The United States Health Care sector is a large and growing segment of the US economy. Herein, I present three distinct research projects regarding aspects of that industry, especially how it responds to public policy and government pro- grams. I focus primarily on the hospital sector, and the Medicare Advantage market. Additionally, I explore how ownership type-publicly owned versus for-profits, for example-behave differently. I investigate the relative efficiency of different ownership types in the US hospital industry. Earlier studies neglect the differential ability of the hospital types to choose their own market. We use a Dubin-McFadden approach to solve the endogeneity problem and estimate hospital efficiencies for each ownership type. Efficiencies are estimated using stochastic frontier analysis. Results indicate that accounting for location choice does affect estimates of efficiency and that for-profit hospitals have a relative advantage in smaller markets while public hospitals have a slight edge in larger markets. Next, I study entry decisions of insurance plans participating in the Medicare Advantage program. I use the prevailing models of entry to compare how for profit and non-profit insurance firms differentially emphasize the characteristics of potential markets. I also determine how the preferential treatment of non-profits affects the composition of markets and whether governments should adjust their treatment to encourage or discourage non-profit entry. Results indicate that non-profit insurance companies are more responsive to higher payment rates which suggest that they act more like for-profit firms than altruistic organizations. Finally, I estimate the how much net welfare, Medicare Advantage contributes to the US economy. I use the Medicare Current Beneciary Survey to estimate a discrete choice model of beneciaries' choice of traditional Medicare, Medigap, and Medicare Advantage. I use the results to calculate the net welfare; I find that Medicare Advantages, on net, increased social welfare by 7.76 billion dollars in 2005.

Thesis--Auburn University, 2008. / Abstract. Vita. Includes bibliographical references (p. 138-146).

Thesis (Ph. D.)--University of Missouri-Columbia, 2002. / Typescript. Vita. Includes bibliographical references (leaves 74-78). Also available on the Internet.

Thesis (Ph. D.)--University of Missouri-Columbia, 2002. / Typescript. Vita. Includes bibliographical references (leaves 74-78). Also available on the Internet.

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Spending trends vary greatly across medical conditions. Nervous system conditions comprising epilepsy has shown an increase in spending growth contrary to a decrease observed in aggregate spending growth of 15 condition categories from 2000 to 2010. Increases in total spending of a medical condition can be explained by an increase in either costs per case or the number of cases or in both elements. Determining the number of epilepsy cases and the cost to treat an individual with epilepsy helps to explain spending trends of the disease. Significant variation in overall Medicare spending across geographic regions unrelated to health outcomes has been well-documented. It is uncertain whether reducing payment rates to high-cost areas would curb spending growth without adversely affecting health care quality for Medicare beneficiaries. Reducing geographic variation is therefore, desirable only if the measured variation represents inefficiencies in the health system. In terms of health care, efficiency is a function of cost of care and quality of care. The identification of factors contributing to inefficiency may guide policy change for its improvement. OBJECTIVES The overall objective of this research was to evaluate the potential for change in prevalence of epilepsy cases, the magnitude of maximum inefficiency and factors contributing to inefficiency for the treatment of epilepsy among Medicare beneficiaries. The first specific aim was to determine whether there has been change in the prevalence of epilepsy among Medicare beneficiaries since 2005. The second aim examined the effects of two value-based programs on the geographic variation of Medicare spending per beneficiary. The third aim sought to identify influential factors driving inefficiency in inpatient care among the beneficiaries with epilepsy by examining cost and quality, accounting for spatial dependence. METHODS Analyses for all specific aims included individual-, county-, and state-level data. Individual-level medical data including beneficiaries’ age, race, sex, zip code, and utilization information five percent random sample were obtained from US Medicare administrative data (2011 to 2013). Epilepsy prevalence information for Medicare beneficiaries (2001 to 2005) was estimated by a previous study. County-level data were obtained from Area Health Resources Files (AHRF) and the American Community Survey. State-level data were obtained from State Physician Workforce Data Book; Dartmouth Atlas of Health Care; Centers for Medicare and Medicaid Services; Tracking Accountability in Government Grants System; US Department of Commerce; National Association of Epilepsy Centers; and US Census Bureau. Epilepsy cases were defined using Medicare claims data with any of the following International Classification of Disease-Version 9-Clinical Modification (ICD 9-CM) diagnostic codes: At least one ICD 9-CM 345.xx (epilepsy), or at least two ICD 9-CM 780.3x (seizure) claims occurring at least 30 days apart. Inpatient inefficiency was defined as a function of cost over quality. Inpatient cost was defined by state-level average adjusted inpatient services spending per hospital stay (AIH). The proxy measure for the quality of inpatient care for beneficiaries with epilepsy was the proportion of hospital stays with an epilepsy or seizure admission diagnosis (PHE). Association analysis was performed using the Spearman correlation coefficient. Generalized linear models with log link and gamma distribution were used for the adjusting and modeling of cost dependent variables. Spatial regression models were used when appropriate to account for spatial dependence. RESULTS The prevalence of epilepsy among older Medicare beneficiaries was estimated to be 22.2 cases per 1,000 persons (2011 to 2013). An increase was observed for all racial groups. However, the subgroup with highest prevalence estimate shifted from the younger age group of 65 to 69 years to the female, 85 years and older. Black beneficiaries persistently had the highest prevalence compared to other racial groups. Analysis for the second specific aim showed that state-level total medical expenditures per beneficiary with epilepsy varied from 11,690 to 29,048 (average 19,890, SD 3,774, US$ 2013), 5.3 times the spending variation for those without epilepsy which ranged from 6,466 to 9,458 (average 7,631, SD 710, US$ 2013). Post-implementation of two value-based programs (hospital readmissions reduction program (HRRP) and the hospital value-based purchasing program (HVBP)), spending variation decreased for both the epilepsy and non-epilepsy cohorts (-14.6% and -9.0% respectively). The primary factor contributing to spending variation was health status for beneficiaries with epilepsy (51.9% of variation) and location of the beneficiary for those without epilepsy (26.1% of variation). Analysis conducted to address the third specific aim showed that different factors influenced inefficiency in inpatient care of beneficiaries with epilepsy among US census regions. For the Northeast region, the number of primary physicians was an inefficiency factor. For the South region, inpatient inefficiency factors included the number of medical residents and fellows, proportion of physicians who were primary care physicians, and retention of physicians who graduated from an institution in the state of practice. Some evidence of defensive medicine was detected in the West region while no specific factors were influential to inpatient inefficiency in the Midwest region. The highest and lowest state-level average adjusted inpatient services spending per hospital stay (AIH) were observed in the District of Columbia (13,376 US$ 2013) and South Dakota (7,901 US$ 2013). Rhode Island (1.06%) had the lowest while Idaho (11.29%) had the highest proportion of hospital stays with an epilepsy admission diagnosis (PHE). Rhode Island also had the lowest inpatient inefficiency index or least inefficient (86) compared to the highest inpatient inefficiency index or most inefficient observed in Idaho (1,417). CONCLUSION The prevalence of epilepsy among Medicare beneficiaries appeared to have increased from previous estimates. Heterogeneity among the 48 contiguous states and District of Columbia with respect to inefficiency in inpatient care was detected. Across-the-board cost reduction policy based on cost alone may not be appropriate for all geographic areas across the US and may even be detrimental to health outcomes in some areas. On both national and regional level, inpatient inefficiency was significantly associated with PHE but not with AIH, indicating that the focus to decreasing inpatient inefficiency for beneficiaries with epilepsy should be based on increasing quality or decreasing PHE. Changes made to decrease PHE (increase in quality) may also increase AIH (increase in cost); therefore, it would be wise to monitor both cost and quality when considering policy change while focusing on quality improvement. Programs such as the HVBP and HRRP that link cost to outcomes appeared to be successful in reducing geographic variation of medical expenditures. Instead of total spending per individual, updated knowledge of the prevalence and cost per case treated for specific chronic medical conditions may better assist resource allocation, budget planning, and health program development.

Introduction Diabetes is highly prevalent among older adults and can result in adverse health and economic outcomes. Patient satisfaction is an important quality of care indicator that often reflects the extent to which individuals have access to care and the ability to engage in preventive screenings and services needed to postpone or delay adverse outcomes associated with diabetes. Few studies have examined the role of patient satisfaction with care, specifically, among Medicare beneficiaries with diabetes. The purpose of the study is to describe provider satisfaction and associated characteristics among Medicare beneficiaries Methods A cross-sectional study was conducted using nationally representative data from the 2019 Medicare Current Beneficiary Survey (MCBS). Analysis was limited to persons 65 years and older who self-reported having diabetes. Satisfaction of care was the primary independent variable of interest, and it was assessed using the MCBS question ‘Have you been very satisfied, satisfied, dissatisfied, or very dissatisfied with the overall quality of health care received over the past year?’ Responses were recoded into dichotomous variables reflecting those with high satisfaction (very satisfied and satisfied) versus those who are not satisfied (dissatisfied and very dissatisfied). Results Approximately 3,852 individuals with diabetes were included in the study. Among study participants, 96.5% (3684) were satisfied with care and 3.5% (132) were dissatisfied with care. Among those satisfied with care, 52% were females, 68% were non-Hispanic Whites, 53% had more than high school education, 69% had more than a household income of more than $2500 married, 82% lived in a metropolitan area, 56% were married and 46% had obesity. Of those satisfied with care, 76% self-reported a general health status ranging from very good to excellent, 79% self-reported not being on insulin treatment and 79% self-reported having concurrent high blood pressure. In addition, about 82% of those satisfied with care, reported a recent HbA1c level of ≤7.5% or an average blood test of ≤140mg/dl, 64% reported self-testing for blood glucose and 65% of respondents reported having an annual foot examination by a doctor or other health professional. However, only 37% of participants satisfied with care reported participating in a diabetes self-management course, and less than 1% of those satisfied with care reported having an annual eye examination. Conclusion Findings from this study suggest that majority of Medicare beneficiaries are satisfied with care. Study participants who are satisfied with care reported low participation in diabetes self-management course and having an annual eye examination. Future studies are needed to examine the association between satisfaction of care and participation in a self-management course and annual eye examinations as these have implications for long-term diabetes outcomes. In addition, it may be important to undertake qualitative research to explore the determinants of dissatisfaction of care among Medicare beneficiaries with diabetes in order to address their specific needs.

Indiana University-Purdue University Indianapolis (IUPUI) / Hospital readmission is of growing importance in the healthcare industry because of associated patient and system costs, impact to the quality of patient care, and hospital Medicare payment penalties. The increasing interest in sepsis readmission prevention has highlighted the uniqueness of severe sepsis or septic shock survivors. The results of this study provide insight into the relationship between index hospital length of stay (LOS) and 30-day readmissions for older adults (> 65 years) who discharged home from an index hospital with a principle or secondary discharge diagnosis of severe sepsis or septic shock. The purpose of this study was to investigate the relationship between index hospital LOS and 30-day readmissions in older adults (> 65 years) whose expected primary payer was Medicare and who discharged home with a principle or secondary diagnosis of severe sepsis or septic shock. Data used to answer the proposed research questions consisted of older adult discharge records from the 2014 Nationwide Readmissions Database (NRD), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality. Differences in 30-day readmissions between older adult age groups, gender, and older adult location were examined. The number of days to readmission since discharge was evaluated for the subset of older adults with a readmission. Approximately 15.6% of older adults were readmitted within 30 days of their discharge. Readmissions were statistically different based on the older adult’s age, gender, and LOS. Location did not have a significant effect on readmissions. Mean LOS among readmitted older adults was 10.1 days. Analysis indicates that an older adult’s LOS had a significant effect on readmissions, although models performed poorly. Findings suggest that there are certain factors that can predict older adults who are at risk for being readmitted after being discharged with a principle or secondary discharge diagnosis of severe sepsis or septic shock.

The marketing of home heal_th care services is unique in its considerable variance in successes across geographic regions in the United States. Through surveys to home health companies, this study investigates four key factors believed to contribute to the success of home health care companies: marketing techniques, variation in technology, demand for services, and effects of regulations. Many factors. determine success, but it is important to determine the significance of regional differences as a factor in that success. Based on the importance of location selection, it is believed that results will show that location and marketing differences play a significant part in the success of a company (Spaeder 2005). It is indicated by the marketing concept that "firms should analyze the needs of their customers and then make decisions to satisfy those needs," (Weitz 1985); This indicates that areas with more companies can actually be more successful because they were forced to develop better marketing practices and plans due to the density of companies in the region. The potential impact of this research upon the home health industry is considerable. Little substantial research has been conducted regarding the marketing of home health, arid even less research projects have been implemented involving regional differences. The importance of researching this is found in its impact on how agencies market themselves. By spreading this new information about what makes a company successful and the regional differences, companies can improve marketing techniques, stimulating their success rates. In addition, given the increased number of people retiring in the next decade, this research is relevant and needed.

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