acase@tulane.edu / 1 / Yongkang Zhang

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Diskussioner kring kostnader inom hälso- och sjukvårdsverksamhets kan betraktas som ett omtvistat ämne. Avvägningen mellan kostnad och kvalitet är kanske mer komplext på detta område än på många andra. Moraliska aspekter, liksom värdighet och diskretion är exempel på avseenden som är svåra att mäta i ekonomiska termer men som är nödvändiga för att kvaliteten på vården skall betraktas som hög. Det kan således anses finnas en inbyggd konflikt mellan vissa kvalitetsaspekter och kostnaden för vården. Denna uppsats har sin utgångspunkt i vårdverksamhetens ökade ekonomiska styrning, vilket är en följd av de rationaliseringar och omstruktureringar som sedan 1980-talet uppmärksammats inom den offentliga sektorn och som går under benämningen New Public Management. Syftet är att utifrån relevant teori genomföra intervjuer för att samla information om hur de förändringar som kommit att ta plats inom hälso- och sjukvården märks av och hur de bemöts av vårdpersonalen, samt konsekvenser av styrningens villkor och effekter. Slutsatserna har landat i att det inte råder något tvivel om att New Public Management kommit att förändra organisation och styrning inom hälso- och sjukvården. Privata inslag, som målstyrning, uppföljning och utvärdering, lokalt verksamhetsansvar förenat med central kontroll, präglar numera verksamheten i syfte mot ökad effektivitet och produktivitet. Detta märks bland annat genom att verksamheten har utvecklats till att bli betydligt mer kostnadsmedveten. Det existerar en bred tillämpning av olika metoder och modeller för styrning av verksamheten, vilket lett till att det administrativa arbetet ökat - en utveckling som upplevs negativ inom verksamheten eftersom den strider mot vårdpersonalens intressen. Politikernas inflytande, vilket kommit att öka, betraktas främst som negativ, dels beroende på politikernas bristande kunskap inom ämnesområdet, dels på grund av att professionens auktoritet minskat. / Discussions on costs in health care activities can be regarded as a questionable substance. The balance between cost and quality is perhaps more complex in this area than in many others. Moral aspects, as well as dignity and discretion are examples of ways that are difficult to measure in monetary terms but which are necessary for quality of care should be regarded as high. It can therefore be considered to be a built-in conflict between certain aspects of quality and cost of care. This paper has its starting point in care activities increased financial control, which is a result of the rationalization and restructuring since the 1980s, attention in the public sector and termed New Public Management. The aim is that based on relevant theory conduct interviews to gather information about the changes that have come to take place in health care organizations and how they are treated by health professionals, as well as the consequences of it. The findings have landed in that there is no doubt that the New Public Management has changed the organization and management in health care. Private elements, as management by objectives, monitoring and evaluation, local business responsibilities associated with central control, now characterizes the activity in order to increase efficiency and productivity. This is shown inter alia by the business has evolved to be much more cost conscious. There is an extensive use of various methods and models for control of the operation, which have led to an increased degree of administrative work - a development that is perceived negatively in the activity since it is contrary to the interests of health professionals. The politicians’ influence, which reached to increase, mainly regarded as negative, partly due to politicians’ lack of knowledge in the subject, partly because of the profession's authority diminished.

<p>Diskussioner kring kostnader inom hälso- och sjukvårdsverksamhets kan betraktas som ett omtvistat ämne. Avvägningen mellan kostnad och kvalitet är kanske mer komplext på detta område än på många andra. Moraliska aspekter, liksom värdighet och diskretion är exempel på avseenden som är svåra att mäta i ekonomiska termer men som är nödvändiga för att kvaliteten på vården skall betraktas som hög. Det kan således anses finnas en inbyggd konflikt mellan vissa kvalitetsaspekter och kostnaden för vården.</p><p>Denna uppsats har sin utgångspunkt i vårdverksamhetens ökade ekonomiska styrning, vilket är en följd av de rationaliseringar och omstruktureringar som sedan 1980-talet uppmärksammats inom den offentliga sektorn och som går under benämningen New Public Management. Syftet är att utifrån relevant teori genomföra intervjuer för att samla information om hur de förändringar som kommit att ta plats inom hälso- och sjukvården märks av och hur de bemöts av vårdpersonalen, samt konsekvenser av styrningens villkor och effekter.</p><p>Slutsatserna har landat i att det inte råder något tvivel om att New Public Management kommit att förändra organisation och styrning inom hälso- och sjukvården. Privata inslag, som målstyrning, uppföljning och utvärdering, lokalt verksamhetsansvar förenat med central kontroll, präglar numera verksamheten i syfte mot ökad effektivitet och produktivitet. Detta märks bland annat genom att verksamheten har utvecklats till att bli betydligt mer kostnadsmedveten. Det existerar en bred tillämpning av olika metoder och modeller för styrning av verksamheten, vilket lett till att det administrativa arbetet ökat - en utveckling som upplevs negativ inom verksamheten eftersom den strider mot vårdpersonalens intressen. Politikernas inflytande, vilket kommit att öka, betraktas främst som negativ, dels beroende på politikernas bristande kunskap inom ämnesområdet, dels på grund av att professionens auktoritet minskat.</p> / <p>Discussions on costs in health care activities can be regarded as a questionable substance. The balance between cost and quality is perhaps more complex in this area than in many others. Moral aspects, as well as dignity and discretion are examples of ways that are difficult to measure in monetary terms but which are necessary for quality of care should be regarded as high. It can therefore be considered to be a built-in conflict between certain aspects of quality and cost of care.</p><p>This paper has its starting point in care activities increased financial control, which is a result of the rationalization and restructuring since the 1980s, attention in the public sector and termed New Public Management. The aim is that based on relevant theory conduct interviews to gather information about the changes that have come to take place in health care organizations and how they are treated by health professionals, as well as the consequences of it.</p><p>The findings have landed in that there is no doubt that the New Public Management has changed the organization and management in health care. Private elements, as management by objectives, monitoring and evaluation, local business responsibilities associated with central control, now characterizes the activity in order to increase efficiency and productivity. This is shown inter alia by the business has evolved to be much more cost conscious. There is an extensive use of various methods and models for control of the operation, which have led to an increased degree of administrative work - a development that is perceived negatively in the activity since it is contrary to the interests of health professionals. The politicians’ influence, which reached to increase, mainly regarded as negative, partly due to politicians’ lack of knowledge in the subject, partly because of the profession's authority diminished.</p>

Pharmaceutical manufacturers’ use of prescription brand-name drugs coupons and vouchers to subsidize patients’ cost-sharing obligations such as co-pays has increased. The co-pays are used by managed care organizations (MCOs) to give their plan members an appreciation of drug costs as well as to offer incentives to use available equivalent generic alternatives due to lower co-pays. With higher tiered co-pays for brand-name drugs being offset by coupons, little is known about MCO representatives’ perceptions about use of co-pay subsidy coupons for brand-name prescription drugs. The objective of this study was to assess health plan managers and pharmacy benefit managers (PBMs) perceptions on the use of prescription drug co-pay subsidy coupons. An online survey instrument was used to collect data. A convenience sample of 834 MCO representatives was selected from the Academy of Managed Care Pharmacy (AMCP) membership directory. A total of 122 surveys were returned of which 105 were usable surveys, giving a response rate of 13.7%. A five-point, 11-item Likert scale ranging from 1 through 5, (1 = ‘Strong Disagree’ and 5 = ‘Strongly Agree’) was used to measure respondents’perceptions. Some items referred to coupons used to get co-pay discounts repeatedly over a year (i.e., long-term use coupons) while some items referred to coupons distributed for trial purposes (i.e., short-term use coupons). Of the 105 respondents, 42 (40%) “agreed,” while 58 (55.2%) “strongly agreed” that co-pay subsidy coupons encouraged non-preferred brand-name drugs over preferred brand-name drugs. A total of 78 respondents (74.3%) reported that brand-name drug coupons undermined tiered formulary structure. Sixty respondents (57.1%) “strongly agreed” that short-term use coupons increased plan sponsor’s costs and 72 respondents (68.6%) “agreed” that sponsor cost increased with long-term use coupons. A total of 42 (40%) reported to “strongly agree” that short-term use coupons should be eliminated whereas 49 (46.7%) respondents reported “strongly agreed” that long-term use coupons should be eliminated. In summary, MCO representatives believe that brand-name drug utilization is increasing due to prescription drug incentives such as coupons which undermines their formulary controls and in turn, increases health care costs. / text

abstract: Social media sites focusing on health-related topics are rapidly gaining popularity among online health consumers, also known as "e-patients". The increasing adoption of social media by e-patients and their demand for reliable health information has prompted several health care organizations (HCOs) to establish their social media presence. HCOs are using social media to connect with current and potential e-patients, and improve patient education and overall quality of care. A significant benefit for HCOs in using social media could potentially be the improvement of their quality of care, as perceived by patients. Perceived quality of care is a key determinant of patients' experience and satisfaction with health care services, and has been a major focus of research. However, there is very little research on the relationship between patients' online social media experience and their perceived quality of care. The objective of this research was to evaluate e-patients' online experience with an HCO's social media sites and examine its impact on their perceived quality of care. Research methodology included a combination of qualitative and quantitative approaches. Data for this study was collected from Mayo Clinic's social media sites through an online survey. Descriptive statistics were used to identify basic demographic profiles of e-patients. Linear regression analysis was used to examine the relationship between online experience and perceived quality of care. Qualitative data was analyzed using thematic analysis. Results showed a positive relationship between online experience and perceived quality of care. Qualitative data provided information about e-patients' attitudes and expectations from healthcare social media. Overall, results yielded insights on design and management of social media sites for e-patients, and integration of these online applications in the health care delivery process. This study is of value to HCOs, health communicators and social media designers, and will also serve as a foundation for subsequent studies in the area of health care social media. / Dissertation/Thesis / M.S.D. Design 2011

Background: The United States health care system faces two fundamental challenges: a high growth rate of health care spending and deficiencies in quality of care. The growth rate of health care spending is the dominant driver of our nation’s long-term federal debt, while the inconsistent quality of care hinders the ability of the health care system to maximize value for patients. To address both of these challenges, public and private payers are increasingly changing the way they pay providers—moving away from fee-for-service towards global payment contracts for groups of providers coming together as accountable care organizations. This thesis evaluates the change in health care spending and in quality of care associated with moving to global payment for accountable care organizations in Massachusetts in the first 4 years. This thesis studies the Blue Cross Blue Shield of Massachusetts Alternative Quality Contract (AQC), a global payment contract that provider organizations in Massachusetts began to enter in 2009. The AQC pays provider organizations a risk-adjusted global budget for the entire continuum of care for a defined population of enrollees insured by Blue Cross Blue Shield of Massachusetts. It also awards substantial pay-for-performance incentives for organizations meeting performance thresholds on quality measures. This work assesses its effect on spending and quality through the first 4 years of the contract. Methods: Enrollee-level claims data from 2006-2012 were used with a difference-in-differences design to evaluate the changes in spending and quality associated with the Alternative Quality Contract over the first 4 years. The study population consisted of enrollees in Blue Cross Blue Shield of Massachusetts plans (intervention group) and enrollees in commercial employer-sponsored plans across 5 comparison states (control group). Unadjusted and adjusted results are reported for each comparison between intervention and control. Changes in spending for all 4 AQC cohorts relative to control were evaluated. In adjusted analyses of spending, I used a multivariate linear model at the enrollee-quarter level, controlling for age, sex, risk score, indicators for intervention, quarters of the study period, the post-intervention period, and the appropriate interactions. For analyses of quality, an analogous model at the enrollee-year level was used. Process and outcome quality were evaluated. Results: Seven provider organizations joined the AQC in 2009, with a total of 490,167 individuals who were enrolled for at least 1 calendar year in the study period. The control group had 966,813 unique individuals enrolled for at least 1 year during the study period. Average age, sex, and risk scores before and after the AQC were similar between the two groups. In the 2009 cohort, claims spending grew on average $62.21 per enrollee per quarter less than control over 4 years (p<0.001), a 6.8% savings. Analogously, the 2010, 2011, and 2012 cohorts had average savings of 8.8% (p<0.001), 9.1% (p<0.001), and 5.8% (p=0.04), respectively, by the end of 2012. Savings on claims were concentrated in the outpatient facility setting, specifically procedures, imaging, and tests (8.7%, 10.9%, and 9.7%, respectively, p<0.001). Organizations with and without risk-contracting experience saw similar average savings of 6.3% and 7.7%, respectively, over 4 years (p<0.001). About 40% of savings were explained by lower volume. Pre-intervention trends were not statistically different between intervention and control (-$4.57, p=0.86), suggesting savings were not driven by inherently different trajectories of spending. No differences in coding intensity were found. In sensitivity analyses, estimates were robust to alterations in the model, variables, and sample. Notably, claims savings were exceeded by incentive payments to providers (shared savings and quality bonuses) in 2009-2011, but exceeded incentives payments in 2012, generating net savings. Improvements in quality among intervention cohorts generally exceeded New England and national comparisons. Quality performance on chronic care measures increased from 79.6% pre-intervention to 84.5% post-intervention in the 2009 cohort, compared to 79.8% to 80.8% for the HEDIS national average, a 3.9 percentage-point relative increase over the 4 years. Analogously, preventive care and pediatric care measures increased 2.7 and 2.4 percentage points relative to control, respectively. On outcome measures, achievement of hemoglobin A1c, LDL cholesterol, and blood pressure control grew by 2.1 percentage points per year in the 2009 cohort after the AQC, while HEDIS averages remained largely unchanged (Figure). Conclusion: After 4 years, physician organizations in the AQC had lower spending growth relative to control and generally outperformed national averages on quality measures. Shared savings coupled with quality bonuses can exceed savings on claims in initial years, but over time, savings on claims may outgrow incentive payments. Incentive payments themselves may serve meaningful purposes, as quality measures may protect against stinting and shared savings may help ease providers into risk contracts. Changes in utilization suggest that this payment model can help modify underlying care patterns, a likely prerequisite for sustainable reform. The AQC experience may be useful to policymakers, insurers, and providers embarking on payment reform. Combining global budgets with pay-for- performance may encourage organizations to embark on the delivery system reforms necessary to slow spending and improve quality.

Bakgrunden till studien bygger på diskriminering av personal som har en annan etnisk tillhörighet än svensk tillhörighet. Utifrån Diskrimineringslagen (2008:567) utgör etnisk tillhörighet en av de sju diskrimineringsgrunderna, och avses när någon eller några personer tillhör en grupp med samma nationella eller etniska ursprung, hudfärg eller annat liknande förhållande utsätts för diskriminering. Diskrimineringen av en annan etnisk tillbehörighet kan leda till en utveckling av olika psykosociala arbetsmiljöproblem, både på samhälls- och individnivå även organisationsnivå. Följande studie belyser vård och omsorgspersonals upplevelse av diskriminering utifrån etnisk tillhörighet inom omsorgsorganisationer. Syftet är att ge en förståelse om och i så fall hur undersköterskor upplever diskriminerande behandling, utifrån deras etniska tillhörighet, i organisationer inom omsorg. Därmed också dess påverkan på deras psykosociala arbetsmiljö med hänsyn till vilken roll chefen har när det handlar om den här behandlingen. Den valda metoden innefattar en intervjustudie med semistrukturerade frågor där åtta informanter deltog. Intervjuarna analyserades med hjälp av kvalitativ innehållsanalys. Resultatet visar att deltagarna i studien upplever orättvis behandling, vilket påverkar deras psykosociala arbetsmiljö på ett negativt sätt. Resultat redovisar dessa två huvudkategorier, hur anställda upplever diskriminering, och hur ledarskapet påverkar upplevelserna av diskriminering. Sammanfattningsvis framträdde ett stort behov av chefens stöd, samt att / The background of the study is based on the discrimination that applies to a group of staff that has a different ethnic accession than a Swedish accession. Based on the discrimination law (2008:567) ethnic accession is based on one of the seven main causes of discrimination, and refers to when someone or a few people belongs to a group with the same national or ethnic origin, skin colour or other similarities are exposed for discrimination. The discrimination of another ethnic origin can lead to the development of various psychosocial problems at the individual level as well as in the community level. The following study highlights care and social care staff's experience of discrimination based on ethnic affiliation within care organizations. The purpose of this qualitative research study is to provide an understanding of how the assistant nurses experience discrimination, based on their ethnic affiliation, at organizations within the care sector, as well as the discriminations impact on their psychosocial work environment. The study is based on the interview guide around assistant nurse’s experiences on discrimination as well as the managers support and awareness. The chosen method includes an interview study with semi-structured questions where eight informants participate. The interviews were analysed with the support of a qualitative content analysis which means that meaning units that equals with the purpose are extracted, after which the material is condensed, coded and categorized systematically. The results showed that the participants in the study experience unfair treatment, which affects their psychosocial work environment in a negative way. Results report these two main categories, how employees experience discrimination, and how leadership affects the experiences of discrimination. In the conclusion emerged a need for the managers support, as well that women feel as they are more affected by discrimination based on their clothes, especially Muslim women.

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Problemformuleringen som ligger till grund för denna undersökning är att det förväntas bli brist på sjuksköterskor i hela landet och att tidigare undersökningar har visat att kommuner generellt anses vara mindre attraktiva arbetsgivare. Syftet med den här studien utgår från att undersöka vilka faktorer sjuksköterskor anser är attraktiva i ett kommunalt arbete. Vidare är syftet att jämföra synen på attraktivt arbete mellan sjuksköterskor och deras arbetsgivare för att se om bilden överensstämmer utifrån de båda perspektiven.   Tidigare forskning har visat att faktorer som är viktiga för en individ att lockas och stanna på en arbetsplats berör ett brett spektrum av faktorer. Viktiga faktorer berör bland annat arbetsmiljö, ledarskap, autonomi, uppskattning och möjlighet till utveckling. Studier som tidigare jämfört sjuksköterskornas och arbetsgivarens syn på attraktivt arbete har inte tagit hänsyn till arbetsmiljö som faktor och har mestadels genomförts i sjukhusmiljö. Den föreliggande studien har genomförts inom en kommunal verksamhet och utgått från individens uppfattning från deras egen livsvärld.  Studien grundar sig i ett fenomenologiskt förhållningssätt och använder en kvalitativ metod då datainsamling skett genom semistrukturerade intervjuer. Undersökningen har genomförts på två urvalsgrupper: sjuksköterskor och representanter från arbetsgivaren.   Faktorer som visar sig viktiga för sjuksköterskor i kommunal verksamhet är bland annat arbetsklimat, kollegor och ersättning. Synen stämmer till stor del överens med arbetsgivarens men skillnader återfinns i hur yrket betraktas, ersättningens betydelse samt vilken möjlighet som finns för utveckling och inflytande. Det finns ett behov av uppskattning och en ökad förståelse för den vård som sjuksköterskor bedriver. För den kommunala sjukvården är det två faktorer att fokusera på för att attrahera och behålla sjuksköterskor. / The background that forms the basis of this study is an expected shortage of nurses nationwide and earlier research that implies that public sector organizations generally are perceived as less attractive organizations. This study intend to obtain knowledge about which factors nurses perceive as attractive in a public sector organization. The aim of this study is to compare nurses and their managers perceptions of which factors that are important to attract and retain nurses, and further if these perceptions differ from each other.   Previous research have shown that there is a wide range of factors that are important to attract and retain nurses. The important factors are for example work environment, leadership, autonomy, appreciation and opportunity for development. Studies that previously been comparing the perceptions of nurses and their employers have not considered work environment as a factor, and they have been carried out mainly in a hospital environment. The present study is made in a public sector and the starting point is how the individual comprehend its reality.   The study has a phenomenological approach and uses an qualitative method on basis that the data collection has been done through semi structured interviews. The research have focused on two groups of candidates: nurses and representatives of the employer.  Factors that have shown to be important for nurses in a public sector is for example work climate, colleagues and salary. The nurse perceptions does in most parts correspond with the employers perception. Contradictions is found in how the profession is valued, the significance of salary and also the opportunity for development and autonomy. There is a clear need for appraisal and understanding for the care that is given by the nurses from the leaders and politicians in the organization. For the public sector healthcare that is two factors that should be focused on to attract and retain nurses.