<p>Despite the proven clinical benefits of use of adjuvant hormone therapy with tamoxifen or aromatase inhibitors for breast cancer, adherence to and persistence with adjuvant hormone therapy are suboptimal. It is critical to understand the clinical and economic impacts of low adherence to and low persistence with adjuvant hormone therapy in breast cancer. The overall objective was to assess associations between adherence to and persistence with adjuvant hormone therapy and mortality, healthcare utilization, and healthcare costs among older women with breast cancer. A retrospective longitudinal analysis of the Surveillance, Epidemiology, and End Results (SEER) registry linked with Medicare claims was conducted. This study included 25,796 older women diagnosed with hormone receptor-positive stage I-III breast cancer from 2009 through 2017. Adherence was defined as having proportion of days covered (PDC) of 0.80 or more. Persistence was defined as having no hormone therapy discontinuation, i.e., a break of at least 180 continuous days. Length of persistence was calculated as time from therapy initiation to discontinuation. All analyses were conducted using SAS 9.4 and RStudio for Linux environment. An <em>a priori</em> alpha level of 0.05 was used to determine significance for all the analyses. Time-dependent Cox models were used to assess associations between adherence to and persistence with adjuvant hormone therapy and mortality. Hurdle generalized linear mixed models were used to assess associations between adherence and persistence with annual number of hospitalizations, hospital days, hospital outpatient visits, inpatient costs, and outpatient costs across five years to account for excess zeroes.  Generalized linear mixed models were used for other types of healthcare utilization and costs. Annual adherence rates were 78.1 percent, 75.2 percent, 72.4 percent, 70.0 percent, and 61.5 percent from year-one to year-five after hormone therapy initiation. Persistence rates were 87.5 percent, 81.7 percent, 77.1 percent, 72.9 percent, and 68.9 percent through cumulative intervals of one year up to five years after hormone therapy initiation. Adherence was associated with lower risk of all-cause mortality, but was not significantly associated with breast cancer-specific mortality. Both being persistent and longer persistence were associated with lower risk of all-cause mortality and lower risk of breast cancer-specific mortality. Being adherent was associated with fewer hospitalizations, fewer hospital days, fewer emergency room visits, and fewer hospital outpatient visits, but was not associated with physician office visits. Being persistent was associated with fewer hospital days, fewer emergency room visits, and fewer hospital outpatient visits, but was associated with more physician office visits. Longer persistence was associated with fewer hospital days, fewer emergency room visits, and fewer hospital outpatient visits, but was not significantly associated with physician office visits. Adherent women had lower inpatient costs, lower outpatient costs, lower medical costs, and lower total healthcare costs despite higher prescription drug costs. Both being persistent and longer persistence were associated with lower inpatient costs, lower outpatient costs, lower medical costs, and lower total healthcare costs despite higher prescription drug costs. </p>

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.

Multiple chronic conditions (MCCs) are defined as two or more health conditions, each requiring treatment and limiting activities for a year or more. In the United States (US), MCCs are more common and costly than any individual chronic condition. The number of adults aged 65 years and older with MCCs is projected to nearly double between 2020 and 2050. Patients with MCCs often experience poor self-reported health and negative symptoms. In addition, they frequently visit emergency departments (EDs) and are hospitalized. Patients with MCCs need ongoing primary care services to manage their symptoms and prevent health deterioration. However, over 20% of the US population (many of whom have MCCs) resides in a primary care Health Professional Shortage Area (HPSA) and experiences poor access to primary care. The growing nurse practitioner (NP) workforce, which is projected to almost double in size between 2018 and 2030, can help meet the demand. Most NPs are trained to diagnose, treat, and manage chronic conditions and can provide a scope and quality of primary care comparable to physicians in many populations. Therefore, if distributed and supported strategically, the NP workforce can meet the complex care needs of patients with MCCs, especially in HPSAs. Maximizing the potential of the NP workforce to deliver MCC care will require enhanced care environments in the practices where NPs work, characterized by administrative support for NP care delivery and autonomous practice, collegial relationships between NPs and physicians, and NP professional visibility. On the other hand, poor NP care environments can negatively affect the quality of chronic disease care. Thus, improving the NP care environments within practices may increase the capacity of the NP workforce to care for MCC patients. Despite the potential of the NP workforce to meet the need for primary care among patients with MCCs, little is known about the impact of NP-delivered primary care models on outcomes in this population. Furthermore, the impact of HPSA status and NP care environments on NPs’ ability to care for patients with MCCs remains poorly understood. Thus, the overall purpose of this dissertation is to produce evidence on NP-delivered primary care models for patients with MCCs and examine the interplay between practice and community factors in shaping outcomes for these patients. In chapter 1, we introduce the unique healthcare needs of patients with MCCs, and the role of NPs in delivering and expanding access to care. In chapter 2, we synthesize the existing evidence on the effect of NP primary care models, compared to models without NP involvement, on cost, quality, and service utilization by patients with MCCs. Our synthesis suggests that NP-delivered primary care has similar or better impacts on outcomes among patients with MCCs compared to care delivered without NP involvement. In chapter 3, we perform secondary data analysis using multiple linked data sources including 1) patient data from the Medicare claims of 394,424 older adults with MCCs, 2) NP survey data on practice characteristics from 880 NPs at 779 primary care practices across five US states, and 3) data on HPSA status of the practice locations from the Health Resources and Services Administration. We examine differences in hospitalization and ED use among patients who receive care from NP practices in HPSAs compared to those in non-HPSAs. We find a higher likelihood of ED use among patients receiving care in NP practices located in HPSAs compared to practices in non-HPSAs, and no difference in the likelihood of being hospitalized. Our results suggest that relieving provider shortages may reduce ED use by MCC patients in HPSA practices that employ NPs, but may be insufficient to lower hospitalization rates unless combined with other interventions. Finally, in chapter 4, we analyze the same linked secondary data source as in chapter 3 to examine the effect of the NP care environment (measured by the NP survey) on the relationship between the HPSA status of the practice location and ED or hospital use among patients with MCCs. We find that the NP care environment moderates the association between primary care provider shortage areas and hospitalization but not ED use. Further analysis reveals that improved NP care environments have a more pronounced association with lowered odds of hospitalization among patients receiving care from practices located in areas with no shortage of primary care providers (i.e., non-HPSAs) compared to those receiving care in practices with provider shortages (i.e., HPSAs). Our findings suggest that improving the care environment may not have the effect of reducing MCC patients’ need for hospitalization unless sufficient providers are also available to care for patients. We suggest that cohesive solution sets addressing practice- and community-level interventions simultaneously may be needed to improve hospitalization outcomes for patients with MCCs. In the concluding chapter of this dissertation, chapter 5, we present a summary of findings, discuss the dissertation’s strengths, limitations, and its contributions to science. In this chapter, we also discuss implications for policy, practice, and directions for future research.

Healthcare fraud is a major problem within the healthcare industry. The study examined medical fraud, its laws, and punishments on federal and state levels. It compared medical fraud to non-fraud crimes done in the healthcare industry. This comparison will be done on a state level. The study attempted to analyze the severity of fraud against non-fraud and that doctors would commit fraud offenses more often than non-fraud offenses.

中國自推動改革開放政策以來，經濟成長迅速，國民所得不斷提升，醫療需求與日俱增；再加上中國為順利加入WTO，2000年起更釋放醫療利多措施，放寬外資投入中國醫療服務市場限制。為此，旺旺集團旗下之湖南旺旺醫院搶得機先，於2005年底開業，不惟成為《中外合資、合作醫療機構管理暫行辦法》頒布後，中國第一家中外合資大型綜合醫院；亦是台商在大陸興建完成且正式營運之首家醫療機構，甚具指標性意義。 本研究除介紹中國醫療產業環境及相關政策法令外，更以個案研究法探討湖南旺旺醫院之興建動機、進入模式及經營策略。透過深入訪談並輔以次級資料分析，本研究發現，目前中外合資醫療機構由於數量少、進入時間短，尚不足以撼動公立醫院的地位，但在中國「看病難，看病貴」問題依然無法有效解決的情況下，以效率及品質著稱的民營大型醫院，應有相當之競爭優勢與發展空間。湖南旺旺醫院營運迄今已兩年餘，其透過醫院資訊系統建構整體醫療流程、以制度及人才奠定厚實根基等著重內部發展之經營策略，已逐漸獲得病人信賴並在經營實績上漸受肯定，應可供作其他跟進者發展布局參考。 至於兩岸醫療交流合作議題，由於台灣醫師薪資普遍較高，未必是符合成本的必然選項，建議應善用台灣管理經驗，就地建置系統性人才來源，方能掌握雙贏契機。總之，無論台資企業或醫療機構，唯有入境問俗、順勢而為，改變傳統思維與既有作法，才能在競爭激烈的中國醫療市場占有一席之地。 / Since China started to adopt the reforming and opening-up policy, it has seen rapid economic growth and ever-increasing medicare demand. To join WTO, China opened its medicare service industry for foreigners to invest in year 2000. Given such a background, the Want Want Group pioneered to found the Hunan Want Want Hospital—the first Chinese-foreigner joint ventured large general hospital following the dictum of “Interim Measures for Administration of Chinese-foreign Joint Venture and Cooperative Medical Institutions”. The hospital consequently sets an example of such joint ventures. In addition to discuss the environment of the Chinese medicare service industry and corresponding policies/regulations, this study explores the founding motivations, the entry mode, and the set of management strategies of Hunan Want Want Hospital. Through in-depth interviews and secondary data analysis, the study finds that owing to the still-small number and the still-short history of which, Chinese-foreigner joint hospitals have not yet gained the high ground to challenge public hospitals’ position in China. However, the study also finds that large private hospitals, renowned for their efficiency and quality, own substantial competitive advantage and expansion potentials. As an example for followers to emulate, Hunan Want Want Hospital has nurtured trust among its customers and performed well on several fronts because it developed a comprehensive information system to handle details of complicated medicare procedures, set up concrete rules for layers of management, and well-utilized human resources after more than two years’ operation. As far as the cross-straight medicare cooperation is concerned, this study finds that disparity in human resource cost across the straight may be an issue for Chinese-foreigner joint hospitals in China to address, and suggests that a win-win situation is achievable through the import of Taiwanese management expertise as well as the localization of human resource management. To conclude, Taiwanese medicare services, just like Taiwanese businesses in China, should adapt to Chinese local market environment and change accustomed management mindset so as to survive and grow in the Chinese medicare market.

基於生存權的保障，國家應提供人民生活扶助與醫療救助等給付。全民健保施行後，大法官釋字四七二號揭示對於無力繳納保費者，國家應予適當救助，不得逕行拒絕給付。遂開啟一連串對經濟弱勢者的保費協助措施，輔以相關醫療補助辦法的補助。惟我國領有醫療補助的人口比例甚低。 以美國醫療救助為例，自一九六五年建立Medicaid制度後，發展自今已有超過百分之十五的人口領有醫療救助，其制度強調實質醫療需求的內涵。在美國採開放式醫療市場的情況下，Medicaid對於貧者所提供的醫療服務更形重要。 相對於我國縣（市）醫療補助辦法對於社會救助法規定之過度限縮，是否有違母法，深值檢討。此外，我國亦應放寬對收入戶的認定，並修正醫療補助的資格與內容，以提供更多實質醫療需求者的醫療保障。

The Diploma work "Health care reform in the United States of America" is the sequel of the Bachelor work of 2008 called "The liberal health care system of the United States of America". The work is focused on the financial means and changes which has been effective since singing The Patient Protection and Affordable Care Act (acronym PPACA) into the United States law on 23rd March 2010 by the democratic president Barack Obama. The special attention is drawn to permanently increasing health care costs and defrauding of money within the social heath care program Medicare that is designated for seniors 65 and over as well as handicapped people. This work deals with Massachusetts Mandatory Health Insurance Program of 2006, which has been used like a model for the new federal law PPACA. The practical part presents the particular changes brought by the new law, including their impact on the chosen social groups -- the uninsured, the employers, the families and their kids, the seniors and the people with "pre-existing conditions". Since the Health care reform is the political issue as well, at the end there are mentioned some pros and cons opinions.

Both diabetes and behavioral health disorders (mental and substance use disorders) are significant health issues in the United States. While previous studies have shown worse health outcomes in people with diabetes and co-occurring behavioral health disorders (BHDs) than those with diabetes alone, it is unclear whether the quality of diabetes care was poorer in the presence of co-occurring BHDs. Although previous research has observed a trend of positive outcomes in people with comprehensive diabetes care, there is a lack of evidence about whether that mode of care delivery can improve outcomes in people with co-occurring BHDs. Therefore, further studies are necessary. Using a combined dataset from Medicare and Medicaid claims for Massachusetts residents, this study compared the quality of diabetes care (e.g., having at least 1 hemoglobin A1c test) and diabetes outcomes (e.g., eye complications) among Medicare and Medicaid beneficiaries with diabetes and co-occurring BHDs to those with diabetes alone in Massachusetts in 2005. The results showed a mixed picture on the relationships between BHDs and diabetes outcomes. While substance use disorders had adverse impact on adherence to quality measures (e.g., 20% less likely to attain full adherence, p0.05). Findings from this dissertation research suggest that disparities exist in the quality of diabetes care and health outcomes between people with substance use disorders and those without. The mode of care delivery needs to be further examined so that interventions can be designed to improve the outcomes of people with diabetes.

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<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>