With the passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Congress made changes to several important federal health programs. First, MACRA reformed the Sustainable Growth Rate, a mechanism created under the Balanced Budget Act of 1997. Second, MACRA instituted the framework for the QPP which solidifies efforts to shift payments to value-based arrangements and streamline several existing programs under a single policy. This thesis aims to better understand how providers are responding to this new policy in four parts. First, I explain how MACRA passed in Congress with nearly unanimous bipartisan support. Second, I review the QPP and the two tracks offered under the program. Third, I review the literature on value-based payment arrangements, including the response of providers and health systems to these arrangements. Finally, I present original research on how major health systems and provider groups in the state of Iowa are preparing for MACRA implementation. I find several characteristics among health systems and provider groups that are associated with efforts to align payments to value-based measures. Across the tracks laid out under the QPP, there is consistency in the types of investments and operational changes being made. Work on these changes has been occurring for several years, and continued investment and reforms are likely.

Medicare Part B is one of the federal health insurance programs available to senior citizens in the United States. Unlike Medicare Part A, Part B enrollment is not automatic, and those missing their initial enrollment period are assessed a 10% or more penalty in addition to their monthly premium rate for the rest of their lives. This problematic enrollment policy has impacted senior citizens who have missed Part B enrollment windows, creating for them an added financial burden when many are transitioning to fixed incomes. Guided by social construction theory and using a nonprobability, convenience sampling approach, the likelihood coefficient values associated with Medicare Part B enrollee awareness, stress, and income of 112 residents of a suburban city in a northeastern state who were 65 years and older were examined. Sequential Forward: LR methodology yielded a significant, negative (b = -1.21, Wald X2(1) = 7.56, OR = .298, p = .006, CI [.126, .707]) and a significant, positive (b = 2.16, Wald X2(1) = 6.29, OR = 8.678, p = .012, CI [1.60, 46.99]) likelihood of predicting Medicare Part B late enrollment penalties for awareness and stress; income was not a significant model predictor. Participants who reported higher stress levels were 8.7 times more likely to be classified in the Medicare Part B late enrollment penalty than those reporting lower stress. Participants who were aware of enrollment needs were 3.4 times more likely to have no late enrollment penalties than those who were unaware. Positive social change centers on increasing Medicare Part B consumer awareness, reducing stress of enrollment deadlines, and providing information to federal policy makers to simplify enrollment policies to reduce or end late enrollment penalties.

Infants and toddlers with developmental disabilities and certain medical conditions are at risk for a variety of adverse outcomes in childhood as well as into adulthood. Early identification and early intervention are essential for improving the trajectories and outcomes of these children. The Individuals with Disabilities Education Act (IDEA) is a federal law that affords protections to children with disabilities and those at risk for developmental delays. IDEA provides guidance and regulations to early intervention programs, schools, and states for identifying and delivering intervention services to children ages birth through 21 years. Although the provision of early intervention services are regulated by the federal government through IDEA, states have autonomy to decide how they define and measure disabilities and developmental delays. As a result, states differ greatly in their eligibility criteria as well as in the percentages of children identified for early intervention (IDEA Part C) and preschool special education (IDEA Part B). Thus, children who receive early intervention services may or may not continue to meet criteria for special education once they reach age 3. Few studies have examined the child, family, and early intervention characteristics that relate to how, when, and if children will transition from Part C to Part B. Those studies that have examined these relationships have not focused specifically on how these transitions occur in Florida. The purpose of the present study was to examine child, family, and early intervention characteristics that increase the likelihood of children transitioning from Part C to Part B in Florida. Participants in this study included infants and toddlers who exited the Bay Area Early Steps Program (one of Florida’s Part C providers) in 2016. Archival data were examined using a combination of descriptive statistics, Chi-squares, independent t-tests, and logistic regression analyses. Results of this study indicate that children exiting the Bay Area Early Steps Program were more likely to be eligible for preschool special education (Part B) if they were Black/African American, Hispanic, had an established/diagnosed condition, had a lower socioeconomic status, received speech/language services in Early Steps, received multiple different service types in Early Steps, and/or received Early Steps services in Polk County (as opposed to Hillsborough County). Children were not more likely to be eligible for Part B based on their gender, primary language, length of time in Early Steps, or receipt of occupational therapy, physical therapy, or early intervention services while in Early Steps. The findings of this study provide preliminary information about factors that relate to children’s transitions from early intervention to preschool special education in Florida. The findings also offer practical implications for the day-to-day operations of the Bay Area Early Steps program and the local school districts to which these children transition.

Thesis (Ph.D.)--RAND Graduate School, 2005. / Includes bibliographical references.

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