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.

The objective of this study is to test whether the Affordable Care Act will have an effect on the professional tax preparation industry of Kingsport, Tennessee. To accomplish this objective, the researcher collected surveys concerning taxpayers’ initial reaction to the realization that the law affects their 1040. A two proportion test for equality was performed and failed to reject the idea that the ACA will have an effect on the tax preparation industry of Kingsport. Because this study failed to prove that the change in legislation causes a jump in clientele for the professional tax preparation market, the fight for market share falls to marketers. They will decide who will benefit from this landmark piece of legislation.

No description available.

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.

Ways in which the implementation of the Patient Protection and Affordable Care Act (ACA) affect parents with chronically ill children are not well understood. The purpose of this phenomenographic study was to gain greater insight into the perceived experiences of parents of chronically ill children regarding implementation of the ACA in a southern state. Argyris's intervention theory provided the framework for the study. Face-to-face interviews were conducted with a purposeful sample of 12 female parents who are caregivers of chronically ill children. Data were analyzed and coded to identify categories and themes. Findings indicated that parents view physicians and policymakers as key actors in their communities to create more equitable services for parents of chronically ill children through the expansion of Medicaid services in southern state. Many participants did not perceive that the ACA had made significant changes to services received prior to its implementation. Findings may assist health care providers, insurance companies, legislators, and other policymakers to develop appropriate health care policies and interventions to lessen the financial burden experienced by parents of chronically ill children. Providing more support services that address the physical, emotional, and financial needs of parents may improve the health outcomes of their chronically ill children.

Magister Curationis - MCur / Background: Psychiatric observation units are the units where 72-hour psychiatric observations are conducted in the district and in some of the regional hospitals. These hospitals were selected under the Mental Health Care Act No. 17 of 2002 (MHCA 2002) to admit patients suspected to be mentally ill, ascertain the cause of symptoms, exclude medical illness as a cause of the symptoms, treat and rehabilitate these patients; and at times transfer the patients to tertiary psychiatric hospitals. These units are often overcrowded as only about 30% of patients are transferred to the tertiary psychiatric hospitals. These units are fraught with challenges such as shortage of crucial facilities like seclusion rooms, specialised staff, resources and minimal budget is allocated to these units. Nursing staff in these units are faced with a number of challenges such as shortage of staff, patient overflow, prolonged patient stay, psychologically disturbed patients who can be agitated and violent, and are working long hours. Therefore, Compassion Satisfaction may be affected and these nurses are prone to Compassion Fatigue, which can lead to low Professional Quality of Life. Aim & objectives: The aim was to investigate Professional Quality of Life among nurses working in psychiatric observation units in Metropole District Health Services in the Western Cape Metropole. The objectives were to measure Compassion Satisfaction, to measure levels of Burnout and determine levels of Secondary Traumatic Stress among nurses working in psychiatric observation units in the Metropole District Health Services. Method: A quantitative research approach using a descriptive design was used to determine the Professional Quality of Life of nurses working in psychiatric observation units in the Metropole District Health Services. A self-administered survey using a structured questionnaire, the Professional Quality of Life version 5 (ProQoL 5) was used to collect data from an all-inclusive sample of 175 nurses, yielding a response rate of 93% (n=163). Data was analysed using the Statistical Package of Social Services (SPSS) version 24. Findings: The findings of this study showed that respondents experienced moderate Compassion Satisfaction, moderate Burnout and high Secondary Traumatic Stress. Advanced psychiatric nurse practitioners and registered nurses reported lower Compassion Satisfaction, higher Burnout and higher Secondary Traumatic Stress than enrolled nurses and enrolled nursing assistants. Recommendations: Qualitative research studies need to be conducted on nurses working in psychiatric observation units in order to understand experiences and factors affecting Professional Quality of Life among nurses. Qualitative research studies need to be conducted in order to understand factors affecting Professional Quality of Life of advanced psychiatric nurse practitioners and general registered nurses in psychiatric observations units.

The Affordable Care Act (ACA) seeks to increase the low-income population’s access to health care coverage by expanding Medicaid eligibility and providing subsidies to individuals meeting certain income thresholds. The citizens of Texas would benefit greatly from the ACA provisions, as the state offers limited opportunities for individuals to access insurance, evidenced by the 6.3 million residents without health care coverage. But political leaders in Texas have a long-standing commitment to limited government, low taxes, and states’ rights in a federal system of government. In the 1990s, Texas legislators, with bipartisan support, laid the groundwork over the last decade for the minimal, yet significant preparations that administration used to coordinate ACA implementation. Yet legislators’ commitment to limited government and states’ rights placed additional constraints on the ability of the Texas Health and Human Services Commission (HHSC) to implement ACA provisions by refusing to utilize the 82nd legislative session to prepare the state for impending deadlines. Instead, administrators developed an interagency effort, the Eligibility Modernization Project (EMP), to streamline eligibility determinations and increase clients’ access to information and services. EMP’s initiatives mirror ACA provisions, but also seeks to achieve policy goals that both Republican and Democratic legislators support, such as providing effective and efficient eligibility determinations. Nevertheless, legislators and administrators must go beyond EMP’s efforts to adequately prepare the eligibility system for impending ACA deadlines. Policy recommendations include further streamlining and integrating the health subsidy system with a state-based health insurance exchange, increasing access to coverage by expanding Medicaid eligibility, adequately preparing the workforce for changes, and promoting long-term planning. These solutions will provide a sounder infrastructure for HHSC to prepare for ACA coordination and implementation, while increasing access to health care coverage for the low-income population. / text

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

This thesis examines ways in which social policy supported by successive Conservative and Labour Governments has affected the British User/Survivor Movement (BUSM) since the introduction of the 1990 NHS and Community Care Act. It focuses on the formalising effects of community care policy, and the discursive resistance tactics of user/survivor activists in opposition to formalisation of their movement. The aims of the thesis are: firstly, exploration of the contradictory potential of community care policy where there is a formal relationship between local and/or health authorities with mental health services user/survivor-led groups; secondly, tracking New Labour’s policy agenda and the responses of user/survivors; finally, an attempt to develop a user/survivor theoretical standpoint towards community care policy. To achieve these aims the following were undertaken: a literature review which informed the development of a theoretical standpoint; interviews with user/survivor pioneers of the movement; and interviews with discussion groups of user/survivors who were active at local, regional, and/or national level. Analysis of respondents’ statements was completed using a theoretical standpoint based on Feminist/Foucauldian methodology. The chosen methodology resulted in an amended theoretical standpoint to take account of the use of reason by user/survivors and the creation of taxonomies which describe ways in which user/survivors discursively resist formalisation. These results formed the basis for the main conclusions which are as follows: first, user/survivors who engage in ‘consumerist’/empowerment activities, such as advocacy or involvement, can rightly claim to be challenging existing power relations; second, user/survivors entering into formal relationships with health/social services authorities do not necessarily reproduce discriminatory forms of care; third, although the culture of the BUSM has changed since the late 1980s, user/survivor activists are still trying to keep informal/empathic values alive; fourth, a danger exists that user/survivors will be pushed out of providing services and relegated to being the objects of consultation; and finally, there is a need to challenge the reason/unreason dichotomy enabling New Labour to characterise user/survivors as ‘dangerous’. The distinctive focus of this thesis on theoretical standpoint and discursive knowledge provides the basis for its contribution to theoretical and social policy debates in the field of mental health.