, for-profit hospitals and managed care corporations have all expanded throughout the health care industry. These changes have resulted in an increase in bureaucratic, capitalist and corporate influences over the system. As a result of the increasing costs of medical practice, the corporatization of health care is occurring in which physicians must not only rely on corporations for access to the capital that they need, but also relinquish some of their power to the corporations. McKinlay and Arches (1985) assert that these changes have led to the proletarianization of the physician. Health maintenance organizations (HMOs) and other forms of managed care companies continue to grow throughout the United States. Therefore, physicians, who have historically dominated the health care system, no longer have the autonomy that they once had. To measure physicians' attitudes toward these changes, The Managed Care in the New River Valley survey was conducted. The findings show that although managed care is not as strong as it is in other parts of the country, physicians still believe that their control of health care is declining. The importance of managed care companies and other third party influences will continue to increase in the future, as they further extend to areas such as the New River Valley. / Master of Science