This is a quantitative study of archival data that examines Merger and Acquisition (M&A) activity using currently established healthcare quality and financial performance metrics. The research seeks to explicate the relationship between M&A activity and M&A experience in the healthcare industry as it relates to initiatives aimed at improving the quality and decreasing the cost of healthcare. The Affordable Care Act (ACA) legislation appears to be contributing to a trend toward M&A consolidation; by illuminating how this trend potentially impacts healthcare quality and cost reduction initiatives, this study’s contribution is both useful and practical. The units of analysis are Medicare reporting hospitals, hospital systems, and related healthcare providers that have or have not experienced an M&A or multiple M&As. The study shows a statistically significant improvement in quality each year from 2006–2014, which is reflected in higher scores for the four quality metrics measured. M&A activity, as measured by acquisition status and acquirer experience, did not appear to influence these quality metrics, with the exception of the heart failure measure, which showed a statistically significant positive influence of acquirer experience across all specifications. M&A activity’s possible effects on hospital financial performance was assessed through operating-cost-to-charge and capital-cost-to-charge ratios (CCRs). The operating CCR appears to be positively influenced by both acquisition status and acquirer experience, while the capital CCR was positively influenced only by acquirer experience. A positive influence is reflected in a decreasing ratio. Results on quality improvement over time, both before and after the ACA, suggest that the ACA itself may not be the driver for quality improvement. Similarly, decreases in OCCR occurred consistently and statistically significantly over time, both pre- and post-ACA, while CCCR showed statistically significant decreases in 2006–2008, 2013, and 2014. These results appear to support the notion that the trend was ongoing before the ACA was enacted and gave these measures high-profile exposure. This is a quantitative study of archival data that examines Merger and Acquisition (M&A) activity using currently established healthcare quality and financial performance metrics. The research seeks to explicate the relationship between M&A activity and M&A experience in the healthcare industry as it relates to initiatives aimed at improving the quality and decreasing the cost of healthcare. The Affordable Care Act (ACA) legislation appears to be contributing to a trend toward M&A consolidation; by illuminating how this trend potentially impacts healthcare quality and cost reduction initiatives, this study’s contribution is both useful and practical. The units of analysis are Medicare reporting hospitals, hospital systems, and related healthcare providers that have or have not experienced an M&A or multiple M&As. The study shows a statistically significant improvement in quality each year from 2006–2014, which is reflected in higher scores for the four quality metrics measured. M&A activity, as measured by acquisition status and acquirer experience, did not appear to influence these quality metrics, with the exception of the heart failure measure, which showed a statistically significant positive influence of acquirer experience across all specifications. M&A activity’s possible effects on hospital financial performance was assessed through operating-cost-to-charge and capital-cost-to-charge ratios (CCRs). The operating CCR appears to be positively influenced by both acquisition status and acquirer experience, while the capital CCR was positively influenced only by acquirer experience. A positive influence is reflected in a decreasing ratio. Results on quality improvement over time, both before and after the ACA, suggest that the ACA itself may not be the driver for quality improvement. Similarly, decreases in OCCR occurred consistently and statistically significantly over time, both pre- and post-ACA, while CCCR showed statistically significant decreases in 2006–2008, 2013, and 2014. These results appear to support the notion that the trend was ongoing before the ACA was enacted and gave these measures high-profile exposure.

The purpose of this study is to explore differences in quality between Medicare Accountable Care Organizations (ACO) and Health Maintenance Organizations (HMO). Three outcomes measures reported by these plans use different methodologies but possess enough alignment to permit comparison: percent of diabetic patients with last HbA1c > 9.0%, colon cancer screening rate and ER visits per 1,000. These outcomes are the dependent variables (DV). A secondary purpose is to explore differences in quality based on the size of the beneficiary population served, using the same measures. As the Medicare program faces threats to its solvency in coming decades, with 10,000 baby boomers becoming eligible every day, and the ongoing national conversation about healthcare more generally, approaches to Value-Based Purchasing (VBP) are becoming more common. Organizations seeking to identify the types of VBP arrangements in which they should enter have precious little information on the comparative performance of VBP approaches relative to outcomes measures. Different structures create different incentives through the plan design and risk/reward. The convergence or dissipation of the plan incentives at the level of the provider, particularly in primary care, may be a source of variance. This study is retrospective, non-experimental, and uses publicly available data on the performance of Medicare ACO and HMO plans in calendar year 2015, for the identified measures. Using the Donabedian Structure-Process-Outcome framework, this study explores the impact of structure by type of plan and size of population served, relative to the outcomes. Race, average Hierarchical Condition Category (HCC) risk score and duration of operations are control variables. The analysis uses multiple hierarchical regression to better understand the relationship between the independent variables (IV) and DVs, after the impact of the control variables (CV). After controls, the IVs did offer some explanation of variation in outcomes. The ACO plans fared better on HbA1c control, while HMO plans had fewer ER visits per 1,000. No discernable difference existed between the HMO and ACO plans with regard to colon cancer screening rate. Serving larger populations led to better performance on all three measures. In general performance was worse on each measure in both models when the percent of not-White patients or average HCC risk score increased. A longer duration of operations also associated to better performance on the outcome measures.

Accountable care organizations (ACOs) are a new health care reform initiative that has been highlighted as one of the most important organizational structures that could lead to quality improvements and cost savings in the United States through shared savings. The inability of health care managers to successfully implement ACOs could result in financial losses, reduced patient access to health care, and poor patient outcomes. Grounded by von Bertanlaffy's general systems theory, the purpose of this multiple case study was to explore the system change strategies health care managers used to implement an ACO to meet ACO quality and cost standards. Health care managers from Arizona, New York, and Wisconsin who successfully implemented ACO system change strategies in their organizations comprised the population for this study. Data were collected through face-to-face semistructured interviews with 9 health care managers. Data were analyzed using methodological triangulation, thematic analysis, and Yin's 5 analytic techniques to identify patterns and themes. Three main themes resulted from the data analysis and included leaders with system change strategies improved successful ACO implementation, leaders who implemented health information technology improved successful ACO implementation, and leaders with care management system change strategies improved successful ACO implementation. The application of the findings from this study may contribute to positive social change because health care managers may use these system change strategies to successfully implement ACOs to improve patient care and access and reduce the financial burden of health care costs throughout the United States.

Amidst mounting federal debt, slowing the growth of health care spending is one of the nation’s top domestic priorities. This dissertation evaluates three current policy ideas: (1) global payment within an accountable care contracting model, (2) physician fee cuts, and (3) expanding the role of competitive bidding in Medicare. Chapter one studies the effect of global payment and pay-for-performance on health care spending and quality in accountable care organizations. I evaluate the Blue Cross Blue Shield of Massachusetts Alternative Quality Contract (AQC), which was implemented in 2009 with seven provider organizations comprising 380,000 enrollees. Using claims and quality data in a quasi-experimental difference-in-differences design, I find that the AQC was associated with a 1.9 percent reduction in medical spending and modest improvements in quality of chronic care management and pediatric care in year one. Chapter two studies Medicare’s elimination of payments for consultations in the 2010 Medicare Physician Fee Schedule. This targeted fee cut (largely to specialists) was accompanied by a fee increase for office visits (billed more often by primary care physicians). Using claims data for 2.2 million Medicare beneficiaries, I test for discontinuities in spending, volume, and coding of outpatient physician encounters with an interrupted time series design. I find that spending on physician encounters increased 6 percent after the policy, largely due to a coding effect and higher office visit fees. Slightly more than half of the increase was accounted for by primary care physician visits, with the rest by specialist visits. Chapter three examines competitive bidding, which is at the center of several proposals to reform Medicare into a premium support program. In competitive bidding, private plans submit prices (bids) they are willing to accept to insure a Medicare beneficiary. In perfect competition, plans bid costs and thus bids are insensitive to the benchmark. Under imperfect competition, bids may move with the benchmark. I study the effect of benchmark changes on plan bids using Medicare Advantage data in a longitudinal market-level model. I find that a $1 increase in the benchmark leads to about a $0.50 increase in bids among Medicare managed care plans.

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The trustee has a fiduciary responsibility towards the parties with an interest in the trust. The parties with an interest in the trust may have certain expectations and requirements of the trustee. The main responsibility and accountability ascribed to and expected of the trustee are for the proper maintenance and administration of the trust and its assets. The parties with an interest in the trust may be classified according to how closely involved or affected they are by the existence of the trust. The parties closest to the trust are listed as the founder, beneficiaries and co-trustees. Parties with a judiciary, legislative and administrative interest in the trust include the Master of the High Court, the High Court and the auditors as well as accountants of the trust. The parties with an interest in the trust may not be satisfied with the actions or performance of the trustee. These parties may seek actions and remedies to hold the trustee accountable. These actions and remedies may be found in legislation, the literature, common law or court judgements. It would also be in the trustee’s interest to be informed of the different actions and remedies that could be utilised to hold him accountable. Different types of action are available to hold the trustee accountable, including civil and criminal remedies. The Trust Property Control Act 57 of 1988 does not provide for criminal remedies, but provides an array of civil remedies to hold trustees accountable. The Aquilian action is also available to parties to hold a trustee accountable who committed a breach of trust. The focus of the mini-dissertation is to determine the landscape of remedies and actions available to parties with an interest in the trust in order to hold the trustee accountable. / LLM (Estate Law), North-West University, Potchefstroom Campus, 2015

The trustee has a fiduciary responsibility towards the parties with an interest in the trust. The parties with an interest in the trust may have certain expectations and requirements of the trustee. The main responsibility and accountability ascribed to and expected of the trustee are for the proper maintenance and administration of the trust and its assets. The parties with an interest in the trust may be classified according to how closely involved or affected they are by the existence of the trust. The parties closest to the trust are listed as the founder, beneficiaries and co-trustees. Parties with a judiciary, legislative and administrative interest in the trust include the Master of the High Court, the High Court and the auditors as well as accountants of the trust. The parties with an interest in the trust may not be satisfied with the actions or performance of the trustee. These parties may seek actions and remedies to hold the trustee accountable. These actions and remedies may be found in legislation, the literature, common law or court judgements. It would also be in the trustee’s interest to be informed of the different actions and remedies that could be utilised to hold him accountable. Different types of action are available to hold the trustee accountable, including civil and criminal remedies. The Trust Property Control Act 57 of 1988 does not provide for criminal remedies, but provides an array of civil remedies to hold trustees accountable. The Aquilian action is also available to parties to hold a trustee accountable who committed a breach of trust. The focus of the mini-dissertation is to determine the landscape of remedies and actions available to parties with an interest in the trust in order to hold the trustee accountable. / LLM (Estate Law), North-West University, Potchefstroom Campus, 2015

Consolidating patient and clinical data to support better-informed clinical decisions remains a primary function of electronic health records (EHRs). In the United States, nearly 6 million patients receive care from an accountable care organization (ACO). Knowledge of clinical decision support (CDS) tool design for use by physicians participating in ACOs remains limited. The purpose of this quantitative study was to examine whether a significant correlation exists between characteristics of alert content and alert timing (the independent variables) and physician perceptions of improved ACO quality measure adherence during electronic ordering (the dependent variable). Sociotechnical theory supported the theoretical framework for this research. Sixty-nine physician executives using either a Cerner Incorporated or Epic Systems EHR in a hospital or health system affiliated ACO participated in the online survey. The results of the regression analysis were statistically significant, R2 = .108, F(2,66) = 3.99, p = .023, indicating that characteristics of alert content and timing affect physician perceptions for improving their adherence to ACO quality measures. However, analysis of each independent variable showed alert content highly correlated with the dependent variable (p = .007) with no significant correlation found between workflow timing and the dependent variable (p = .724). Understanding the factors that support physician acceptance of alerts is essential to third-party software developers and health care organizations designing CDS tools. Providing physicians with improved EHR-integrated CDS tools supports the population health goal of ACOs in delivering better patient care.

The Patient Protection and Affordable Care Act (PPACA) represents one of the most significant pieces of legislation in the history of United States healthcare. The PPACA has two main goals: to increase the insured patient population in the US and to reduce the overall cost while improving the quality of healthcare in the US. To accomplish the latter goal, healthcare providers are experiencing a movement toward integrated, team-oriented models that place increasing accountability on the providers and institutions. At the same time, these integrative models emphasize effective preventive care, which is critical in reducing the country’s overall healthcare costs. As more health care institutions and providers across the country adopt the healthcare reform models of the Patient-Centered Medical Homes (PCMH) and Accountable Care Organizations (ACOs) directly under the PPACA, the demand for pharmacists is increasing. In addition, the role of the pharmacist through Medication Therapy Management (MTM) is growing as more public and private sectors adopt MTM and its standards are being used as the medication-related cornerstone for the ACOs. There is a call for lower costs and higher quality outcomes in healthcare, and the pharmacists are increasingly integrated into direct patient care and medication management. The newly integrated responsibilities of the pharmacist are numerous and almost limitless. The roleof pharmacists is expanding, and as many studies suggest, their contributions produce auspicious results.

On its own, the Recognition of Prior Learning (RPL) is not a solution to either inequalities or unemployment, but it is an important strategy to address access to education and training for those previously excluded (SAQA, 2003a, p. 31) This study deals with the search for valid and sustainable mechanisms for the implementation of the Recognition of Prior Learning (RPL) in South Africa. Some of the elements that facilitate implementation include stringent quality criteria and common benchmarks that build trust in the process and ensures the protection of the integrity of the system. In an education and training system, which is subject to intense change, RPL has an important contribution to make to the opening up of access to education and training for individuals previously denied the privilege. / Dissertation (MEd)--University of Pretoria, 2005. / Curriculum Studies / Unrestricted