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

Bakgrund: Hög personalomsättning påverkar patientvården negativt, vilket gör det avgörande att behålla personalen inom vården. Social exchange theory och the unfolding model beskriver personalomsättning och faktorer som driver omsättningen, inklusive organisationellt engagemang. Generellt rapporterar organisationellt engagerade arbetstagare lägre nivåer på intentionen att lämna. Syfte: Att granska och sammanställa empirisk forskning om organisatoriskt engagemang och dess påverkan på personalomsättningen inom vården. Metod: En begränsad systematisk översikt utfördes, vilket resulterade i 44 inkluderade artiklar av 204 granskade vilka sammanställdes narrativt. Resultat: Organisationellt engagemang var negativt korrelerat med intentionen att lämna och positivt korrelerat med intentionen att stanna. Organisationellt engagemang medierade även delvis och helt för relationen mellan uppsatsens olika identifierade faktorer med påverkan på beteendeintentionerna att lämna och stanna. Affektivt engagemang korrelerade måttligt negativt med avsikt att lämna, medan normativt engagemang visar en svag positiv korrelation. Faktorer som påverkar organisationellt engagemang och omsättning är bland annat arbetsrelaterade aspekter, organisatoriska förutsättningar, professionella faktorer, kommunikation och möjlighet till feedback, samt personliga faktorer. Studier fokuserar främst på kvinnliga vårdpersonal, data om könsskillnader är för begränsad för att dra slutsatser. Slutsatser: Organisationellt engagemang korrelerar med båda beteendeintentionerna och medierar delvis eller helt de påverkande faktorerna i det vetenskapliga underlaget. Uppsatsen finner stöd för att det saknas en direkt korrelation mellan organisationellt engagemang och personalomsättning, förhållandet medieras av beteendeintentionerna att stanna eller lämna. Att stärka organisationellt engagemang, främja hälsa och tillgodose personalens behov är väsentligt för att utveckla säkrare, mer hållbara och attraktivare vårdorganisationer. För att förbättra personalomsättning bör insatser fokusera på utvecklingsarbete av arbetsmiljö och arbetsuppgifter, värderade förmåner och möjlighet till kompetensutveckling. / Background: High staff turnover negatively affects patient care, which makes it crucial to retain staff in care. In general, organizationally committed workers are less likely to quit. Social exchange theory and theories of employee turnover and organizational commitment explain factors that drive turnover. Purpose: To review and compile empirical research on organizational commitment and its impact on staff turnover in healthcare. Method: A limited systematic review was performed, which included 44 included articles out of 204 reviewed compiled narratively. Results: Organizational commitment is negatively correlated with intention to leave and positively correlated with intention to stay. Organizationally engages the media's relationship between identified factors and turnover. Affective commitment correlates moderately with intention to leave, while normative commitment shows a weak correlation. Factors that affect organizational commitment and turnover include work-related aspects, organizational conditions, professional factors, communication and the opportunity for feedback, as well as personal factors. Studies focus mainly on female healthcare workers, data on gender differences are too limited to draw conclusions. Conclusions: Organizational commitment has a weak direct correlation with behavioral intentions. It is crucial to staff retention, and basically reflects how well the organization meets employee needs, which can affect staff turnover. There is no direct relationship between commitment and turnover, but relationships are mediated by behavioral intentions. Improving turnover requires effective resource allocation in the form of development work, valued benefits and opportunities for training. Strengthening engagement, promoting health and meeting staff needs is essential to developing safer, more sustainable and more attractive healthcare organizations.

This thesis aims at investigating the importance of effective implementation of health safety and hygiene legislations and practices in Health Care delivery systems. A new System Based Approach for Strategic Implementation of Occupational Health & Safety Practices is proposed in this thesis. The underlying principle of the approach is based on involvement and inputs from staff and management rather than by pre-specified requirements and objectives. Furthermore, the development process is a closed loop process that provides a mechanism for continuously evaluating system performance and monitoring activities that have considerable impact on health and safety practices. A case study was conducted in the medical laboratories of five major hospitals in the Emirate of Abu Dhabi. Data were collected through questionnaires, staff interviews, and reviewing laboratory safety reports compiled over a three years period. The main conclusions from this study are: 1. The proposed approach has proven to be useful in analyzing existing health and safety systems. The methodology and tools proved to be instrumental in defining inefficiencies and determining the status of the Health & Safety policies & practices in the selected medical laboratories. 2. Effective implementation of the proposed approach has shown improvements in productivity, operational cost, service quality, staff and management satisfaction. 3. The case study has demonstrated that a developing country such the UAE, with no previously existing Health & Safety legislation and little risk prevention culture, can rapidly and effectively introduce effective industry specific H&S by adopting an integrated systems based approach. 4. UAE has highly advanced and economically developing base, there is a general willingness at senior level within the UAE to achieve high levels of competence and standards in all industrial sectors. 5. CAP is a system based management tool which has been implemented globally, but only limited in the gulf region; CAP has been implemented by the author and colleges within Zayed Military Hospital between 2003-2007.

O gerenciamento de recursos materiais na área hospitalar tem assumido destaque principalmente com os avanços tecnológicos ocorridos nas últimas décadas. A incorporação de tecnologia sofisticada pode ser percebida pelo aumento da complexidade das práticas assistenciais e dos desafios que os gestores de instituições públicas e privadas enfrentam diante do aumento da oferta de produtos, que visam maior segurança aos pacientes e equipe de profissionais que lhes assistem, e do consumo dos materiais médico-hospitalares, com consequente elevação dos custos na prestação de serviços. A Agência Nacional de Vigilância Sanitária (ANVISA) tem como atribuição a regulamentação e regulação dos produtos para a área da saúde como forma de promover a vigilância em saúde e subsidiar as instituições quanto ao controle dos produtos na fase de pós-comercialização. Compete à Gerência de Risco Hospitalar o controle dos produtos das áreas de Tecnovigilância, Hemovigilância e Farmacovigilância. O objetivo desta pesquisa é analisar o processo de notificação da queixa técnica de material de consumo de uso hospitalar no contexto do gerenciamento de recursos materiais em um hospital universitário público, no período de 2007 a 2009. Trata-se de um estudo descritivo, retrospectivo, documental com abordagem quantitativa. Compreende a análise de 409 Impressos de Notificação, enviados para a Seção de Parecer Técnico, utilizados na instituição para formalizar o relato da ocorrência de queixa técnica. Destes, 260 preenchem os critérios de inclusão, constituindo-se na população investigada. As notificações analisadas estão agrupadas de acordo com sua finalidade, formando-se três grupos: material médico-hospitalar, material para higiene pessoal e material para uso no processo de esterilização. A construção do fluxograma do encaminhamento do Impresso de Notificação para material padronizado evidencia que a sequência de trabalho possibilita a caracterização da ação dos profissionais e das instâncias de decisão. No conjunto dos anos em análise, o mês de junho apresenta o maior número de notificações (36). Em relação à queixa técnica evidenciam-se os maiores índices no grupo de material médico-hospitalar. Os produtos identificados com maior frequência de notificação são representados pela luva cirúrgica, dispositivo de acesso venoso, equipo, seringa, papel toalha interfolha, fralda e embalagem para processo de esterilização. De acordo com a categoria de queixa técnica (embalagem, estrutura e aspecto alterado) destaca-se a presença das questões de estrutura nos três grupos de material. A participação da equipe de enfermagem é marcante, em especial a do profissional enfermeiro, totalizando 211 notificações; destas 69 enviadas pela Divisão de Centro Cirúrgico e 51 pela Divisão Materno Infantil. Em relação ao turno de trabalho, predomina o período diurno. Um dos objetivos do monitoramento das notificações de queixas técnicas é subsidiar informações para o sistema de Notificações em Vigilância Sanitária (NOTIVISA); sendo assim, foi possível a contribuição desta instituição com 20 notificações pertinentes à área de Tecnovigilância. Conclui-se que o Impresso de Notificação é uma ferramenta importante no gerenciamento de recursos materiais na área hospitalar. Através desse feedback é possível realizar o monitoramento da qualidade dos produtos na pós-comercialização, preservando a segurança para o paciente e equipe de saúde. / The management of material resources in the nosocomial field has gained prominence mainly due to the technological advances that have occurred in recent decades. The incorporation of sophisticated technology can be perceived by the increase in the complexity of care practices and the challenges that the managers of public and private institutions face due to both the increase in the supply of products that aim at greater safety for the patients and the team of professionals who assist them, and the consumption of medical-nosocomial material, with a consequent increase in costs in the provision of services. The National Health Surveillance Agency (ANVISA) is in charge of the rules and regulation of products for the health care area to promote health surveillance and assist the institutions as to the control of the products in the after sales phase. The Hospital Risk Management is in charge of the control of products in the areas of Tecnovigilância, Haemovigilance and Pharmacovigilance. This research aims to analyze the notification process of technical complaints about consumption material for hospital use in the context of material resources management in a public university hospital, in the period from 2007 to 2009. This is a documentary retrospective descriptive study with a quantitative approach. The analysis comprises 409 Notification Forms sent to the Section on Technical Advice, used by the institution to formalize the report of technical complaint occurrences. Of these, 260 met the inclusion criteria, thus composing the investigated population. The notifications under analyzes have been categorized according to their purpose, forming three groups: medical and nosocomial material, material for personal hygiene and material for use in the sterilization process. The construction of a flow chart of Notification Forms Reference for standardized material shows that the work sequence enables the characterization of the actions of professionals and decision-makers. In all the years under review, the month of June presents the greatest number of notifications (36). In relation to the technical complaints this research reveals that the group of medical nosocomial products received the highest indices. The products identified with increased notification rates are surgical gloves, devices for venous access, hoses, syringes, interfolha paper towels, diapers and packaging for the sterilization process. According to the category of technical complaints (packaging, structure and altered appearance), structure stands out in all three groups. The participation of the nursing team is notable, especially the professional nurses, totaling 211 notifications, 69 of which sent by the Surgical Center Division and 51 by the Infant Maternal Division. In relation to work shift, the day shift prevails. One of the objectives of monitoring technical complaints notifications is to feed the Sanitary Surveillance Notification System (NOTIVISA) with information. Thus this institution contributed with 20 pertinent notifications to the area of Tecnovigilância. It is concluded that the Notification Form is an important tool in material resources management in the nosocomial area. Through this feedback it is possible to carry out the monitoring of the quality of the products after sale while preserving the safety for the patient and the health care team.

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

Over the past 25 years, health care organization scholars have observed the dramatic emergence of hospital-based clusters in local markets throughout the U.S. These important organizational forms require same-system ownership of multiple general, acute care hospitals operating within a single local market, and as such they include multi-hospital systems that are entirely contained in a single urban market as well as clustered extensions or subsystems of larger regional and national systems. However, despite their noted growth as powerful forces in local markets, relatively few studies have examined these clusters, and as a result there remains a significant gap in our knowledge regarding their continued growth or the diverse components and configurations they may exhibit. This study endeavors to both describe and explain the diversity observed across hospital-based clusters. To fulfill this objective, a national inventory of clusters is updated to reflect cluster membership as of 2012, and a catalog of cluster components – including their hospital-based and non-hospital-based sites – is created, acknowledging that clusters today consist of more than just general, acute care hospitals. Cluster analysis methods are then employed to develop a taxonomy of cluster forms, using a sample of 114 clusters from local markets in Florida, Maryland, Nevada, Texas, Virginia, and Washington. Applying a conceptual framework informed by concepts from contingency theory and strategic management theory, cluster analysis methods yield a five-group solution, which is then externally validated using a multi-theoretical perspective synthesizing arguments from population ecology, institutional theory, industrial organization economics, transaction cost economics, and resource dependence theory. Results from descriptive and multinomial logistic regression analyses identify organizational and environmental factors that are significantly associated with various cluster forms. The study’s results suggest that today’s hospital-based clusters continue to grow and vary according to the dimensions of differentiation-configuration and integration-coordination. These findings provide a foundation for future examinations of hospital-based clusters, including their provision of services within and outside of hospital walls. These results also accentuate the importance of accounting for geographic considerations when examining health care organization forms, and they display the utility and value of employing a multi-theoretical perspective to examine and explain such complex forms.

O gerenciamento de recursos materiais na área hospitalar tem assumido destaque principalmente com os avanços tecnológicos ocorridos nas últimas décadas. A incorporação de tecnologia sofisticada pode ser percebida pelo aumento da complexidade das práticas assistenciais e dos desafios que os gestores de instituições públicas e privadas enfrentam diante do aumento da oferta de produtos, que visam maior segurança aos pacientes e equipe de profissionais que lhes assistem, e do consumo dos materiais médico-hospitalares, com consequente elevação dos custos na prestação de serviços. A Agência Nacional de Vigilância Sanitária (ANVISA) tem como atribuição a regulamentação e regulação dos produtos para a área da saúde como forma de promover a vigilância em saúde e subsidiar as instituições quanto ao controle dos produtos na fase de pós-comercialização. Compete à Gerência de Risco Hospitalar o controle dos produtos das áreas de Tecnovigilância, Hemovigilância e Farmacovigilância. O objetivo desta pesquisa é analisar o processo de notificação da queixa técnica de material de consumo de uso hospitalar no contexto do gerenciamento de recursos materiais em um hospital universitário público, no período de 2007 a 2009. Trata-se de um estudo descritivo, retrospectivo, documental com abordagem quantitativa. Compreende a análise de 409 Impressos de Notificação, enviados para a Seção de Parecer Técnico, utilizados na instituição para formalizar o relato da ocorrência de queixa técnica. Destes, 260 preenchem os critérios de inclusão, constituindo-se na população investigada. As notificações analisadas estão agrupadas de acordo com sua finalidade, formando-se três grupos: material médico-hospitalar, material para higiene pessoal e material para uso no processo de esterilização. A construção do fluxograma do encaminhamento do Impresso de Notificação para material padronizado evidencia que a sequência de trabalho possibilita a caracterização da ação dos profissionais e das instâncias de decisão. No conjunto dos anos em análise, o mês de junho apresenta o maior número de notificações (36). Em relação à queixa técnica evidenciam-se os maiores índices no grupo de material médico-hospitalar. Os produtos identificados com maior frequência de notificação são representados pela luva cirúrgica, dispositivo de acesso venoso, equipo, seringa, papel toalha interfolha, fralda e embalagem para processo de esterilização. De acordo com a categoria de queixa técnica (embalagem, estrutura e aspecto alterado) destaca-se a presença das questões de estrutura nos três grupos de material. A participação da equipe de enfermagem é marcante, em especial a do profissional enfermeiro, totalizando 211 notificações; destas 69 enviadas pela Divisão de Centro Cirúrgico e 51 pela Divisão Materno Infantil. Em relação ao turno de trabalho, predomina o período diurno. Um dos objetivos do monitoramento das notificações de queixas técnicas é subsidiar informações para o sistema de Notificações em Vigilância Sanitária (NOTIVISA); sendo assim, foi possível a contribuição desta instituição com 20 notificações pertinentes à área de Tecnovigilância. Conclui-se que o Impresso de Notificação é uma ferramenta importante no gerenciamento de recursos materiais na área hospitalar. Através desse feedback é possível realizar o monitoramento da qualidade dos produtos na pós-comercialização, preservando a segurança para o paciente e equipe de saúde. / The management of material resources in the nosocomial field has gained prominence mainly due to the technological advances that have occurred in recent decades. The incorporation of sophisticated technology can be perceived by the increase in the complexity of care practices and the challenges that the managers of public and private institutions face due to both the increase in the supply of products that aim at greater safety for the patients and the team of professionals who assist them, and the consumption of medical-nosocomial material, with a consequent increase in costs in the provision of services. The National Health Surveillance Agency (ANVISA) is in charge of the rules and regulation of products for the health care area to promote health surveillance and assist the institutions as to the control of the products in the after sales phase. The Hospital Risk Management is in charge of the control of products in the areas of Tecnovigilância, Haemovigilance and Pharmacovigilance. This research aims to analyze the notification process of technical complaints about consumption material for hospital use in the context of material resources management in a public university hospital, in the period from 2007 to 2009. This is a documentary retrospective descriptive study with a quantitative approach. The analysis comprises 409 Notification Forms sent to the Section on Technical Advice, used by the institution to formalize the report of technical complaint occurrences. Of these, 260 met the inclusion criteria, thus composing the investigated population. The notifications under analyzes have been categorized according to their purpose, forming three groups: medical and nosocomial material, material for personal hygiene and material for use in the sterilization process. The construction of a flow chart of Notification Forms Reference for standardized material shows that the work sequence enables the characterization of the actions of professionals and decision-makers. In all the years under review, the month of June presents the greatest number of notifications (36). In relation to the technical complaints this research reveals that the group of medical nosocomial products received the highest indices. The products identified with increased notification rates are surgical gloves, devices for venous access, hoses, syringes, interfolha paper towels, diapers and packaging for the sterilization process. According to the category of technical complaints (packaging, structure and altered appearance), structure stands out in all three groups. The participation of the nursing team is notable, especially the professional nurses, totaling 211 notifications, 69 of which sent by the Surgical Center Division and 51 by the Infant Maternal Division. In relation to work shift, the day shift prevails. One of the objectives of monitoring technical complaints notifications is to feed the Sanitary Surveillance Notification System (NOTIVISA) with information. Thus this institution contributed with 20 pertinent notifications to the area of Tecnovigilância. It is concluded that the Notification Form is an important tool in material resources management in the nosocomial area. Through this feedback it is possible to carry out the monitoring of the quality of the products after sale while preserving the safety for the patient and the health care team.

This thesis aims at investigating the importance of effective implementation of health safety and hygiene legislations and practices in Health Care delivery systems. A new System Based Approach for Strategic Implementation of Occupational Health & Safety Practices is proposed in this thesis. The underlying principle of the approach is based on involvement and inputs from staff and management rather than by pre-specified requirements and objectives. Furthermore, the development process is a closed loop process that provides a mechanism for continuously evaluating system performance and monitoring activities that have considerable impact on health and safety practices. A case study was conducted in the medical laboratories of five major hospitals in the Emirate of Abu Dhabi. Data were collected through questionnaires, staff interviews, and reviewing laboratory safety reports compiled over a three years period. The main conclusions from this study are: 1. The proposed approach has proven to be useful in analyzing existing health and safety systems. The methodology and tools proved to be instrumental in defining inefficiencies and determining the status of the Health & Safety policies & practices in the selected medical laboratories. 2. Effective implementation of the proposed approach has shown improvements in productivity, operational cost, service quality, staff and management satisfaction. 3. The case study has demonstrated that a developing country such the UAE, with no previously existing Health & Safety legislation and little risk prevention culture, can rapidly and effectively introduce effective industry specific H&S by adopting an integrated systems based approach. 4. UAE has highly advanced and economically developing base, there is a general willingness at senior level within the UAE to achieve high levels of competence and standards in all industrial sectors. 5. CAP is a system based management tool which has been implemented globally, but only limited in the gulf region; CAP has been implemented by the author and colleges within Zayed Military Hospital between 2003-2007.

The thesis deals with the problem of blind people in the Czech Republic. It describes the care for the blind from their birth to an old age. It deals with the specifics of different age groups and describes organizations providing care for them. The thesis contains the current problems from the practical point of view, case studies and the interviews with blind people.

<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>