Advance care planning is a conversation about personal values, future treatment choices, and designation of a surrogate decision-maker, that someone has in advance of a health crisis. Most existing studies on advance care planning have taken place outside of home health among populations with HIV/AIDS, cancer, dementia, and end stage renal disease. The U.S. home health population is living longer with chronic conditions such as pulmonary and cardiovascular illnesses, and hospitalization is a poor outcome. In 2016, Medicare implemented the Home Health Value-Based Purchasing Model, in which reimbursement rates for agencies in 9 regionally representative states were dependent on quantitative measures of quality performance. Part of the program was a process-level mandate requiring agencies to report on advance care planning. The aim of this study was to examine the relationship of home health advance care planning protocols with hospitalization rates. Descriptive and regression analyses were conducted on survey data of protocols and agency data of demographics and outcomes. Statistical significance was found in the positive correlation between advance care planning protocols and hospitalization. Recommendations are made for broadening the scope of evaluation of quality in home health to include goal-concordant care and transitions to appropriate services.

Thesis advisor: Julie Mortimer / Essays on the effects of health policy payment systems in long-term care and end-of-life care institutions are studied. In the arena of long-term care, state Medicaid agencies have recently implemented pay-for-performance (P4P) programs to address poor quality of care in nursing homes. Using facility-quarter level data from 2003 to 2010, we evaluate the effects of Medicaid nursing home P4P programs on clinical quality measures, relying on variation in the timing of P4P implementation across states. Further, we exploit variation in the structure of states' programs to investigate whether programs that reward certain dimensions of quality are associated with larger improvements. We find P4P decreases the incidence of adverse clinical outcomes by as much as 8%, and the improvements are concentrated among the measures that experienced an increase in their relative returns and share strong commonalities in production. In the Hospice industry, changes to the current reimbursement system are mandated by the Patient Protection and Affordable Care Act. The motivation stems from noticeable hospice utilization changes since the Medicare Hospice Benefit (MHB) introduced a per-diem reimbursement in 1983. This research analyzes the abilities of a multi-tiered payment system, and a simpler two-part pricing system, to accurately match Medicare payments with hospice patient costs. Both systems improve on the current payment mechanism, while two-part pricing is the only system to maintain access to care for all MHB eligible patients. In addition, consumer disutility incurred by driving to airports is estimated and used to define air travel markets. Though an accurate definition of an economic market is important for any study of industry, there is no rule governing what exactly constitutes a market. To define a market we must ask the question ``between which products do consumers substitute,'' knowing that the answer to this question will depend on how ``close'' products are to one another in product space, as well as how close they are to one another, and to consumers, in geographic space. We estimate a discrete choice model of air travel demand that uses known information about the locations of products and consumers, which allows us to study substitution patterns among air travel products at different airports. We evaluate the commonly used city-pair and airport-pair definitions of a market for air travel, and conclude that a city-pair is the appropriate definition. We also employ the Hypothetical Monopolist test for antitrust market definition, as defined by the Department of Justice and Federal Trade Commission, and conclude that the relevant geographic market for antitrust analysis is frequently more narrowly defined as an airport-pair. / Thesis (PhD) — Boston College, 2013. / Submitted to: Boston College. Graduate School of Arts and Sciences. / Discipline: Economics.

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.

Advance care planning is a conversation about personal values, future treatment choices, and designation of a surrogate decision-maker, that someone has in advance of a health crisis. Most existing studies on advance care planning have taken place outside of home health among populations with HIV/AIDS, cancer, dementia, and end stage renal disease. The U.S. home health population is living longer with chronic conditions such as pulmonary and cardiovascular illnesses, and hospitalization is a poor outcome. In 2016, Medicare implemented the Home Health Value-Based Purchasing Model, in which reimbursement rates for agencies in 9 regionally representative states were dependent on quantitative measures of quality performance. Part of the program was a process-level mandate requiring agencies to report on advance care planning. The aim of this study was to examine the relationship of home health advance care planning protocols with hospitalization rates. Descriptive and regression analyses were conducted on survey data of protocols and agency data of demographics and outcomes. Statistical significance was found in the positive correlation between advance care planning protocols and hospitalization. Recommendations are made for broadening the scope of evaluation of quality in home health to include goal-concordant care and transitions to appropriate services.

Background: Home health is the fastest-growing healthcare setting in the country. Through Home Health Value-Based Purchasing (HHVBP), the Center for Medicare and Medicaid Services (CMS) provides incentives or penalties to HHAs based on outcomes. Hospitalization and emergency department use are weighted heaviest as poor outcomes. HHVBP requires HHAs to report on whether they are engaging in advance care planning (ACP) conversations. For this study, ACP was defined as a conversation held in advance of a medical crisis with a loved one and/or a health care provider about goals; values; preferences for future medical treatments; and choice of a surrogate decision-maker. Purpose: to determine whether the proportion of Black patients was correlated with robustness of HHAs’ ACP protocols and levels of acute care services use. Methods: A cross-sectional, quasi-interventional design was used. The sample size was n = 89. Electronic surveys about ACP protocols were distributed to HHAs. Existing data about demographics and acute care services use were accessed via CMS websites. Spearman’s correlation coefficient was used. Results: No relationship was found between robustness of ACP protocols and the proportion of Black population per agency. No relationship was found between overall acute care services use rates proportion of Black patients. However, a trend was found: The greater proportion of Black patients, the greater the tendency for an agency to have a higher hospitalization rate. Discussion: Results are compared to current literature and to a CMS-commissioned study’s discussion about the potential for value-based purchasing programs to exacerbate health disparities in vulnerable populations.

Medicare paid $388.7 billion to acute care hospitals in 2014 representing the largest portion of the health care sector in the United States. Medicare implemented an innovative reimbursement model called Value Based Purchasing (VBP) to ensure hospitals provide quality care for the dollars spent. This correlation study used the VBP theoretical framework developed by Dudley as the foundation for the reimbursement model implemented by Medicare in 2013. The data used for this study came from the Centers of Medicare and Medicaid, as well as from Guidestar. The data focused on acute care, nonprofit hospitals located in New Jersey, New York, and Pennsylvania. Data trending and scatter plot graphs were used to analyze trends and basic correlation. Pearson correlation coefficient tests were performed to confirm correlation. The results showed no statistically significant relationship between program service revenue and the VBP domains for years 2013 and 2015. A weak positive relationship existed between 2014 program service revenue and the process of care domain; however, no statistically significant relationship existed between the remaining domains. The results from this study showed that quality metrics for acute care hospitals did not improve as the VBP criteria from Medicare expanded across the institutions included in the study. Hospital quality metrics are publicly accessible to everyone and allows patients to see actual results rather than the only resource being positive marketing campaigns. Accessibility to actual data has a positive influence on social change because patients can make informed choices for their personal health care needs.

No description available.

Chronic cardiovascular and pulmonary diseases are prevalent in the US home health population. Heart failure and chronic obstructive pulmonary disease are both chronic and terminal, but they are not always perceived as serious illnesses with imminent death. Therefore, they provide a context for advance care planning that is distinct from the diagnostic contexts of cancer, end-stage renal disease, or dementia. Advance care planning is defined as a process that supports adults at any age or stage of health in understanding and sharing their goals, values, and preferences about future medical care, including the designation of a surrogate decision-maker. This study tests the hypothesis that US home health agencies with higher percentages of patients with chronic cardiovascular and pulmonary conditions have less robust advance care planning protocols. The Spearman correlation coefficient was r = 0.22 (S = 74684, P =.025, 1-tailed), which was statistically significant and an unexpected finding. The greater percentage of patients with chronic cardiac and pulmonary diagnoses in an agency, the more robust the advance care planning protocol was. This supports our previous findings and existing literature indicating that agencies may be using exacerbation events marked by acute care use as opportunities to initiate or repeat advance care planning.

Advance care planning is a conversation about personal values, future treatment choices, and designation of a surrogate decision-maker, that someone has in advance of a health crisis. Most existing studies on advance care planning have taken place outside of home health among populations with HIV/AIDS, cancer, dementia, and end stage renal disease. The U.S. home health population is living longer with chronic conditions such as pulmonary and cardiovascular illnesses, and hospitalization is a poor outcome. In 2016, Medicare implemented the Home Health Value-Based Purchasing Model, in which reimbursement rates for agencies in 9 regionally representative states were dependent on quantitative measures of quality performance. Part of the program was a process-level mandate requiring agencies to report on advance care planning. The aim of this study was to examine the relationship of home health advance care planning protocols with hospitalization rates. Descriptive and regression analyses were conducted on survey data of protocols and agency data of demographics and outcomes. Statistical significance was found in the positive correlation between advance care planning protocols and hospitalization. Recommendations are made for broadening the scope of evaluation of quality in home health to include goal-concordant care and transitions to appropriate services.

Provider incentives are a commonly used policy tool to mold provider behaviors.1 However, while we frequently measure the change in patient outcomes, failure to consistently produce changes in outcomes does not mean that providers are not changing their behavior. This paper focuses on two programs with null or inconsistent quality outcomes to try to identify why such inconsistency occurs. The two programs, both ratified in the Affordable Care Act, are 1) patient-centered medical homes (PCMHs), and 2) the Medicare Hospital Value-Based Purchasing (HVBP) program. Chapter 1: Using data from the Medical Expenditure Panel survey (MEPS), I match provider characteristic surveys to member experience with care in order to evaluate characteristics key to patient-centered medical homes. I find that patient-perceived patient-centeredness of a practice is not related to the number of PCMH attributes a practice reports. However, some characteristics do play specific and significant roles in patient perception and outcomes. For instance, case management is not only associated with increased patient perception of after-hours access to care, but overall costs were reduced. Interestingly, having after hours clinic hours was more common with practices highly consistent with PCMH criteria, but these hours did not result in decreased emergency department use or cost of care. Chapter 2: The second provider incentive studied is the Medicare Hospital Value-Based Purchasing Program (HVBP). This program assigns payment adjustments based on performance on a series of rotating quality metrics. To date, changes in patient outcomes cannot be attributed to the program; however, it should not be concluded that hospitals are not responding at all. I identify changes in staffing by provider type as an early indicator of hospital response to payment incentives. Data come from the Virginia Health Information (VHI) Hospital Cost Report, 2010-2017. Using a generalized linear model, I find that when receiving a penalty, hospitals reduce staffing among the most and least expensive personnel (physicians and nursing aides). Hospitals increase nursing and administrative staff following a bonus. These findings are consistent with hospitals responding to incentives both by aiming to improve efficient use of resources and maintain or improve quality of care. Chapter 3: Finally, I assess potential unintended consequences of the HVBP program, specifically the provision of charity care. Using the VHI cost reports for year 2013 to 2017 with a regression discontinuity model, I find that hospitals receiving a bonus decrease their charity care among the lowest income patients (under 100% federal poverty level (FPL)). Hospitals receiving a penalty tend to reduce charity care among higher income patients (100%-200% FPL). These findings are consistent with two separate responses to the incentives. Hospitals receiving bonuses appear to be cream-skimming healthier, wealthier individuals while hospitals receiving penalties appear to be shifting the focus of their charity care to the most needy, likely in an effort to reduce cost of care levels overall while maintaining their community benefit programs, potentially as a result of goal gradient cognitive bias.