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Financial incentives offered by payers to health care providers and patients have been identified as a key mechanism to lower costs while improving quality of care. How to effectively design incentive programs that can align the varying objectives of health care stakeholders, as well as predict programs' performance and stakeholders' decision response is an unresolved research challenge. The objective of this study is to establish a novel approach based on multiscale decision theory (MSDT) that can effectively model and efficiently analyze such incentive programs, and the complex health care system in general. The MSDT model captures the interdependencies of stakeholders, their decision processes, uncertainties, and how incentives impact decisions and outcomes at the payer, hospital, physician, and patient level. In the first part of this thesis, we study the decision processes of agents pertaining to the investment and utilization of imaging technologies. We analyze the payer-hospital-physician relationships and later extend the model to include radiologist and patient as major stakeholders in the second part of this thesis. We focus on a specific incentive program, the Medicare Shared Savings Program (MSSP) for Accountable Care Organizations (ACOs). The multi-level interactions between agents are mathematically formulated as a sequential non-cooperative game. We derive the equilibrium solutions using the subgame perfect Nash equilibrium (SPNE) concept and the backward induction principle, and determine the conditions under which the MSSP incentive leads to the desired outcomes of cost reduction and quality of care improvements. In the third part of this thesis, we study the multi-level decision making in chronic disease management. We model and analyze patients' and physicians' decision processes as a general-sum stochastic game with perfect information and switching control structure. We incorporate the Health Belief Model (HBM) as the theoretical foundation to capture the behavioral aspect of agents. We analyze how incentives and interdependencies affect patients' engagement in health-promoting activities and physicians' delivery of primary care services. We show that a re-alignment of incentives can improve the effectiveness of chronic disease management. / Ph. D.

Five areas of hospital foodservice management, including; Inpatient Services, Cafeteria Services, Special Foodservices, Out-of-Hospital Services and Consolidation of Services, were studied to determine the impact of the 1983 Medicare Prospective Payment System. Ten Kentucky hospital foodservice directors were surveyed by phone. The Prospective Payment System had an impact on all areas of foodservice management, especially in the Inpatient Services. Foodservice directors developed cost containment and revenue generating programs in response to the DRG's. Note: The author has requested that her vita be removed from this Electronic Theses and Dissertation. / Master of Science

This dissertation aims to explore the performance of health provider participation inthe Medicare Quality Payment Program by investigating the relationship among the performance metrics of value and quality and the capacities of geography, technology, finance, and administration. There is a theory-practice gap in the research that examines the impact of these capacities on the value and quality of clinical services delivered by healthcare providers participating in the Medicare Quality Payment Program. The study will address this theory-practice gap by applying the capacity-performance paradigm to better understand the influences of geographical, technological, financial, and administrative capacity have on the performance of value and quality metrics of healthcare providers engaging in the Medicare Quality Payment Program. This study also provides prudent findings that demonstrate the impact of the capacities on the performance of value and quality among healthcare providers which can influence programmatic policy reforms by policymakers who are overseeing the Quality Payment Program. This study utilizes the CMS 2021 QPP Experience dataset which contains the performance outcome metrics of value and quality among healthcare providers participating in the program. Ordinary Least Squares (OLS) regression is employed to examine the relationship among the capacities of geography, technology, finance, and administration and the performance providers. The findings of this study show a significant relationship between these capacities and the performance outcome metrics of value and quality among healthcare providers participating in the Medicare Quality Payment Program.

Medasolution is a virtual company designed by the author to handle Medicare insurance business. The web application (which uses ASP.net and SQL Server 2000) facilitates communication between Medasolution and all its clients: members, employers, brokers, and medicare providers through separate web pages based on their category levels. The program incorporates security so that it follows government privacy rules regarding client information.

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Musculoskeletal complaints are one of the most common reasons for visits to medical and chiropractic professionals in the United States, and spine-related symptoms in particular comprise the largest share of these complaints. Spine-related conditions increase as people age, having implications for rising disability and consequent spending by Medicare and Medicaid on increased health services use and long-term services and support. Chiropractic is one type of treatment used by older adults with these types of health problems. Covered by Medicare since 1972, chiropractic spinal manipulation is allowed for the express purpose to arrest the progression of functional decline or restore and possibly improve patient function. No studies, however, have examined whether chiropractic use by Medicare beneficiaries has indeed arrested functional decline, delayed disability, or restored health. The purpose of this dissertation research is to examine the comparative effectiveness of chiropractic use relative to no treatment and alternative medical care on the health and functional trajectories of community-dwelling older adults. I also examine the comparative effect of chiropractic on satisfaction with care. This is accomplished through the use of two longitudinal surveys with representative Medicare populations linked to Medicare provider claims. The first analysis examines the long-term comparative effect of chiropractic relative to no use and alternative care on functional decline, self-rated health decline, and the onset of additional depressive symptoms in a cohort of older Medicare beneficiaries, both with and without back conditions. The second study examines the effect of chiropractic compared to medical only episodes of care on health and functional decline in an older adult population with uncomplicated back conditions over a two-year period. The third and final study examines the comparative effect of chiropractic relative to medical care only on one-year changes in function, self-rated health, and satisfaction with care in a nationally representative age-eligible Medicare population with spine-related musculoskeletal conditions. Study results suggest that chiropractic has a consistently protective effect when compared to routine alternative medical care against decline in function among older adults with spine-related conditions, both over the long-term and the short-term. Chiropractic also has a comparative protective effect against decline in self-rated health in the short-term, but has no differential effect on the onset of depressive symptoms either in the short-term or long-term . Medicare beneficiaries using chiropractic for spine-related health conditions are relatively more satisfied than those using medical care only with the information provided to them about their condition, and with follow-up care provided after the initial visit. This research is the first of its kind to examine the comparative effectiveness of chiropractic relative to other usual sources of care for Medicare beneficiaries, in general and specifically among those with spine-related conditions, finding that chiropractic use has a comparatively beneficial effect on function, health, and satisfaction with care. The results have important policy implications for clinicians, patients, and Medicare because of the potential to shift clinical practice away from technologically intense and expensive treatments toward therapies like chiropractic spinal manipulation that demonstrate a comparative advantage in preserving health and function among older adults.

Understanding how health care markets function is important not only because competition has a direct influence on the price and utilization of health care services, but also because the proper functioning, or lack thereof, of health care markets has a very real impact on patients who depend on health care markets and providers for their personal well-being. In this dissertation, I examine the role of government policies and regulation in health care markets, with a focus on the response of health care providers. In Chapter 1, I analyze the impact of Medicare payment rules on hospital ownership of physician practices. Since the mid-2000’s, there has been a rapid increase in hospital ownership of physician practices, however, there is little empirical research which addresses the causes of this recent wave of integration. Medicare’s “provider-based” billing policy allows hospital-owned physician practices to charge higher reimbursement rates for services provided compared to a freestanding, independent physician practice, without altering how or where services are provided. This “site-based” differential creates a premium for physicians to integrate with hospitals, and the size of this differential varies with the types of health care services provided. I find that Medicare payment rules have contributed to hospital ownership of physician practices and that the response varies across physician specialties. A 10 percent increase in the relative reimbursement rate paid to integrated physicians leads to a 1.9 percentage point increase in the probability of hospital ownership for Medical Care specialties, including cardiology, neurology, and dermatology, which explains about one-third of observed integration of these specialties from 2005 through 2015. Magnitudes for Surgical Care specialties are similar, but more sensitive across specifications. There is no significant response for Primary Care physicians. In combination with other empirical literature which finds that integration between physicians and hospitals typically results in higher prices with no impact on costs or quality of care, I cautiously interpret this responsiveness as evidence that Medicare’s provider-based billing policy overcompensates integrated physician practices and leads to an inefficiently high level of vertical integration between physician and hospitals. In Chapter 2, I analyze the effect of anti-fraud enforcement activity on Medicaid spending, with a particular focus on the False Claims Act. The False Claims Act (FCA) is a federal statute which protects the government from making undeserved payments to contractors and suppliers. Individual states have chosen to enact their own versions of the federal FCA, and these statutes have increasingly been used to target health care fraud. FCA statutes commonly include substantial monetary penalties such as “per-violation” monetary fines and tripled damages, as well as a “whistleblower” provision which allows private plaintiffs to initiate a lawsuit and collect a portion of recoveries as a reward. Using variation in statelevel FCA legislation, I find state FCAs reduce Medicaid prescription drug spending by 21 percent, while other spending categories - which are less lucrative for FCA lawsuits - are unresponsive. Within the prescription drug category, drugs prone to off-label use show larger declines in response to the whistleblower laws, consistent with FCA lawsuits being used to prosecute pharmaceutical manufacturers for off-label marketing and promotion. Spending and prescription volume for drugs prone to off-label use fall by up to 14 percent. This effect could be driven by pharmaceutical manufacturers’ changes in physician detailing for drugs prone to off-label use and/or physicians’ changes in prescribing behavior.

Elderly patients with chronic obstructive pulmonary disease may be at increased risk of exacerbation due to physical and cognitive deficits that make proper inhaled medication adherence more difficult despite consistent medication access. This retrospective study utilized administrative medical and pharmacy claims data to examine the likelihood of having a COPD exacerbation requiring acute medical care by means of an emergency room visit or hospitalization in elderly patients receiving maintenance COPD medications from mail order and retail pharmacies. It was hypothesized that mail order patients would be more likely to experience exacerbations despite differences in medication access when compared to retail patients. The primary outcome of interest was exacerbation frequency expressed as the incidence density rate, and the secondary outcome was the proportion of days covered (PDC). The incidence rate ratio for acute exacerbations was not significantly different for mail order and retail groups, indicating patients using mail-order pharmacies were not significantly more likely to experience an exacerbation requiring acute medical care. Despite insignificant differences in incidence rates, mail order patients had significantly higher adherence rates.