Thesis advisor: Rocío Calvo / Hispanics are less likely than non-Hispanic whites to use mental health service, even after controlling for various social, environmental, and health factors. Mental health services disparities between Hispanics and non-Hispanic whites have been well-documented and consistent over time. However, very little is known about the impact mental health care organizations have on Hispanics’ access to mental health care, especially since the implementation of the Patient Protection and Affordable Care Act (ACA). The three papers in this dissertation utilize the 2010, 2014, and 2016 waves of the National Mental Services Survey (N-MHSS) to assess the impact of the ACA on Hispanics’ access to mental health care and mental health care organizations’ provision of integrated services. The N-MHSS is a national repository of data on the mental health organizations in the United States. This dataset was created to report the characteristics and client enrollment at mental health care organizations. Paper 1 uses the 2014 N-MHSS to describe the structural characteristics of mental health care organizations according to the proportion of Hispanics they serve and the organizations’ structural characteristics in Medicaid expansion and non-expansion states. Paper 2 uses the 2010, 2014, and 2016 N-MHSS waves to examines the impact of the ACA and the health safety net on Hispanic admissions at mental health care organizations. These three waves were merged together using a repeated cross-sectional design to assess whether Hispanic admissions increased after the implementation of the ACA. The final paper uses the 2014 and 2016 N-MHSS waves to assesses whether integrated care has increased at Hispanic-serving organizations compared with mainstream organizations two years after the implementation of the ACA. This paper also assessed whether the increased funding for integrated services under the ACA has disproportionately affected mainstream organizations compared with Hispanic-serving organizations. / Thesis (PhD) — Boston College, 2018. / Submitted to: Boston College. Graduate School of Social Work. / Discipline: Social Work.

The Hospital Value-Based Purchasing Program (HVBP), created by Section 3001 of the Patient Protection and Affordable Care Act passed in 2010, enacted a major industry shift in Medicare towards "pay for performance," or paying for high marks on a variety quality metrics rather than the traditional reliance on volume of care delivered. This study examines one of these quality metrics in particular: patient satisfaction. The trajectory of this paper begins with an overview of the current focus on patient satisfaction as a modern quality metric in American healthcare, contextualizes this emphasis on satisfaction within the intellectual movement of "patient-centered care," and moves on to a review of the relevant scholarship that attempts to explain the numerous determinants of patient satisfaction scores (with special attention to the inpatient hospital setting), as well as the robust academic debate over whether satisfaction is even an appropriate quality metric at all relative to clinical outcomes in care. The second half of my discourse moves on to more practical applications - first I break down the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey and the impact of its methodology on providers, then the Medicare HVBP program itself and its various directions towards the value-based care model. I conclude with a quantitative analysis of trends in patient satisfaction over time between 1) HVBP-participating providers (as of FY2014) and 2) those providers who have not opted in (including those ineligible to do so). My comparison aims to study the strength of the HVBP incentives to improve patient satisfaction in those subject to the financial incentive relative to those who are not. Additionally, I preface this analysis whether patient satisfaction scores are associated with either clinical process of care scores or outcome scores in the HVBP program. My research questions aim to shed light on the academic debate between patient satisfaction and more traditional clinical outcomes - are they related in the context of FY2014 HVBP? Are the new incentives to improve patient satisfaction actually doing so in a meaningful way among providers newly accountable to these incentives? Finally, in a market defined by zero-sum resources, is there evidence that a financial incentives around patient satisfaction are channeling resources and by extension improvement away from clinical outcome performance? I believe this last question is the true concern of patient satisfaction skeptics, and hope to address it with applicable data. By providing a thorough qualitative grounding in the topic followed by current quantitative analysis, my goal is to create an informed perspective on the use of patient satisfaction as a quality metric in U.S. healthcare, which can be applied meaningfully from policy, provider, and consumer vantage points. With patient satisfaction becoming increasingly more internalized in the value-based care model, these analyses of the initial results in HVBP potentially serve as predictive insight into provider behavior in this area moving forward.

In most markets, competition induces efficiency by ensuring that goods are priced according to their marginal cost. This is not the case in health insurance markets. This is due to the fact that the cost of a health insurance policy depends on the characteristics of the consumer purchasing it, and asymmetric information or regulation often precludes an insurer from matching the price an individual pays to her expected cost. This disconnect between cost and price causes inefficiency: When the premiums paid by consumers do not match their expected costs, consumers may sort inefficiently across plans. In this dissertation, I study the effects of policies used to alleviate selection problems. In Chapter 1, I develop a model to study the effects of risk adjustment on equilibrium prices and sorting. I simulate consumer choice and welfare with and without risk adjustment in the context of a Health Insurance Exchange. I find that when there is no risk adjustment, the market I study unravels and everyone enrolls in the less comprehensive plan. However, diagnosis-based risk adjustment causes over 80 percent of market participants to enroll in the more comprehensive plan. In Chapter 2, we study an unintended consequence of risk adjustment: upcoding. When payments are risk adjusted based on potentially manipulable risk scores, insurers have incentives to maximize those risk scores. We study upcoding in the context of Medicare, where private Medicare Advantage plans are paid via risk adjustment but Traditional Medicare is not. We find that when the same individual enrolls in a private plan her risk score is 5% higher than if she would have enrolled in Traditional Medicare. In Chapter 3, we study two forms of insurance for insurers: Reinsurance and risk corridors. Protecting insurers from risk can lower prices and improve competition by inducing entry into risky markets. It can also induce inefficiencies by causing insurers to manage risk less carefully. We use simulations to compare the power of reinsurance and risk corridors to protect insurers against risk while limiting efficiency losses. We find that risk corridors are always able to limit insurer risk with the lowest efficiency cost.

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Patients with dementia, especially Alzheimer’s disease and particularly those in early stages, are susceptible to become victims of predators: Their agnosia (see Case 1) prevents them from detecting and accurately interpreting subtle signals that otherwise would have alerted them that they are about to fall for a scam. Furthermore, their judgment is impaired very early in the disease process, often before other symptoms manifest themselves and usually before a diagnosis is made. Patients with early stages of dementia are therefore prime targets for unscrupulous predators, and it behooves caregivers and health care professionals to ensure the integrity of these patients. In this case study, we discuss how a man with mild Alzheimer’s disease was about to fall for a scam were it not for his vigilant wife. We discuss what went wrong in the patient/caregiver interaction and how the catastrophic ending could have been avoided or averted.

Business leaders lack strategies to implement the employer shared responsibility provision of the Patient Protection and Affordable Care Act (ACA). Small businesses pay approximately 18% more than larger companies for the same health coverage. Within a conceptual framework of management by objectives, the purpose of this qualitative multiple case study was to explore the strategies small business leaders use to implement the employer shared responsibility provision of the ACA. Data were gathered from the review of company documents, observations, and semistructured interviews with 5 senior business leaders from small business organizations in the Mid-Atlantic region of the United States. Data were coded via Atlas.ti to identify themes from the narative segments. Key themes that emerged from the study included business cost, lack of transparency, and consultation. Recommendations include examining alternative health providers to reduce company health premiums to improve business costs, network with other small businesses for ACA clarity, and work with health consultants for new business processes. Implications for social change include contributing to the effective implementation of the employer shared responsibility provision of the ACA that can improve the economic well-being of small businesses.

Successfully designing and delivering a large-scale information technology (IT) system to meet new organizational objectives is a difficult undertaking in any context. The failure of the federally-facilitated online health insurance exchanges – known most commonly by their website address Healthcare.gov – to properly function when they opened for operations in 2013 provides a case study in how politics and policy-making can uniquely complicate IT projects in the public sector. Analysis reveals several instances where the legislative and regulatory process contributed to the project’s initial failure: from the project’s inception, elected representatives oversold the familiarity and simplicity of the site; statutory and regulatory law amplified the underlying technological complexity of the exchanges; partisan tensions extended the uncertainties around project scope until much too late in the process; legal and political concerns for maintaining stated delivery deadlines came at the cost of adequate testing and site functionality when it first opened; and the team appointed to oversee the project was more sensitive to political challenges then technological ones. Based on these findings, several recommendations are provided to help future representatives and government administrators minimize the negative toll that politics and policy-making can exact on a public sector IT project’s success. These include actively managing expectations, increasing information flow, simplifying functionality, providing fluid but reasonable delivery timelines, and appointing independent and technically savvy project leadership. Using Healthcare.gov as a case study on the effects politics and policy can have on developing IT systems can better prepare legislators and the public for future challenges of developing and implementing technology solutions in the public sector. / text

The Little Sisters of the Poor v. Burwell, a 2016 landmark religious liberty case, illustrates the ongoing debate between religious non-profit organizations and the government regarding the contraception mandate of the Affordable Care Act. Although the Little Sisters, in part because of their public relations and political advantages, received a relatively favorable outcome at the Supreme Court, their true successes lie on their impact on conservative politics and on the 2016 election. The Little Sisters became a significant component of political and religious leaders’ strategy to reframe the issue.

Expenditures on health are currently an important and growing item of public as well as private budgets in the developed world. This diploma thesis analyzes two different approaches to the function of health insurance on the example of the Czech Republic and the United States of America. The theoretical part will generally characterize access to health care through different theories; there will be also introduced the system of health insurance and the agents on health care market. The specifics of the health care market will be also explained. The analytical part of the work will focus on health insurance systems in the Czech Republic and the United States and their development, with accent on major reforms of recent years. With mutual comparison of the two systems, thesis will examine the shortcomings of public health insurance and private health insurance, including the effectiveness of their removal. Afterwards, the analysis of selected indicators of health care will be provided. The aim of the work is an analysis of the different systems of health insurance in the Czech Republic and the United States with relationship to the recent reforms and evaluation of their mutual effectiveness.

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