Health policy makers are struggling to manage health care and spending. To identify strategies for improving health quality and reducing health spending, policy makers need to first understand health risks and outcomes. Despite lacking some desirable clinical detail, existing health care databases, such as national health surveys and claims and enrollment data for insured populations, are often rich in information relating patient characteristics to heath risks and outcomes. They typically encompass more inclusive populations than can feasibly be achieved with new data collection and are valuable resources for informing health policy. This dissertation illustrates how the Medicare Current Beneficiary Survey (MCBS) and MassHealth data can be used to develop models that provide useful estimates of risks and health quality measures. It provides insights into: 1) the benefits of a proxy for the Framingham cardiovascular disease (CVD) risk score, that relies only on variables available in the MCBS, to target health interventions to policy-relevant subgroups, such as elderly Medicare beneficiaries, based on their risk of developing CVD, 2) the importance of setting appropriate risk-adjusted quality of care standards for accountable care organizations (ACOs) based on the characteristics of their enrolled members, and 3) the outsized effect of high- frequency hospital users on re-admission measures and possibly other quality measures. This work develops tools that can be used to identify and support care of vulnerable patients to both improve their health outcomes and reduce spending – an important step on the road to health equity.

Bakgrund: Barnet som föds prematurt genomgår en stor omställning från livet i magen till livet utanför, och behöver anpassad omvårdnad.  Det prematura barnets familj hamnar i en omvälvande situation som kan kännas ovan och skrämmande. Vårdpersonalens bemötande av familjen är avgörande för familjens delaktighet, vilket ställer krav på personalens kompetens. Samskapande omvårdnad handlar om samspel mellan personal och förälder för att ge barnet så bra vård som möjligt. Syfte: Studiens syfte är att beskriva barnsjuksköterskans erfarenheter av att göra föräldrarna delaktiga i vården av sitt prematurfödda barn. Metod: Kvalitativ design användes och data samlades in genom fokusgruppsintervjuer med barnsjuksköterskor på neonatalavdelningar. Intervjuerna analyserades med kvalitativ innehållsanalys. Resultat: I resultatet beskrivs kommunikationens betydelse för föräldrarollen genom vikten av stöd och anpassad information till den enskilda familjen. Föräldrarna behöver information, stöd och vägledning för känna sig trygga och delaktiga. Vidare beskrivs den psykosociala och fysiska miljöns betydelse för föräldrarollen och hur även miljön påverkar föräldranärvaron. Slutsats: Familjecentrerad och samskapande omvårdnad uppnås med fördel genom att familjen får en patientansvarig sjuksköterska (PAS), där en förtroendefull relation bidrar till att kommunikationen och informationsflödet fungerar optimalt. Strategier och modeller behövs för att lättare kunna applicera kunskapen om PAS-relationen i verksamheterna. / Background: Premature babies undergoes a major adjustment from the womb into life at the neonatal ward with special care. The family ends up in a new and frightening situation. Nurse´s treatment of the family is crucial for parental participation, which demands competent nurses. Co-productive care is about a parent-nurse partnership to provide the best possible care for the baby. Aim: The aim of the study is to describe the pediatric nurses experiences of making the parents involved in caring for their premature baby. Method: A qualitative design was used, data was gathered through focus group interviews with pediatric nurses at neonatal wards, and analyzed with qualitative content analysis. Result: The result describes the importance of communication for the parental role through support to the individual family and personalized information. Parents need information, support and guidance to become confident participants in their baby's care. The result also describes how the psychosocial and physical environment affects the parental role and parental participation. Conclusion: Family centered and co-productive care can be reached by providing an accountable nurse where a trustful relationship with the family contributes to good communication. Strategies and models are needed to apply the knowledge of the family-nurse relationship in the neonatal care.

Background: While value-based payment models emphasizing care coordination have been widely implemented to improve quality and lower expenditures, supporting empirical evidence is sparse. Our objective was to quantify the impact of specialist-to-primary care physician involvement within accountable care organization (ACO) and its association with lower spending. Methods: We conducted a retrospective cohort study of Medicare Shared Savings Program ACOs from 2012-2016 using publicly available data provided by the Centers for Medicare and Medicaid Services at the ACO level. We examined the association between the proportion of primary care services delivered by specialists versus other types of care providers and ACO spending using a generalized estimating equation model. Results: The analytic dataset included 1381 MSSP-years. When compared to ACOs at the lowest (60) levels of providing primary care services through specialists, ACOs who had 35% to 40% of primary care services delivered by specialists spent $1,124 (95% CI, $358 to $1,891) and $969 (95% CI, $250 to $1,688) less per capita, respectively. When stratified at varying levels of specialists providing primary care services, having four years of experience in the Medicare Shared Savings Program was consistently associated with lower spending when compared to having one to three years of experience. Conclusions and Relevance: The optimal portion of specialists providing primary care services - to reduce spending - was found to be 35% to 40%. These findings suggest that integrating specialists in to the activities and objectives of MSSP ACOs could lead to lower spending and better performance.

Educational authority in a situation where schooling is democratised is explored. The bases of authority such as social order, legal authority, knowledge, moral values and societal structures are established. The role of authority in education relationships and in the realisation of the educational aim is researched in order to attempt formulating criteria for accountable authority. The basic tenets of democracy that included aspects such as involvement, consultation, communication and reflective decision making are explored. Since fundamental human rights is a critical issue and precondition for a democracy, a focus on Chapter Two of the Constitution of the Republic of South Africa is related to the research. Attention is also given to the hierarchical school structure and the rights and responsibilities of those involved in this structure. Through an extensive literature study and a qualitative analysis of the responses to a questionnaire, conclusions are reached and recommendations made. / Educational Studies / M. Ed. (Philosophy of education)

<p>Mervärdesskatten infördes i Sverige den 1 januari 1969 med lagen (1968:430) om mervärdeskatt, så kallad moms. År 1994, året innan Sveriges inträde i EU, infördes Mervärdesskattelagen (1994:200) som anpassats till EG-rätt. Mervärdesskatten är alltid 25 procent om inget annat anges. Kunderna betalar moms till företaget och företagaren betalar in skillnaden mellan utgående moms och ingående moms till Skatteverket. Många företag bedriver blandad verksamhet, det vill säga både momsfri och momspliktig verksamhet som berättigar till avdrags- eller återbetalningsrätt av mervärdesskatten. Verksamheten delas in tre delar; momspliktig, momsfri och blandad. I den momsfria delen får inga avdrag göras medan fullt avdrag får göras i den momspliktiga. I den blandade verksamheten sker avdrag genom fördelningsnycklar.</p><p> </p><p>Syftet med studie var att se hur verkligheten stämmer överens med de teoretiska idéerna. Författaren har valt att göra en flerfallsstudie med ett juridiskt synsätt. Empiriskt material har samlats in genom semistrukturerade intervjuer för att skapa en mångsidig bild av mervärdesskatten och blandade verksamheter. Resultatet visar att verkligheten är mer komplext än vad teorin beskriver. Studiens teoretiska referensram består av lagar, beskattningsmyndighetens uppbyggnad, EG-rätt och anpassning av Svenska lag till denna och slutligen täcker referensramen viss redovisningsteori när det gäller blandad verksamhet.</p><p> </p><p>Analysen är en tolkning av intervjusvaren som ställts mot referensramen för att se hur de stämmer överrens med varandra eller inte stämmer överrens. Författarens slutsatser av arbetet berör skillnader mellan empirin och teorin. Slutsatserna berör även vad som påverkat uppkomsten av dessa skillnader. Författarens slutsats är att den teoretiska basen stämmer till viss del med den empiriska verkligheten hos redovisningsbyråerna och att redovisningsbyråerna ställer högre krav på företagarens redovisning än förväntat. Författarens slutsats är att fastighetsbolagens verklighet inte stämmer överrens med den teoretiska basen då samma fördelningsnyckel används på hela verksamheten. Mervärdesskattedirektivets uppgift om uppdelning efter årsomsättning i respektive verksamhet frångås då yta är den vanligaste fördelningen enligt författarens slutsats.</p><p><strong> </strong></p><p><strong>Nyckelord:</strong> Redovisning, mervärdesskatt, blandad verksamhet, fastigheter, momsfri verksamhet, momspliktig verksamhet</p> / <p>Added-value tax was introduced in Sweden January 1^st 1969 through legislation and the term is shorted as VAT. 1994, the year before Sweden's entry to the European Union, the VAT legislation was adapted and reformed. The added-value tax is always 25 percentages if nothing else is stated. The customers pay VAT to the company and the company's task is to deliver this money to The Swedish Tax Agency, the company pays the difference. A lot of companies conduct business that are blended which means that there are activities that are both free of VAT and activities where VAT has to be accounted for. Added-value tax that needs to be accounted for qualifies the company for deduction or payback of the VAT. The company's operation can be divided into three areas; free of VAT, VAT needs to be accounted for, and blended. The area that is free of VAT allows no deduction while in the other full deduction needs to be done. In the blended area the deductions are made through something called distribution keys.</p><p> </p><p>The purpose of the study is to see how the empirical world harmonize whit the existing theoretical base. The author has chosen to conduct a case study that involves more than one case. The study is based on a legal perspective and the collection of the empirical material is conducted through semi-structured interviews. The reason is to provide a versatile picture of VAT and the blended area. The results demonstrate that reality, in other words empiric, is more complex than the theory describes it. The theoretical base describes legislation, the framing of the Swedish Tax Agency, European Community legislation and the adoption to EC in Swedish legislation. Also some specific accounting theories are mentioned that concerns the case study and the blended area of a company.</p><p> </p><p>The analyze is an interpretation of the interviews put against the theoretical base to see how well they coincide or not. The authors conclusion of the study concerns differences between the empirical world and the theory. The authors conclusion is that the real estate concerns empirical world is different towards the theory because they only use one distribution key at all blended area instead of diversify in distribution keys. European Community endorse annual turnover as distribution key and Swedish legislation deviate from that because they endorse area as distribution key.</p><p> </p><p><strong>Keywords:</strong> Accounting, added-value tax (VAT), blended areas/operations, real estate, VAT free areas/operations, VAT accountable areas/operations.</p>

Mervärdesskatten infördes i Sverige den 1 januari 1969 med lagen (1968:430) om mervärdeskatt, så kallad moms. År 1994, året innan Sveriges inträde i EU, infördes Mervärdesskattelagen (1994:200) som anpassats till EG-rätt. Mervärdesskatten är alltid 25 procent om inget annat anges. Kunderna betalar moms till företaget och företagaren betalar in skillnaden mellan utgående moms och ingående moms till Skatteverket. Många företag bedriver blandad verksamhet, det vill säga både momsfri och momspliktig verksamhet som berättigar till avdrags- eller återbetalningsrätt av mervärdesskatten. Verksamheten delas in tre delar; momspliktig, momsfri och blandad. I den momsfria delen får inga avdrag göras medan fullt avdrag får göras i den momspliktiga. I den blandade verksamheten sker avdrag genom fördelningsnycklar.   Syftet med studie var att se hur verkligheten stämmer överens med de teoretiska idéerna. Författaren har valt att göra en flerfallsstudie med ett juridiskt synsätt. Empiriskt material har samlats in genom semistrukturerade intervjuer för att skapa en mångsidig bild av mervärdesskatten och blandade verksamheter. Resultatet visar att verkligheten är mer komplext än vad teorin beskriver. Studiens teoretiska referensram består av lagar, beskattningsmyndighetens uppbyggnad, EG-rätt och anpassning av Svenska lag till denna och slutligen täcker referensramen viss redovisningsteori när det gäller blandad verksamhet.   Analysen är en tolkning av intervjusvaren som ställts mot referensramen för att se hur de stämmer överrens med varandra eller inte stämmer överrens. Författarens slutsatser av arbetet berör skillnader mellan empirin och teorin. Slutsatserna berör även vad som påverkat uppkomsten av dessa skillnader. Författarens slutsats är att den teoretiska basen stämmer till viss del med den empiriska verkligheten hos redovisningsbyråerna och att redovisningsbyråerna ställer högre krav på företagarens redovisning än förväntat. Författarens slutsats är att fastighetsbolagens verklighet inte stämmer överrens med den teoretiska basen då samma fördelningsnyckel används på hela verksamheten. Mervärdesskattedirektivets uppgift om uppdelning efter årsomsättning i respektive verksamhet frångås då yta är den vanligaste fördelningen enligt författarens slutsats.   Nyckelord: Redovisning, mervärdesskatt, blandad verksamhet, fastigheter, momsfri verksamhet, momspliktig verksamhet / Added-value tax was introduced in Sweden January 1st 1969 through legislation and the term is shorted as VAT. 1994, the year before Sweden's entry to the European Union, the VAT legislation was adapted and reformed. The added-value tax is always 25 percentages if nothing else is stated. The customers pay VAT to the company and the company's task is to deliver this money to The Swedish Tax Agency, the company pays the difference. A lot of companies conduct business that are blended which means that there are activities that are both free of VAT and activities where VAT has to be accounted for. Added-value tax that needs to be accounted for qualifies the company for deduction or payback of the VAT. The company's operation can be divided into three areas; free of VAT, VAT needs to be accounted for, and blended. The area that is free of VAT allows no deduction while in the other full deduction needs to be done. In the blended area the deductions are made through something called distribution keys.   The purpose of the study is to see how the empirical world harmonize whit the existing theoretical base. The author has chosen to conduct a case study that involves more than one case. The study is based on a legal perspective and the collection of the empirical material is conducted through semi-structured interviews. The reason is to provide a versatile picture of VAT and the blended area. The results demonstrate that reality, in other words empiric, is more complex than the theory describes it. The theoretical base describes legislation, the framing of the Swedish Tax Agency, European Community legislation and the adoption to EC in Swedish legislation. Also some specific accounting theories are mentioned that concerns the case study and the blended area of a company.   The analyze is an interpretation of the interviews put against the theoretical base to see how well they coincide or not. The authors conclusion of the study concerns differences between the empirical world and the theory. The authors conclusion is that the real estate concerns empirical world is different towards the theory because they only use one distribution key at all blended area instead of diversify in distribution keys. European Community endorse annual turnover as distribution key and Swedish legislation deviate from that because they endorse area as distribution key.   Keywords: Accounting, added-value tax (VAT), blended areas/operations, real estate, VAT free areas/operations, VAT accountable areas/operations.

La présente thèse explore la dynamique des institutions informelles dans la gouvernance nationale et mondiale et l'ajustement de l'ordre politico-économique, dans un pays en transition et à l'échelle mondiale dans un contexte de crise financière internationale, en utilisant l'approche institutionnelle comparative. Elle adopte le point de vue de la nouvelle économie institutionnelle (New Institutional Economics - NIE) afin d'étudier comment différentes formes de gouvernance, notamment les mécanismes de gouvernance informels, émergent et fonctionnent dans diverses circonstances. Le chapitre deux fournit la preuve de la prédominance des relations accommodante et concurrente entre les systèmes de fourniture de services publics et d'ordre public, qui sont formellement et informellement décentralisés dans soixante-quatre provinces vietnamiennes. Notre analyse de l’«informalité» dans le chapitre trois soutient l'argument selon lequel les mécanismes formels ne sont pas suffisants pour inciter les acteurs publics à assumer leur pleine responsabilité, mais doivent être accompagnés de ceux informels pour combler les déficits de responsabilité du système formel. L'analyse empirique de quarante-cinq pays développés et en développement dans le chapitre quatre découvre que la non-congruence institutionnelle, en général, a un effet complémentaire sur la taille de l'économie informelle, mais agit comme un substitut dans les pays qui ont un faible niveau de non-congruence, une bonne gouvernance de la corruption, ou une grande pro-activité dans la prise d'initiatives visant à réduire l'écart de perception de la légitimité des activités économiques informelles. / This dissertation explores the dynamics of informal institutions in national and global governance and the adjustment of the economic political order in a transition country as well as on the global scale after two recent global financial crises, using the comparative institutional approach. It adopts the perspective of the New Institutional Economics (NIE) to study how alternative forms of governance, particularly, informal mechanisms of governance, emerge and work in various circumstances. Chapter two provides evidence to the prevalence of the accommodating and competing relationships between the formally and informally decentralized systems of providing public services and public order in 64 provinces in Vietnam. Our “informality” analysis in chapter three has supported the argument that formal mechanisms alone are not sufficient to create incentives for public actors to make private efforts to full accountability, but needs accompanying with other informal ones to fill in accountability deficits of the formal system. The empirical analysis of 45 developed and developing countries in chapter four finds that institutional incongruence, in general, has a complementary effect on the size of the informal economy, but acts as a substitute in those countries that have a low level of incongruence, good governance of corruption, or high proactivity in taking initiatives to minimize the perception gap about the legitimacy of informal economic activities.

Educational authority in a situation where schooling is democratised is explored. The bases of authority such as social order, legal authority, knowledge, moral values and societal structures are established. The role of authority in education relationships and in the realisation of the educational aim is researched in order to attempt formulating criteria for accountable authority. The basic tenets of democracy that included aspects such as involvement, consultation, communication and reflective decision making are explored. Since fundamental human rights is a critical issue and precondition for a democracy, a focus on Chapter Two of the Constitution of the Republic of South Africa is related to the research. Attention is also given to the hierarchical school structure and the rights and responsibilities of those involved in this structure. Through an extensive literature study and a qualitative analysis of the responses to a questionnaire, conclusions are reached and recommendations made. / Educational Studies / M. Ed. (Philosophy of education)

<div>This dissertation consists of three chapters. The first chapter, Inertia and Switching in Health Insurance Plans, seeks to examine health insurance choice of families and individuals employed by a large Midwestern public university during the years 2012-2016. A growing number of studies indicate that consumers do not understand the basics of health insurance, make inefficient plan choices, and may hesitate to switch plans even when it is optimal to do so. In this study, I identify what are later defined as unanticipated, exogenous health shocks in the health insurance claims data, in order to examine their effect on families' plan choice and switching behavior. Observing switches into relatively generous plans after a shock is indicative of adverse selection. Adverse retention and inertia, on the other hand, may be present if people remain in the relatively less generous plans after experiencing a shock. The results could help inform the policy-makers about consumer cost-effectiveness in plan choice over time.</div><div> Physicians’ relationships with the pharmaceutical industry have recently come under public scrutiny, particularly in the context of opioid drug prescribing. The second chapter, Pharmaceutical Opioid Marketing and Physician Prescribing Behavior, examines the effect of doctor-industry marketing interactions on subsequent prescribing patterns of opioids using linked Medicare Part D and Open Payments data for the years 2014-2017. Results indicate that both the number and the dollar value of marketing visits increase physicians’ patented opioid claims. Furthermore, direct-to-physician marketing of safer abuse-deterrent formulations of opioids is the primary driver of positive and persistent spillovers on the prescribing of less safe generic opioids - a result that may be driven by insurance coverage policies. These findings suggest that pharmaceutical marketing efforts may have unintended public health implications.</div><div> The third chapter, Accountable Care Organizations and Physician Antibiotic Prescribing Behavior, examines the effects of Accountable Care Organizations (ACOs). Physician accountable care organization affiliation has been found to reduce cost and improve quality across metrics that are directly measured by the ACO shared savings program. However, little is known about potential spillover effects from this program onto non-measured physician behavior such as antibiotic over-prescribing. Using a two-part structural selection model that accounts for selection into treatment (ACO group), and non-treatment (control group), this chapter compares physician/nurse antibiotic prescribing across these groups with adjustment for geographic, physician, patient and institutional characteristics. Heterogeneous treatment responses across specialties are also estimated. The findings indicate that ACO affiliation helps reduce antibiotic prescribing by 23.9 prescriptions (about 19.4 percent) per year. The treatment effects are found to vary with specialty with internal medicine physicians experiencing an average decrease of 19 percent, family and general practice physicians a decrease of 16 percent, and nurse practitioners a reduction of 12.5 percent in their antibiotic prescribing per year. In terms of selection into treatment, the failure to account for selection on physician unobservable characteristics results in an understating of the average treatment effects. In assessing the impact of programs, such as the ACO Shared Savings Program, which act to augment how physicians interact with each other and their patients, it is important to account for spillover effects. As an example of such spillover effect - this study finds that ACO affiliation has had a measurable impact on physician antibiotic prescribing.</div>

Studiens syfte är att bidra med kunskap om huvudmannens uppfattning av vetenskaplig grund och beprövad erfarenhet och huvudmannens beskrivning av organisering enligt uppdraget med en utbildning som vilar på vetenskaplig grund och beprövad erfarenhet. Essän utgår från två övergripande frågeställningar; Hur uppfattar huvudmannen innebörden av vetenskaplig grund och beprövad erfarenhet? och Hur beskriver huvudmannen arbetet med att planera, genomföra och följa upp en utbildning som vilar på vetenskaplig grund och beprövad erfarenhet? Teoretiska utgångspunkter är fenomenografin, där uppfattningsbegreppet är centralt, och en teori om organisering som bidrar till att utforska organisering genom att identifiera organisationens handlingsnät. Semistrukturerade intervjuer har genomförts utifrån ett målstyrt urval med informanter vilka representerar huvudmän som samtliga har en pågående samverkan med akademin. Vetenskapsrådets etiska principer för forskning utgör grund genom hela processen. Huvudmannens uppfattningar av vetenskaplig grund och beprövad erfarenhet omfattar lärande och förbättringsarbete hos enskilda professionella och verksamheter, lärande och förbättringsarbete mellan professionella och mellan verksamheter och ett stöd för det systematiska kvalitetsarbetet. Huvudmannens berättelser om planering, genomförande och uppföljning av utbildningen beskrivs vara en system- och organisationsfråga där chefer ger service genom att producera organisering. Identifierade handlingsnät omfattar utvecklingsarbete på styrkedjans olika ansvarsnivåer, samverkan med akademin och dokumentation baserat på det systematiska kvalitetsarbetet vilket bidrar till huvudmannens skolförbättringsprocess. / The aim of the study is to contribute with knowledge about the accountable authority´s understanding of scientific knowledge and proven experience and organising for leadership towards education based on scientific knowledge and proven experience. The essay is based on two overarching questions: How does the accountable authority perceive the meaning of scientific knowledge and proven experience? and How does the  accountable authority plan, implement and follow up the work with an education based on scientific knowledge and proven experience? Theoretical startingpoints are phenomenography where the concept of perception is central and a theory of organization that helps to explore organization by identifying the organization's action nets. Semi-structured interviews have been conducted based on a goal-oriented selection with informants who represent the  accountable authority who all have an ongoing collaboration with the Academy. Vetenskapsrådets (The Swedish Research Council's) ethical principles for research constitutes basis throughout the process. The accountable authority's understanding of scientific knowledge and proven experience include learning and improvement work among individual professionals and school units, learning and improvement work between professionals and between school units and a support for the systematic quality work. The accountable authority's stories about the planning, implementation and follow-up of the education describes as a system- and organizational issue where managers provide service by producing organization. Identified action nets include development work at the different levels of responsibility in the chain of command, collaboration with the academy and documentation based on the systematic quality work that contributes to the accountable authority's  school improvement process.