<p> Continued escalation in health care expenditures in the United States has led to an unsustainable model that consumes almost 20% of GDP. Policymakers have recognized the need for industry reform and have taken action through the passage of the Affordable Care Act (ACA). The purpose of this quantitative, longitudinal study was to examine the relationship between the type of health insurance and health care costs. Mechanism theory and game theory provided the theoretical framework. The analysis of secondary data from the Healthcare Cost and Utilization Project included a sample of 1,956,790-inpatient hospital stays from 2007 to 2014. Results of one-way ANOVAs indicated that between 2% and 9% of health care costs could be attributed to type of health insurance, a statistically significant finding. Results also supported the effectiveness of the ACA in stabilizing health care costs. The average annual rate of health care cost increase was 38.6% from 2007 until 2010, decreasing to an average annual increase of 4.3% from 2011 until 2014. Results provide important information to generate positive social change for consumers, providers, and policymakers. This includes improving decisions related to health care costs, improved understanding of the costs of health care services, increased transparency, increased patient engagement, maximizing consumer utility, facilitation of reduction of waste within the industry, and increased understanding of the impact of health policy on health care costs and efficiencies within newly created health policies. Results may also improve transparency of health care costs, which allows consumers, providers, and policymakers to take specific action to reduce health care costs, resulting in a more just and sustainable health care model.</p><p>

<p> Pneumoconiosis is a chronic and slowly progressive parenchymal lung disease. Estimates suggest that about 68,000 ex-miners in Botswana will develop or have already developed pneumoconiosis. However, most of these cases do not know they have the disease because of the poor quality of care in primary healthcare settings and weak implementation of the Occupational Diseases in the Mines and Works (ODMW) Act. </p><p> This dissertation was a health service research framed from the systems approach using the chronic care model as a theoretical tool. The study employed a concurrent, convergent parallel mixed method research which combined quantitative and qualitative methods of inquiry. The quantitative arm of the study evaluated whether the Botswana primary care settings meet &lsquo;reasonably good standards&rsquo; of the pneumoconiosis quality of care measured on the chronic care model. The chronic care model measures quality of care on a 0 to 11 scale, where &ldquo;0&rdquo; denotes lack of quality care and &ldquo;11&rdquo; stands for optimal quality of care. Reasonably good quality of care comprises scores between 6 and 8 on the scale. The qualitative arm of the study assessed the implementation of the ODMW Act in the Botswana primary healthcare settings. The study mixed quantitative and qualitative results at the interpretation stage to determine the extent to which quality of care for pneumoconiosis and the ODMW Act implementation promote equitable access to pneumoconiosis services among ex-miners in Botswana. (Abstract shortened by ProQuest.) </p>

<p><b>Background</b>: Throughout the twentieth century, Brazil developed a Social Health Insurance, providing coverage to formal workers and their dependents. In 1988, the country implemented a health reform adopting a National Health Service model, based on three core principles, universal coverage, open-ended benefit package and striving for health equity. During this transition, formal workers recomposed their privileged access to healthcare through private health insurance, resulting in a two-tier system represented by those with dual coverage&mdash;public and private&mdash;and those who must rely exclusively on the public insurance. Private health insurance coverage has a positive correlation with income, however, between 1998 and 2008 private coverage expanded vigorously among the poor, while remained stable among the rich. The health equity literature in Brazil consistently reports the presence of relevant inequalities in utilization of health services favoring privately insured individuals. A gap in this literature, however, is to determine whether inequalities in utilization of health services remain among insured individuals, i.e., does private insurance improve access regardless of individuals&rsquo; income? </p><p> <b>Methods</b>: The study relies on Andersen&rsquo;s behavioral model as a theoretical framework to analyze data from two rounds (1998 &amp; 2008) of a national household survey, assessing levels of utilization of fourteen dependent variables across income quintiles and calculating concentration indexes as summary measures of inequality. Dependent variable distributions across income are standardized by need using the indirect method. Concentration curves compare the evolution of inequality during that time. Curve dominance is formally tested between survey years. Decomposition analysis identifies the most relevant contributors to inequality. Physician services are analyzed as the probability of having a physician visit and the number of physician visits. Hospital services are analyzed as the number of hospital admissions, the probability of having a hospitalization, and the number of hospital days during the last hospitalization. The latter two variables are broken down according to their financing source, either public (SUS) or private insurance. </p><p> <b>Results</b>: Physician services present very low inequalities, although a statistically significant positive gradient persists in both survey rounds. Poor PHI beneficiaries have an advantage compared to national levels. SUS financed hospitalizations are a rare phenomenon among privately insured individual but strongly concentrated on the poor. Poor PHI beneficiaries utilize private hospital at lower levels than the rich. Compared at a national level, they are at a disadvantage. In 1998, this was not the case, suggesting that insurers may be developing mechanisms to deter hospital utilization among the poor. Premium value and income are the most relevant contributors to inequality in physician and hospital services. </p><p> <b>Conclusions</b>: The Brazilian government (ANS) needs to monitor utilization levels across income and develop policies to increase accountability of PHI products particularly preventing insurers from purposefully pushing their beneficiaries to use SUS hospitals. Greater availability on insurance policies segmented as ambulatory care only and inpatient services only would increase the range of options for consumers that could sort more adequate coverage according to their capacity to pay and healthcare needs. </p>

<p> Healthcare quality measurement and care reimbursement have become a central focus for leaders and administrators of healthcare organizations. The provision of high-quality healthcare is contingent on the skills and abilities of leaders and clinical staff who support evidence-based clinical practice through implementation strategies. The problem defined in this qualitative exploratory multiple-case study was concerned with the frequency of unplanned hospital readmissions occurring in the state of Florida specifically, in healthcare facilities located in Broward, Miami-Dade, and Monroe Counties (tri-county area). Healthcare stakeholders working in organizations located in the tri-county area report hospital readmission rates of 23%, that resulted in higher financial penalties. The purpose of this qualitative exploratory multiple-case study was to explore the reasons for higher than expected unplanned hospital readmissions in healthcare facilities located in the tri-county area of south Florida to help hospital administrators to improve healthcare quality through reducing unplanned rehospitalizations. Thirteen participants contributed to this study: 4 (31%) healthcare leaders, 4 (31%) clinicians, and 5 (38%) registered nurses. Through the collective experiences of healthcare stakeholders, two primary and two secondary themes emerged to provide a clearer understanding of the contributing factors related to unplanned hospital readmissions. Four themes namely, education, population, and cultures and resources supported existing literature and provided new knowledge related to the importance of executive leader knowledge, nurse educational and skill levels, patient literacy and language, and cultural elements when applying evidence-based clinical practices in complex healthcare environments. </p><p>

<p> This dissertation used a mixed-methods approach to investigate both how intergovernmental relationships influence collaboration between regulators and to what extent their regulatory tools affect nursing home regulatory violations. Chapter 1 examines the impact of the five-star quality rating system and market competition on nursing home violations. Chapter 2 explores the intergovernmental relationships between state and federal regulators and whether it is facilitated by collaborative action. Chapter 3 evaluates the impact of two government tools (one direct and one indirect) and their association with regulatory compliance in nursing homes. The findings suggest that the five-star quality rating system has a positive association with nursing home providers&rsquo; regulatory compliance. Meanwhile, communication among regulators appears to be the key to collaboration, and the current structure of their regulatory regime might be inhibiting collaboration. Furthermore, the findings suggest that the direct governance tool leads to improvements in subsequent regulatory compliance as compared to the indirect tool. These three essays on the intergovernmental regulation of nursing homes and the specific regulatory tools contribute to the future policy decisions that affect the well-being of approximately 1.4 million individuals residing in nursing homes and primarily funded by the public.</p><p>

<p> The Internal Revenue Service (IRS) requires tax-exempt hospitals to conduct Community Health Needs Assessment (CHNA) every three years, formulate implementation strategies, and report yearly to the IRS and the public the progress of their work. The IRS CHNA incentivizes hospitals to provide programs responsive to community health needs. The purpose of this study was to examine the relationship between community benefit programs and prioritized community health needs in the context of a national IRS reporting requirement through analysis of published community benefit reports among North Carolina&rsquo;s (NC) tax-exempt hospitals. </p><p> This study employed quantitative research that analyzed longitudinal and cross-sectional data; qualitative research that reviewed published documents; and mixed-methods research that analyzed the integrated quantitative and qualitative results. The findings indicate that performing IRS-mandated CHNA did not substantially increase the alignment of community benefit programs with prioritized community health needs but did clearly highlight those needs. NC tax-exempt hospitals continue to focus on providing patient care financial assistance than population health, a strategy misaligned with community health needs. Although the hospitals are beginning to address population health and access to care concerns, their dollar expenditures in these areas paled in comparison to patient care financial assistance. If the IRS&rsquo; purpose in mandating CHNA was to spur a shift in community benefit priorities toward population health needs and away from the traditional patient care financial assistance, then, the evidence from 4 years after the requirement&rsquo;s implementation, indicates it is currently failing in North Carolina. As elucidated in the articles, their ingrained patient-level intervention perspective and desire to recover high unreimbursed costs or lost revenues for providing care to Medicare, Medicaid, and poor patients likely influence the hospitals&rsquo; community benefit programming to favor individual welfare over population health. Nevertheless, policymakers should continue to direct community benefit programs toward population health because it is a step in the right direction. Organizational change takes time and the desired results of policy interventions are usually incremental. Thus, conducting CHNA must remain a legal obligation by non-profit hospitals for maintaining their privileged tax status to facilitate organizational paradigm shift in community benefit programming toward population health programs or community building activities and away from individual welfare.</p><p>