This qualitative case study examined the perceived effectiveness of executive leadership team processes at a community hospital in the southeastern U.S. in relation to the Value-Based Purchasing (VBP) requirements of the Patient Protection and Affordable Care Act (PPACA) through an analysis of documents and a repository database (http:www.hospitalcompare.hhs.gov) relating to service quality, patient satisfaction, and governmental reimbursements; and, structured interviews. Today, the PPACA or “Obamacare” continues to challenge the executive leadership teams at U.S. hospitals to effectively navigate the intricacies of the legislation in order to remain solvent in a volatile healthcare arena. The Plan-Do-Check-Act (PDCA) model was utilized to guide the theoretical framework for this qualitative case study in terms of process improvement. Hill’s (2010) team leadership model was also applied to examine the perceived effectiveness of the executive leadership team processes in terms of analyzing any change in core measures and patient satisfaction scores from the federal fiscal year (FFY) 2013 and 2014, respectively. The VBP data reflected consistent core measure scores in the 48th percentile and an increase in patient satisfaction scores from the 20th to 33rd percentile. The results revealed that the executive leadership team processes were perceived by the researcher as effective as evidenced by a strong collaboration among administration, the bord, and medical staff in implementing several strategies via a team oriented approach that impacted Medicare patients during the FFY of 2013-2014. This study offers a starting point in terms of generating more understanding of the importance of executive leadership team processes at a community hospital in relation to the VBP requirements of the PPACA which can be studied on a broader scale in the future.

This dissertation examines three health insurance eligibility policies and their impact on reproductive health outcomes for low-income women of reproductive age. The first paper examines the effects of expanded eligibility for Medicaid under the Affordable Care Act (ACA), on fertility among low-income women of childbearing age. The second paper explores the effect of presumptive eligibility policies in Medicaid for pregnant women on access to prenatal care and health insurance coverage. Finally, the third paper exploits state-level differences in eligibility for public versus private insurance under the ACA, and the effects on perinatal coverage patterns, childbirth outcomes, and access to care.

Although women offenders face barriers to successful reentry into their communities, as yet, no research has explored their experiences in accessing health care reentry services. Medicaid enrollment, the process of applying for Medicaid coverage, can be offered as a health care reentry service. Women offenders in jails have shorter sentencing times compared to those in prison, which presents Medicaid enrollment opportunities before release. The Second Chance Act provides the opportunity for reentry services, and the Affordable Care Act provides the opportunity for Medicaid coverage for women offenders. This phenomenological study explored the attitudes of women offenders about Medicaid enrollment and coverage. The conceptual framework for this study was the Andersen's behavioral model. Interviews were conducted with 11 women offenders who were randomly recruited, spoke English, had a minimum of a 6th grade education, and were not on restriction based on jail policy. Data were collected and coded to develop themes for analysis and interpretation. Most participants had an adequate understanding of the purpose of Medicaid coverage and had favorable perceptions of Medicaid enrollment. Barriers to Medicaid enrollment were identified: a lack of language proficiency, denial of coverage, poor health literacy, and a lack of understanding of health information. Facilitators to Medicaid enrollment were identified: providing a translator, being treated with respect as a person to reduce stigma, and assistance with enrollment forms. These findings can contribute to positive social change. Jails have the chance to address these barriers and incorporate the facilitators to make it simpler for women offenders to enroll in Medicaid before released from jail.

No description available.

Chapter 1 presents the backgrounds and research questions of the dissertation project. Although everyone hopes to die with dignity, a “good death” is often privileged. Inequality in end-of-life care in the United States is striking; older minorities are 3 times more likely to receive intrusive care and experience hospital readmission and less likely to use hospice care and die at home. With the hope to address disparities in end-of-life outcomes, as part of the Affordable Care Act, Medicare expanded its benefit and started to reimburse end-of-life care planning services from 2016. This dissertation examines the roles of health insurance policy and its advocated intervention in ensuring person-centered dying experiences in the United States and the public readiness for establishing a similar end-of-life care policy in China. The second chapter examines whether physician–patient advance care planning (ACP) discussions, the “intervention” embedded in the policy, is effective at prompting end-of-life care planning behaviors and improving end-of-life experiences. I also studied the heterogenous effects by race and ethnicity. I used exit data about 7,282 deceased Medicare-eligible respondents from the Health and Retirement Study (HRS) from 2012 to 2020, a nationally representative biennial survey of U.S. older adults. I conducted latent class analysis to identify different end-of-life experiences and used multinomial logistic regression models to study the relationship between having ACP discussions with doctors and different end-of-life experiences in full and stratified samples by race and ethnicity. Then I used path analyses to test whether completing legal documentation initiated by ACP services explains the effectiveness of the intervention. The results show three types of end-of-life experiences among White, Black, and Hispanic older adults; significant effects of end-of-life care discussions with doctors on uncomfortable dying experiences and extensive use of invasive treatments in the older White population; and the partial mediating role of completion of legal health care documents on the relationship between ACP discussions and end-of-life outcomes. This study identified the limited effectiveness of physician–patient ACP discussions among minority older adults and emphasizes the importance of quality, content (e.g., to cover legal documentation during the conversation), and cultural appropriateness of ACP consultations led by doctors. The third chapter examines the heterogenous intent-to-treat effect of the Medicare policy on older adults’ motivation to plan for care by exploiting policy intervention as a natural experiment. Taking advantage of the longitudinal nature of the HRS, I used core data with 47,982 observations nested in 15,647 individuals across 9 years (2012–2020). I used two quasi-experimental models—interrupted time series analysis and difference-in-difference—to study the care-planning outcomes before and after the policy implementation between older adults eligible or not eligible for Medicare. I studied the heterogenous effects in stratified samples by race and ethnicity, immigration background, and socioeconomic status proxied by education and wealth. I used coarsened exact matching to address the potential bias of the comparison group not being the ideal counterfactual control unit. I found that in the total population, the Medicare policy was associated with a significant increase in the proportion of older adults who completed a living will and designated a durable power of attorney for health care, but not having an ACP conversation. Furthermore, although there were immediate positive policy effects, the increases in ACP outcomes driven by the ACA Medicare benefit expansion were not sustained. Finally, I found no evidence that the ACA Medicare benefit expansion was effective in improving the rates of ACP among Black, Hispanic, Asian, Native American, or non-U.S.-born older adults. I also identified heterogeneous policy effects by socioeconomic status. I discuss promising recommendations for health care policy and practice to improve the participation rate of end-of-life care planning. Chapter 4 explores the feasibility of encouraging physicians to discuss end-of-life care wishes with older patients in China. Knowledge of a medical diagnosis is critical for end-of-life decision making. However, a patient’s right to know their diagnosis is neither guaranteed nor protected by law in China. Doctors typically inform family members of the patient’s illness diagnosis and prognosis and let them decide whether to disclose this information to the patient. This study examined middle-aged and older Chinese adults’ preferences for disclosing their and significant others’ diagnoses and whether sociodemographic, economic, and cultural factors were associated with these preferences. The research team surveyed 571 adults aged 50 or older in Shanghai from 2021 to 2022. The outcome measures are preferences for diagnosis disclosures, including whether and to whom diagnoses should be disclosed. I characterized preference types using latent class analysis and estimated multinomial logistic regression to identify the covariates associated with each preference type. Three latent classes were identified. The transparent group (34%) believed patients, whether self or a significant other, should be informed of their diagnoses. The contradictory group (50%) held conflicting attitudes; they preferred to know their diagnosis but preferred that significant others not be informed of their diagnoses. The avoidant group (16%) preferred not to know their diagnosis or to disclose significant others’ diagnoses to them. Familism attitudes were positively associated with holding contradictory views. Experiences with hospitalization and medical decision-making for family members were associated with holding transparent views. I discuss the importance of illness disclosure for honoring patients’ autonomous decision-making.

No description available.

On March 23, 2010, President Barack Obama signed the Patient Protection and Affordable Care Act (PPACA) into law. This reform, it is argued, is projected to increase insurance coverage of pre-existing conditions, to expand access to insurance for more than 30 million Americans, and to increase estimated National medical spending while lowering projected Medicare spending. This thesis sought to investigate and analyze the perceptions of senior citizens in Central Florida about PPACA and their perceived effects on the healthcare quality provided to them under this law. Four sections of PPACA bill, thought to specifically pertain to the elderly, were selected for this study; respondents were asked their opinions regarding PPACA's aspects of: (1) the reform on preventive healthcare services; (2) Medicare Part D (prescription drugs); (3) Medicare; and (4) Medicaid. This thesis employed both qualitative and quantitative methodologies; data were collected and analyzed with findings presented and discussed.

Bakgrund: Patienters delaktighet i sin vård ses idag som en självklarhet i Sverige och personcentrerad vård (PCV) är ett verktyg för att öka delaktigheten. Genom att lyssna till patientens berättelse, sträva efter ett jämbördigt partnerskap och dokumentera det som framkommer får sjuksköterskan möjlighet att med patienten skapa en hållbar och långsiktig effekt av vården. Inom tvångsvården enligt Lagen om psykiatrisk tvångsvård (LPT) ges sjukvården rätten och skyldigheten att vårda patienten mot deras vilja när det anses vara befogat för att skydda patientens liv och hälsa. Enligt LPT är syftet med tvångsvården att förmå patienten till att ta emot vården som erbjuds frivilligt.   Syfte: Syftet med denna studie är att undersöka erfarenheter hos sjuksköterskor i psykiatrisk vård av att arbeta med PCV med patienter som vårdas enligt LPT.  Metod: Studien har genomförts med en kvalitativ semistrukturerad intervju. Detta har sedan analyserats med en kvalitativ innehållsanalys.  Resultat: Studiens resultat uppvisar erfarenheter av att främja patientberättelsen men även hinder för denna. Det framkommer även erfarenheter av partnerskap som bedrivs under LPT. Partnerskapet främjas till stor del av sjuksköterskans bemötande. Till sist framkommer erfarenheter av dokumentationens betydelse för PCV som bedrivs enligt LPT. Slutsats: Utifrån den fakta som läggs fram rörande PCV och LPT i bakgrunden är dessa två begrepp relativt komplicerade att förena. I resultatet av denna studie kan det konstateras att delaktighet kan främjas PVC i vård som bedrivs enligt LPT, som i sin tur främja delaktighet. Förhållandet mellan begreppen PCV och delaktighet blir i det närmsta cirkulärt där de stödjer varandra och skapar uppbyggande symbios Kliniska implikationer: Baserat på resultatet framkommer en tilltro till att PCV kan vara positiv i bemärkelsen att det skapas ökad delaktighet mellan patient och sjuksköterska i vård som bedrivs enligt LPT. / Background: Patients' participation in their care is today seen as a matter of course in Sweden and person-centred care (PCV) is a tool to increase participation. By listening to the patient's story, striving for an equal partnership and documenting what emerges, the nurse has the opportunity to create a sustainable and long-term effect of care with the patient. In coercive care under the Compulsory Psychiatric Care Act (LPT), healthcare is given the right and obligation to care for the patient against their will when this is considered justified to protect the patient's life and health. According to LPT, the purpose of coercive care is to induce the patient to receive the care offered voluntarily.   Aim: The aim of this study is to investigate the experiences of nurses in psychiatric care of working with PCV with patients being cared for according to LPT. Method: The study has been conducted with a qualitative semi-structured interview. This has then been analyzed with a qualitative content analysis. Results: The results of the study show experiences in promoting the patient's story but also obstacles to it. There is also experience of partnerships conducted under LPT. This partnership is largely promoted by the nurse's treatment. Finally, experience of the importance of documentation for PCVs carried out under LPT emerges. Conclusion: Based on the facts presented regarding PCV and LPT in the background, these two concepts are relatively complex to reconcile. In the results of this study, it can be concluded that participation can be promoted PVC in care conducted according to the LPT, which in turn promotes participation. The relationship between the concepts of PCV and participation becomes almost circular where they support each other and create constructive symbiosis. Clinical implications: Based on the results, there is a belief that PCV can be positive in the sense that increased participation between patient and nurse is created in care conducted according to LPT.

<p>The dissertation is consisted of two essays on Affordable Care Act Marketplace plan pricing. These two essays are the two chapters of the dissertation respectively.  </p> <p>First essay studies the effect of Medicaid expansion on ACA Marketplace plan premium. The Affordable Care Act (ACA) aims to mitigate Americans’ uninsured crisis by expanding Medicaid and establishing the ACA Marketplace. The Medicaid expansion has a profound impact on Marketplace plan premiums. On the one hand, it lowers the premiums because the expansion drives out the people with lower income from Marketplace plans, resulting in a pool with a lower risk score for these plans. On the other hand, the Medicaid expansion may shrink the pool size of Marketplace plans, resulting in a riskier pool and a higher Marketplace plan premium. Integrating data from multiple sources, we study how these two competing effects vary across markets with different demographics. We find that the premium-reduction effect is less pronounced in more wealthy markets, while the premium-increase effect is less pronounced in more populous markets. We further find that the Medicaid expansion overall decreased the Marketplace premiums, with more reduction for Silver plans than Bronze plans. We also explore how the Medicaid expansion can lower Marketplace premiums indirectly through the change of the market structure. We finally show the heterogeneity of the net impact of the Medicaid expansion on Marketplace premiums across markets. Our results offer important policy and managerial implications.</p> <p>The second essay explores the effect of insurer competition on marketplace plan premiums. ACA Marketplace is a new market opportunity for insurers that grant them access to a new group of customers who were not insured before. Previous studies utilize ACA marketplace data and find that additional insurers on the market are associated with a premium decrease in Marketplaces for a benchmark plan. However, the impact of the insurer entry on the premium is not the same for all plans. Using data from 2014 to 2017, we empirically examine the effect of insurer entry on the premium on Marketplace. Our study first confirms the finding that the premium of the second-lowest Silver plans decreases in the number of insurers. We further find evidence of different price trends across plans of different quality levels with additional insurers on the market. When more insurers are on the market, the premium increases for higher-end plans and decreases for lower-end plans. Our analysis shows that intensified competition may exaggerate price discrimination in certain segments while alleviate price discrimination in other markets. The results offer important managerial implications. </p>

This dissertation examines the effects of physician ownership of hospitals on the quality of patient-centric care in the U.S. The health care sector in the U.S. is becoming more aligned with markets and in turn, with consumers’ preferences. In consumer driven service industries, consumer satisfaction is considered a key criterion to judge quality. In the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction surveys, physician-owned hospitals (POHs) get more top 5-Star ratings than other hospitals. However, it is not known whether higher perceived patient satisfaction is because of better inpatient experience or due to better health related outcomes. Ratings also do not clarify variations between specialty and general service POHs. The study compares the quality of care in POHs with that in other major forms of hospitals (corporate-owned, and not-for-profit). The Affordable Care Act (ACA) regulated physician ownership of hospitals due to concerns that physicians’ profit motive might negatively affect the quality of care. This non-experimental study used bivariate and multivariate analyses to examine variation in the quality of care among types of hospitals in 2017 and 2018 using patient satisfaction and clinical outcomes as indicators of quality. This study used two samples, a full and a restricted sample. Full sample compared all POHs (specialty and general service) with other hospitals. Restricted sample included only general service hospitals. Patients in POHs were found to have higher perceived satisfaction, and viewed providers’ practices more favorably in the full sample. In the restricted sample, however, not-for-profit (NFP) hospitals provided relatively better care. Corporate-owned hospitals had lowest patient satisfaction and poorest outcomes. Results indicate POHs are competitive with not-for-profit hospitals on patient satisfaction dimension of quality care. Multivariate analyses suggest that the effects of physician ownership go away when mediation by providers’ practices is considered. NFP hospitals, however, continue to provide better overall value of care. The results do not support reconsideration of the ACA restrictions on POHs. Patient satisfaction may be contingent upon patient-centric practices than type of hospital, but hospital ownership may affect preference for some practices over others. Outcomes may not matter when patients’ perceptions measure quality. / Ph. D. / The health care sector is becoming more closely linked to markets, and consumer experience and satisfaction, like any other consumer services industry due to growing influence of for-profit hospitals and hospital forms. Physician-owned hospitals are a relatively new form of hospitals in the U.S. Along with more traditional not-for-profit and corporate-owned hospitals; physician-owned hospitals compete for patients and patient dollars. Many physician-owned hospitals are specialty and surgical hospitals, in addition to general service hospitals. According to federal government surveys, patients usually perceive medical care provided by physician-owned hospitals to be of superior quality to that of other kinds of hospital. However, physician-owned hospitals are a type of for-profit hospital, and it is not clearly known if general service physician owned hospitals provide similar care as specialty hospitals. This research compared possible quality differences between specialty and general service physician-owned hospitals as well as with corporate-owned and not-for-profit hospitals. The results indicate that patients’ perceptions of quality of care are not consistent for physician-owned specialty and general service hospitals; the higher patient perception ratings for physician-owned hospitals reflect the better performance of specialty hospitals. In comparison with other hospitals, not-for-profit hospitals seem to provide better quality of care (tapped by both patient satisfaction and clinical outcomes) than for-profit hospitals. Corporate-owned hospitals were found to have lowest quality of care. Patients should consider tradeoffs between having better inpatient experiences and better outcomes of care.