nÃo hà / Nos Ãltimos anos, em parte por forÃa da Emenda Constitucional n 29, a UniÃo passou a execuÃÃo de parte das aÃÃes de saÃde para os municÃpios e estados, caracterizando uma tendÃncia de reduÃÃo da participaÃÃo do governo federal em paralelo à ampliaÃÃo das participaÃÃes dos Estados e MunicÃpios, notadamente destes Ãltimos. Em funÃÃo dessa nova redistribuiÃÃo de competÃncias, o papel dos municÃpios, notadamente daqueles pertencentes aos estados mais pobres da FederaÃÃo, ganhou importÃncia no debate sobre os problemas enfrentados na saÃde pÃblica brasileira. Embora seja consenso que o subfinanciamento do setor pÃblico de saÃde à um fator impeditivo do cumprimento dos preceitos constitucionais de acesso universal e atendimento integral, muitos dos problemas que afetam o usuÃrio do SUS podem ser equacionados mediante boas prÃticas de gestÃo. Diante da necessidade de buscar, na aplicaÃÃo dos recursos financeiros escassos, uma combinaÃÃo de insumos que gera os melhores resultados, a eficiÃncia dos gastos pÃblicos passou a fazer parte da pauta de discussÃo da sociedade brasileira, motivada principalmente pelo reconhecimento da escassez de recursos e a necessidade de analisar a qualidade dos referidos gastos. Faz-se necessÃrio, portanto, identificar que tipos de gastos e utilizaÃÃo de insumos relacionados ao atendimento da saÃde tÃm obtido melhores resultados para os municÃpios, com o objetivo de replicÃ-los aos demais integrantes do grupo, gerando ganhos gerais de eficiÃncia. O presente trabalho se propÃe a fazer tal anÃlise no Ãmbito dos 184 municÃpios do Estado do Cearà no perÃodo de 2001 a 2011. Para tal anÃlise, foi utilizada a metodologia economÃtrica de Dados em Painel, que combina sÃries temporais e dados de corte transversal, o que resulta em um maior nÃmero de observaÃÃes, ou pooling de dados de vÃrios perÃodos de tempo para cada indivÃduo, oferecendo dados mais informativos, maior variabilidade, menos colinearidade entre variÃveis, mais graus de liberdade e mais eficiÃncia. As evidencias empÃricas indicam que as despesas correntes apresentam impactos positivos imediatos, ao passo que as despesas com investimentos causam impacto apÃs trÃs anos, sendo este superior ao impacto das despesas correntes. As despesas custeadas com recursos prÃprios apresentam impacto positivo superior ao das custeadas com recursos transferidos pela UniÃo e o Estado. Com relaÃÃo aos insumos fÃsicos e 5 humanos da saÃde, verificou-se que a anÃlise de impacto nÃo deve ser vista de forma isolada, mas sim integrada. / In recent years, in part by virtue of Constitutional Amendment 29, the Union managed the execution of part of health programs for municipalities and states, featuring a trend of reduced participation of the federal government in parallel with the increase of participation of States and municipalities, especially the latter. In accordance with this new redistribution of powers, the role of municipalities, especially those belonging to the poorest states in the country, has gained importance in the debate about the problems facing public health in Brazil. Although it is generally agreed that the underfunding of the public health sector is an impediment to compliance with the constitutional principles of universal access and comprehensive care, many of the problems that affect users of the SUS can be addressed through good management practices. Faced with the need to seek, in the application of scarce financial resources, a combination of inputs that produces the best results, the efficiency of public spending became part of the discussions of the Brazilian society, motivated primarily by the recognition of the scarcity of resources and the need to analyze the quality of those expenditures. It is necessary, therefore, to identify what types of expenditures and use of inputs related to health care have gotten better results for the municipalities, with the goal of replicating them to other group members, generating overall efficiency gains. This paper proposes to do this analysis in the context of the 184 municipalities in the state of Cearà in the period 2001 to 2011. For this analysis, the econometric methodology of Panel Data, which combines time series and cross-sectional data was used, the which results in a larger number of observations, or pooling data from various time periods for each individual, providing more informative data more variability less collinearity amongst variables, the more degrees of freedom and more efficiently. Empirical evidence indicates that current expenditures have immediate positive impacts, while investment expenditure impact after three years, higher than the impact of current expenditures. Expenses borne from its own resources to show the upper borne with funds transferred by the Union and state positive impact. With respect to physical inputs and human health, it was found that the impact analysis should not be viewed in isolation, but integrated.

Orientador: Francisco Luiz Cazeiro Lopreato / Dissertação (mestrado) - Universidade Estadual de Campinas, Instituto de Economia / Made available in DSpace on 2018-08-16T06:46:33Z (GMT). No. of bitstreams: 1 Motta_AlexandreRibeiro_M.pdf: 2857260 bytes, checksum: 2518e0ec1358f8826efecc761ff66877 (MD5) Previous issue date: 2010 / Resumo: A presente dissertação discute a questão das compras públicas no âmbito da Administração Direta do Poder Executivo Federal Brasileiro. Seu principal objetivo é analisar a contribuição deste sistema de compras na busca de maior eficiência do gasto público federal. São utilizados como referências comparativas, o conhecimento acumulado pela iniciativa privada no campo das aquisições de produtos e serviços, e ainda o sistema de compras públicas federais norte-americano. A estratégia adotada foi estabelecer uma matriz conceitual para a análise dos capítulos do trabalho. Tal matriz compõem-se de três dimensões: "Estrutura e Sistemas", "Legislação, Normatização e Processos" e "Recursos Humanos Especializados". Estes elementos servem como eixos fundamentais e fio condutor na discussão de cada um dos capítulos. No campo metodológico, o trabalho utilizou uma combinação de métodos qualitativos, tais como pesquisa bibliográfica e estudo de casos. Em relação ao terceiro capítulo, as informações foram também obtidas por meio de entrevistas semi-estruturadas. O tratamento de tais informações foi procedido via análise de conteúdo temático. As reflexões apresentadas ao longo da dissertação indicam que o sistema federal brasileiro de compras públicas poderia ser classificado como "Corruptocêntrico", por conta da centralidade do Combate à Corrupção, elemento em torno do qual gravitam, em órbitas hierarquizadas por ordem de importância, a Legislação, os Sistemas, as Pessoas e por último, quando passível de clara identificação, o Resultado. Neste sentido, a conclusão do trabalho é a de que o sistema brasileiro de compras não contribui substancialmente para a melhora da eficiência do gasto público federal. Como subsídio ao debate, a dissertação também apresenta sugestões para a superações do quadro apontado / Abstract: This thesis discusses the issue of public procurements by the Executive Branch of Brazilian Federal Government. Its main objective is to analyze the contribution of this procurement system looking foward to having a greater and efficient public spending. The knowledge accumulated by the private sector and by the U.S. federal procurement system on the acquisiton activities are used as comparative references. The strategy adopted was to establish a conceptual framework to analyze the chapters of the thesis. This framework consists of three dimensions: "Structures and Systems", "Legislation, Standards and Processes" and "Skilled Human Resources". These elements serve as the bases and conduct the discussion of each chapter. In the methodological field, the study used a combination of qualitative methods such as literature review and case studies. In the third chapter, the information was also obtained through semi-structured interviews. The evaluation of such information was carried out via thematic content analysis. The reflections presented throughout the dissertation indicate that the Brazilian federal procurement system could be classified as "Corruptocentric", once it strives for the extinguishment of corruption, idea around which it gravitates, in hierarchical orbits by importance order: the Legislation, the Systems, the People and finally, when the identification is neat, the results. Taking this into consideration, the conclusion is that the Brazilian Federal procurement system does not contribute substantially to improve the efficiency of public spending. As a support to the debate, the thesis also presents suggestions to overcome the issues raised / Mestrado / Desenvolvimento Economico, Espaço e Meio Ambiente / Mestre em Desenvolvimento Econômico

nÃo hà / This study aims to analyze the efficiency of public spending on health in the state of Cearà in Microregion Baturità in the period 2006 to 2010. To this end, we used the database system Public Health Budget (SIOPS) and indicators of the program by Covenant Health, prioritized and monitored by the Municipal Health, intercropped with tool use Data Envelopment Analysis (DEA) with constant returns to scale-oriented products with raw material as per capita spending and as products of the indicators: coverage rate by the Family Health Program (PSF), proportion of live births to mothers with more than 4 or more queries antenatal (prenatal) and rate of hospitalization for stroke (CVA), service rate by accident with diabetes (diabetes) and rate of hospitalization (inttx) and rate of children under 05 years with low weight (weight). The study shows Guaramiranga with increased spending between 2008 and 2010 without, however, present significant variation in the indicators in relation to other units. The PC is markedly higher spending other unit in the entire period (2006 to 2010). It has the worst scores of overall efficiency and recovery in 2010 although it has never reached the efficiency frontier. In the five years observed (2006-2010), the unit package and Baturità were four times the efficiency frontier, ItapiÃna, Capistrano and Mulungu 2 times AraÃoiaba a time. Aratubaand Guaramiranga did not reach the efficiency frontier in any year noted. The wide variation in per capita spending associated with the small variation of the corresponding indicators among the units studied points to a low standardization of procedure and highlights the need to broaden the selection of indicators for health managers, seeks to include the major actions of five blocks funding created that defines the cost of health, to enable better monitoring of management and unit performance. / Este estudo tem como objetivo analisar a eficiÃncia dos gastos pÃblicos com saÃde no Estado do CearÃ, na MicrorregiÃo de BaturitÃ, no perÃodo de 2006 a 2010. Para tanto, utilizou-se o banco de dados do Sistema de OrÃamento PÃblico em SaÃde (SIOPS) e indicadores do programa Pacto pela SaÃde, considerados prioritÃrios e acompanhados pelas Secretarias Municipais de SaÃde, consorciados com o uso da ferramenta AnÃlise EnvoltÃria de Dados (DEA) com retornos constantes de escala orientada para os produtos, tendo como insumo o gasto per capita e como produtos os indicadores: taxa de cobertura pelo Programa de SaÃde da FamÃlia(PSF); proporÃÃo dos nascidos vivos de mÃes com quatro ou mais consultas de prÃnatal (prÃ-natal); taxa de internaÃÃo por acidente vascular cerebral (avc); taxa de internaÃÃo por diabetes (diabetes); taxa de internaÃÃo por residÃncia (tx de int); taxa de crianÃas menores de 05 anos com baixo peso (peso). O estudo mostra Guaramiranga com o maior gasto entre 2008 e 2010 sem, contudo, apresentar significativa variaÃÃo nos indicadores em relaÃÃo Ãs demais unidades. O Gasto pc à acentuadamente superior Ãs demais unidades em todo o perÃodo (2006 a 2010). Tem os piores escores de eficiÃncia do conjunto e, embora apresente recuperaÃÃo em 2010, nunca atingiu a fronteira de eficiÃncia. Nos cinco anos observados (2006 a 2010), as unidade de Pacoti e Baturità estiveram quatro vezes na fronteira de eficiÃncia, ItapiÃna, Capistrano e Mulungu, duas vezes, Aracoiaba, trÃs vezes. Aratuba e Guaramiranga nÃo atingiram a fronteira de eficiÃncia em nenhum ano observado. A grande variaÃÃo do gasto per capita associada à pequena variaÃÃo dos indicadores correspondentes entre as unidades estudadas aponta para uma baixa padronizaÃÃo de procedimento e evidencia a necessidade de se ampliar a seleÃÃo de indicadores pelos gestores de saÃde, visando contemplar as principais aÃÃes dos cinco blocos de financiamento criados, o que define o custeio das aÃÃes de saÃde, de modo a permitir melhor acompanhamento da gestÃo e do desempenho das unidades.

Introdução: A obesidade é um problema de saúde pública com múltiplos determinantes e consequências. Objetivos: 1) Analisar a relação entre a disponibilidade domiciliar de produtos alimentícios processados e ultraprocessados e a prevalência de excesso de peso e obesidade; 2) Descrever o gasto familiar privado com saúde, segundo a presença de indivíduos obesos nos domicílios; e 3) Estimar a influência da presença de indivíduos obesos nos domicílios sobre o gasto total com medicamentos (obtidos nos setores privado e público). Métodos: Tese composta por três manuscritos baseados em dados da Pesquisa de Orçamentos Familiares (POF) 2008-2009. O primeiro manuscrito utilizou os 550 estratos amostrais da POF como unidade de análise e modelos de regressão linear para avaliar a relação entre a disponibilidade calórica domiciliar de produtos processados e ultraprocessados e a prevalência de excesso de peso e de obesidade, ajustados para variáveis de confusão. Ainda, foram estimados os valores preditos dos desfechos, segundo quartos de disponibilidade de produtos ultraprocessados. Os demais manuscritos consideraram os 55.970 domicílios como unidade de análise. O segundo manuscrito descreveu a distribuição do gasto privado mensal com saúde, considerando o gasto com medicamentos e com assistência à saúde, segundo a presença de obesos nos domicílios. O terceiro analisou a influência da obesidade sobre o gasto mensal per capita com medicamentos, obtidos nos setores privado e público, por meio de modelo de duas partes (two-part model), com ajuste para variáveis de confusão. Resultados: Com relação aos determinantes alimentares, verificou-se que a disponibilidade de produtos ultraprocessados, mas não a de processados, foi positivamente associada com a prevalência de excesso de peso e obesidade. No quarto superior de disponibilidade de ultraprocessados a prevalência de obesidade foi 37 por cento superior à do quarto inferior. No que tange as consequências financeiras, verificou-se que, na presença de obesos no domicílio, o gasto privado com medicamentos total e específico para doenças crônicas foi maior, o mesmo não sendo observado para a assistência à saúde. Ainda, considerando os medicamentos obtidos por desembolso direto e no SUS, a presença de obesos nos domicílios resultou em um gasto com medicamentos 18 por cento superior. Conclusões: A disponibilidade de produtos ultraprocessados é um dos determinantes alimentares da obesidade, que tem como uma de suas consequências financeiras o maior gasto com medicamentos resultando em impacto negativo para o orçamento familiar e para o SUS. / Introduction: Obesity is a public health problem with multiple determinants and consequences. Objectives: 1) To analyze the relationship between household availability of processed and ultra-processed products and the prevalence of excess weight and obesity; 2) To describe the private spending on health, according to the presence of obese individuals in households; and 3) To estimate the influence of the presence of obese individuals in households over the total spending on medicines (obtained in the public and private sectors). Methods: Thesis comprising three manuscripts based on data from the Brazilian Household Budget Survey (HBS) 2008-2009. The first manuscript used the 550 sampling strata of HBS as the unit of study and linear regression models to evaluate the relationship between household caloric availability of processed and ultra-processed products and the prevalence of excess weight and obesity in the stratum, adjusted for confounding variables. Furthermore, predictive values of outcomes were estimated according to quartiles of the household caloric share from ultra-processed products. The other manuscripts considered the 55,970 households as the unit of study. The second manuscript described the distribution of private spending on health, considering the spending on medicines and healthcare, according to the presence of obese individuals in households. The third manuscript analyzed the influence of obesity on the household spending on medicines, obtained in the private and public sectors, using two-part models controlling for potential confounders. Results: Relative to the dietary determinants, we verified that the availability of ultra-processed products, but not of the processed, was positively associated with both outcomes studied. Moreover, the prevalence of obesity was 37 per cent higher in the upper quartile of availability of ultra-processed products, compared with the lower quartile. In relation to the financial consequences, we verified that the presence of obese individuals in households resulted in higher total private spending on medicines and on medicines for non-communicable diseases, but for healthcare this was not observed. Furthermore, considering the medicines obtained in SUS and by out-of-pocket, the presence of obese in households increased the total spending on medicines by 18 per cent . Conclusion: The availability of ultra-processed products is one of the determinants of obesity and one of the financial consequences of this disease is the larger spending on medicines, resulting in negative impact to the household budget and to the public health system

Les dépenses militaires constituent un phénomène économique important puisque 1630 milliards de dollars sont affectés au secteur de la défense en 2010 au niveau mondial. Les économistes se sont alors intéressés aux conséquences économiques de telles dépenses. Pourtant depuis près de 40 ans, force est de constater qu'aucun consensus n'émerge de cette littérature. Une telle absence se traduit par des difficultés pour formuler des conclusions de politique économique adaptée. L'objet de cette thèse est alors de déterminer quelles pourraient être les causes de la diversité des résultats de la littérature passée. Nous proposons alors deux pistes expliquant ce phénomène: d'une part une diversité de modélisations ayant des hypothèses diamétralement opposées quant à l'impact de la défense sur la croissance et d'autre part l'existence de non-linéarité, de nature à modifier cet impact pour un même modèle.La thèse se compose alors de quatre chapitres. Dans le chapitre un, nous proposons une revue de littérature permettant de mettre en exergue les régularités, en termes de résultats, associées à chaque modèle théorique. Le chapitre deux constitue alors une vérification empirique, pour un échantillon donné de pays de l'OCDE, de la contingence des conclusions quant à l'utilisation de différentes modélisations. Notre stratégie empirique permet de considérer les modèles comme complémentaires plutôt qu'en concurrence. Dans le troisième chapitre, nous étudions les phénomènes de non-linéarité au travers d'une démarche et d'une méthode empirique originales. Nous montrons que la régression non-linéaire est préférable à la régression linéaire et qu'elle conduit à caractériser un effet asymétrique de la défense sur la croissance. Le dernier chapitre a pour but d'étudier plus précisément le cas de la France afin de confirmer, en termes de politique économique, la stratégie développée dans les chapitres précédents. / Military spending constitutes an important economic phenomenon because in 2010, 1630b dollar are affected to the defense sector all around the world. Economists are interested in the economic consequences of such spending. However, since 40 years, one has to note that there is no consensus from this literature. This absence leads to difficulties to formulate relevant economic policy conclusions. The aim of this thesis is to determine what are the causes of the diversity of results in the past literature. Two ways are then considered: on the one hand, a diversity of models with hypothesis diametrically opposed concerning the impact of the defense sector on economic growth and on the other hand, non-linear behavior which may modify this impact for a same model.This dissertation contains four chapters. In the first one, we detail a literature review in order to draw the principal regularities in terms of results for each theoretical model. The chapter two constitutes an empirical verification of the contingency of results from different models, for a sample of OECD countries. Our empirical strategy leads to consider the complementary rather than the competition between models. In the third chapter, we examine the non-linear phenomenon with original steps and empirical method. We show that non-linear regression outperforms linear regression and characterizes asymmetric effects of the military spending on growth. The last chapter aims to analyze the case of France in order to confirm the usefulness of the strategy developed in past chapters for raising economic policy recommendations.

In this dissertation, I visit areas of government spending that are core to human development and economic growth, and have equity and efficiency considerations. In the first essay, I examine the relationship between education and air pollution. How pollution affects education is typically studied through the health aspects of pollution exposure, and its subsequent effects on academic performance. This essay proposes a financing channel of pollution’s impact on education outcome. School districts with better air quality are endowed with higher tax base, and can generate more resources. Panel fixed effect analysis for a group of metropolitan school districts in the USA suggests that decrease in air pollution increases property tax revenue per pupil in the district. The second essay investigates the incidence of broad-based energy subsidies, and whether poor households could gain from targeted transfer programs financed by savings from reform. I analyze the tariff differential subsidy program in Pakistan, and find that the subsidy is regressive. I conduct a CGE exercise and find that reducing energy subsidy and redistributing savings to poor households, would improve poor household’s welfare. The third essay studies how public infrastructure capital affects growth in developing countries. The relationship between infrastructure and economic growth is widely studied in developed country context. This study contributes to literature by estimating output elasticities with respect to public infrastructure capital stock for two developing countries – Mauritius and Bangladesh. Estimated output elasticities are mostly positive for both countries, which suggests that public infrastructure stimulates economic growth in developing countries.

Philosophiae Doctor - PhD / Over the last two decades, budgetary allocations to both the Health and Education sectors have been on the increase in Nigeria, while a counter-factual feedback on its effects for various economic groups and distributional effect for different population households has not been defined and well known. The resultant effect has been gross inefficiency and sub-optimality in terms of observed outcomes of the fiscal framework. In-addition, there have been a continuous quest by the citizenry for increased allocations to these sectors because of its supposed impact on the poverty index and standard of living. Although this is a compelling reason, but what is worrisome and equally troubling, is that the increasing incidence of poverty and expanding inequality in the Nigerian society have not mitigated, despite the scaling up of funding on the social sectors. Furthermore, the current level of socioeconomic development in Nigeria is not in tandem with the distributive outcome targets set by the 2004 reforms. Thus, understanding the current structure of poverty in Nigeria as well as beneficiaries of public sector spending provides a sound basis for tackling inequality and redesigning the current pro-poor frameworks. However, our analysis is focused on the distributional spread of beneficiaries from services and the counterfactual reciprocity of expenditure benefits rather than measuring the exact value to recipients of government-sponsored services. Our research methodology used the 2004 Nigerian Living Standard Survey; 2010 Harmonized Nigerian Living Standard Survey; Recent Cros-sectional data (2014) in South East Nigeria and secondary sources. Econometric methods (Error Correction Method); Marginal Odds estimation techniques, Concentration Curves and Ordered Logistic Regression were used for our analysis. Statistical and Econometric Software’s (E-Views; SPSS; DAD and STATA) were used for estimations. Econometric results showed misalignments between population dynamics and public sector expenditure on education, health and economic services. The government consumption expenditure was not sensitive to demographic changes. The derived adjustment coefficients of -1.38, -1.51 and 0.51 respectively, for education, health and economic services indicate huge gaps in terms of what optimal spending should have been, giving the population dynamics. Our benefit incidence analysis indicates that substantive gains have been made at the primary education and health care level, at the state level for SE Nigeria but there is a gross misapplication of funds at the secondary and tertiary levels of both education and health sectors. Results show that the state governments’ is subsidizing the rich at the levels of both secondary and tertiary for education and health care. In addition, country wide results indicate that apart from public primary education and health care for urban residents, no other level of social service was absolutely progressive in general terms, by gender or by location while the tertiary level of both services were regressive as shown by the 2010 survey results, in comparism to the 2004 survey results. Using the Ordered Logistic Regression, our result inclines to the lifecycle hypothesis which maintains that poverty oscillates depending on the age. At a younger age, it tends to be on the high side and decreases during the middle ages and increases with age. Our results discards the feminization of poverty general framework that women or female headed households are more prone to poverty due principally to low education and lack of opportunity to own assets such as land amongst others. This wasn’t the case for the South East Region of Nigeria. Estimates indicate that education status, health status and access to health facilities affected the category of welfare of head of households and invariable, the entire household. In general, our analysis shows misalignment of social expenditure for various population groups, both at the federal and state levels; making doubtful the realization of basic MDGs. Nigeria has to combine growth policies and assuring that demographics count, with the poor fully participating in economic development. Also, the need for a refocusing in resource allocation taking into cognizance gender dimensions cannot be overemphasized. A general re-allocation of spending going to females and the poorer households would lead to improvement in gender equality and health status of women and children. Expediting actions towards qualitative education will lead directly to an acceleration of many of the other MDGs, especially those focusing on the reduction of poverty and inequality. To attain MDG targets (post 2015) within a shorter period of time, there is the need to improve the quality of social infrastructure and services. Furthermore, research should be focused on improving knowledge and understanding of what policies, technologies and investments matter for sustained growth in the country. This will create the much needed multiplier effect on other aggregates. The degree to which the poor participate in the growth process and share in its proceeds matter; both in the pace and pattern of growth. It is therefore important to have categorization of the population into economic groups when formulating a developmental framework for poverty reduction programmes. The study recommends sequencing of interventions, strengthening of institutions and other several interrelated areas to attain effectiveness of public sector spending.

Background: The United States health care system faces two fundamental challenges: a high growth rate of health care spending and deficiencies in quality of care. The growth rate of health care spending is the dominant driver of our nation’s long-term federal debt, while the inconsistent quality of care hinders the ability of the health care system to maximize value for patients. To address both of these challenges, public and private payers are increasingly changing the way they pay providers—moving away from fee-for-service towards global payment contracts for groups of providers coming together as accountable care organizations. This thesis evaluates the change in health care spending and in quality of care associated with moving to global payment for accountable care organizations in Massachusetts in the first 4 years. This thesis studies the Blue Cross Blue Shield of Massachusetts Alternative Quality Contract (AQC), a global payment contract that provider organizations in Massachusetts began to enter in 2009. The AQC pays provider organizations a risk-adjusted global budget for the entire continuum of care for a defined population of enrollees insured by Blue Cross Blue Shield of Massachusetts. It also awards substantial pay-for-performance incentives for organizations meeting performance thresholds on quality measures. This work assesses its effect on spending and quality through the first 4 years of the contract. Methods: Enrollee-level claims data from 2006-2012 were used with a difference-in-differences design to evaluate the changes in spending and quality associated with the Alternative Quality Contract over the first 4 years. The study population consisted of enrollees in Blue Cross Blue Shield of Massachusetts plans (intervention group) and enrollees in commercial employer-sponsored plans across 5 comparison states (control group). Unadjusted and adjusted results are reported for each comparison between intervention and control. Changes in spending for all 4 AQC cohorts relative to control were evaluated. In adjusted analyses of spending, I used a multivariate linear model at the enrollee-quarter level, controlling for age, sex, risk score, indicators for intervention, quarters of the study period, the post-intervention period, and the appropriate interactions. For analyses of quality, an analogous model at the enrollee-year level was used. Process and outcome quality were evaluated. Results: Seven provider organizations joined the AQC in 2009, with a total of 490,167 individuals who were enrolled for at least 1 calendar year in the study period. The control group had 966,813 unique individuals enrolled for at least 1 year during the study period. Average age, sex, and risk scores before and after the AQC were similar between the two groups. In the 2009 cohort, claims spending grew on average $62.21 per enrollee per quarter less than control over 4 years (p<0.001), a 6.8% savings. Analogously, the 2010, 2011, and 2012 cohorts had average savings of 8.8% (p<0.001), 9.1% (p<0.001), and 5.8% (p=0.04), respectively, by the end of 2012. Savings on claims were concentrated in the outpatient facility setting, specifically procedures, imaging, and tests (8.7%, 10.9%, and 9.7%, respectively, p<0.001). Organizations with and without risk-contracting experience saw similar average savings of 6.3% and 7.7%, respectively, over 4 years (p<0.001). About 40% of savings were explained by lower volume. Pre-intervention trends were not statistically different between intervention and control (-$4.57, p=0.86), suggesting savings were not driven by inherently different trajectories of spending. No differences in coding intensity were found. In sensitivity analyses, estimates were robust to alterations in the model, variables, and sample. Notably, claims savings were exceeded by incentive payments to providers (shared savings and quality bonuses) in 2009-2011, but exceeded incentives payments in 2012, generating net savings. Improvements in quality among intervention cohorts generally exceeded New England and national comparisons. Quality performance on chronic care measures increased from 79.6% pre-intervention to 84.5% post-intervention in the 2009 cohort, compared to 79.8% to 80.8% for the HEDIS national average, a 3.9 percentage-point relative increase over the 4 years. Analogously, preventive care and pediatric care measures increased 2.7 and 2.4 percentage points relative to control, respectively. On outcome measures, achievement of hemoglobin A1c, LDL cholesterol, and blood pressure control grew by 2.1 percentage points per year in the 2009 cohort after the AQC, while HEDIS averages remained largely unchanged (Figure). Conclusion: After 4 years, physician organizations in the AQC had lower spending growth relative to control and generally outperformed national averages on quality measures. Shared savings coupled with quality bonuses can exceed savings on claims in initial years, but over time, savings on claims may outgrow incentive payments. Incentive payments themselves may serve meaningful purposes, as quality measures may protect against stinting and shared savings may help ease providers into risk contracts. Changes in utilization suggest that this payment model can help modify underlying care patterns, a likely prerequisite for sustainable reform. The AQC experience may be useful to policymakers, insurers, and providers embarking on payment reform. Combining global budgets with pay-for- performance may encourage organizations to embark on the delivery system reforms necessary to slow spending and improve quality.

Is avocado toast the reason that I am still living with my parents? In other words, does the consumption of avocado toast, or more specifically eating out in general, have any impact on one’s ability to be a homeowner. In May of 2017, an Australian real estate developer by the name of Tim Gurner was asked to provide advice to young people who could not afford to purchase a home. He responded by saying, “when I was trying to buy my first home, I wasn’t buying smashed avocado for $19 and four coffees at $4 each,” (Victor, 2017). While the claim may appear to be laughable at first glance, this is not the first time that statements such as this have been made. The United States Census Bureau tells us that annual homeownership rates for individuals under the age of 35 has been on the steady decline. Additionally, per Goldman Sachs, it is known that the percentage of adults age 18-31 that were married and living in their own homes has decreased from 56% in 1968 to 23% in 2012. This paper assesses and compares the spending habits of different generations, working to discern if there are notable differences particularly between Millennials and other generations. Data sets from the Consumer Expenditure Survey (CEX) and Zillow between the years 2000-2013 were examined. Although there is not data on avocado toast specifically, it is possible to broaden the hypothesis to examine the expenditures on the consumption of meals prepared away from home. For the purpose of this study, I take Tim Gurner’s statement and apply it more broadly to the idea of spending money on the experience of eating out. The results show that the consumption of avocado toast, defined as money spent on meals prepared away from home, does not have an impact on whether an individual owns a home, nor is it an indicator as to whether they will be renters or living with their parents. Rather, the results indicate that owning a home leads to consuming more avocado toast. This means that although it is commonly perceived that Millennials are consumers as opposed to savers, their inability to afford home ownership does not have any direct connection to their spending habits on avocado toast, and more broadly, eating out in general.

Canadian federalism has experienced pressure for change in recent years. By the end of the twentieth century, collaboration became the catch word and federations throughout the world, including Canada, witnessed an emergent movement toward collaborative governance, collaborative public service delivery, collaborative management and collaborative approaches to addressing social and economic issues. But even if the number of collaborative arrangements has grown since the 1990s, the understanding of the design, management and performance of collaborative arrangements in the Canadian federation remains weak. Accordingly, this dissertation argues that, in order to understand and open the black box of intergovernmental collaboration, it is necessary to put collaboration in a historical context and explore the roles of elites and political institutions in shaping intergovernmental collaborative practices. The role of the former provides the necessary complement of agency, while that of the latter represents a perspective that gives theoretical importance to political institutions. The integration of the two theoretical schools, elite theory and historical institutionalism, into one approach constitutes an attractive solution and offers the tools necessary to explore the complex processes of intergovernmental collaboration. The theoretical framework constructed in this dissertation is then applied to analyze whether the Agreement on Internal Trade, the Social Union Framework Agreement and the Council of the Federation can be considered in reality as examples of collaborative federalism.