BACKGROUND: High-cost healthcare users (HCUs) are patients who use disproportionate healthcare resources compared to their peers. A better understanding of their co-morbidity status, medication use, and healthcare utilization is needed to improve health interventions and policies. OBJECTIVES: We aimed to: (1) synthesize what is known about HCUs and interventions for managing them, (2) characterize how HCUs differ from non-HCUs, and (3) explore the impact of medications and whether prescribing quality contributes to differences in healthcare costs and HCU status development. METHODS: We synthesized what is known about HCUs and used the GRADE framework to evaluate the evidence for interventions designed to improve their health. We conducted retrospective population-based matched cohort and case-control studies of incident older adult HCUs using health administrative data. We examined prescribing and medication costs over the non-HCU to HCU transition period and compared them to non-HCUs. We conducted logistic regression to evaluate associations between HCU status development and the use of high-cost drugs and potentially inappropriate medications. RESULTS: HCU interventions to date have shown inconsistent effects on clinical outcomes and healthcare costs and the overall quality of evidence supporting their efficacy is low. Compared to non-HCUs, HCUs have higher rates of polypharmacy, hospitalization, and mortality. Medications are the highest healthcare cost category in the pre-HCU year and these costs rise nearly 1.7-fold in the HCU year. High-cost drug use increases significantly during the HCU transition period and 3.6% achieve HCU status based on drug costs alone. Use of several potentially inappropriate medications and high-cost drugs significantly increase the odds of HCU development. CONCLUSIONS: Medications can contribute to high-cost healthcare directly through drug costs alone or indirectly through adverse effects on health. Medication optimization interventions and policies to reduce inappropriate medication use and ensure cost-effective medication use are needed to manage high-cost healthcare and prevent HCU development. / Thesis / Doctor of Philosophy (PhD) / High-cost healthcare users (HCUs) are patients who use disproportionate healthcare resources compared to their peers. More research is needed to better understand HCUs to design interventions to improve their health outcomes and costs. In this thesis, we evaluated what previous studies have discovered about HCUs and we used Ontario’s health system data to explore whether the quality of prescribing and medication use in older adults influences their risk of becoming a HCU. We found that current interventions for HCUs have had inconsistent effects on improving health outcomes and costs. We also found two medication-related factors contributing to the risk of becoming an older adult HCU: (1) use of very expensive medications, and (2) use of potentially inappropriate medications where the risk of harm may outweigh potential benefits. Interventions and health policies to optimize the appropriate and cost-effective use of medications are needed to manage high-cost healthcare and prevent HCU development.

Many manufacturing firms, driven by the goal of beating the competition, have relocated their manufacturing operations from a high to a low cost environment, creating issues for the western social welfare. In order to maintain manufacturing in high cost environments, firms located in such environments must improve their competitiveness. Research has shown that firms need to be able to identify, develop and improve the operations capabilities that have the highest impact on the competitiveness. However, there is presently no coherent and contemporary framework of operations capabilities in the literature. There is also a lack of knowledge about operations capabilities in a high-cost environment. Therefore, the purpose of this research is to investigate critical operations capabilities in a high-cost environment. This purpose has been addressed through two studies. The first investigated critical operations capabilities in a general environment, and was conducted through a systematic literature review (Paper I). The second study investigated critical operations capabilities in a high cost environment and was conducted through a focus group (Paper II) and a multiple case study (Paper III). The result of this research is a framework of operations capabilities in a high cost environment. The framework includes seven dimensions and 23 operations capabilities. Specifically, the dimensions are: cost, quality, delivery, flexibility, service, innovation and environment. The findings revealed that quality is considered as the most critical dimension in a high cost environment, while environment is considered as the least critical in a high cost environment. The findings also revealed two additional operations capabilities in the empirical data, which are 'flow efficiency' and 'employee flexibility'. This research contributes to the current body of knowledge by introducing a novel perspective and original thinking about operations capabilities in a high cost environment. The framework of operations capabilities could support both practitioners and researchers in the identification and development of critical operations capabilities for winning strategies in a high cost environment.

Doctor of Philosophy(PhD) / In the public hospital sector in Australia there is no dedicated scheme to offset costs associated with high cost medications (HCMs) to the institution or the public. (1) Concerns exist as to the equity of access and appropriate mechanisms to manage access to HCMs in public hospitals. (2) There are gaps in the literature as to how decisions are made, and in particular, decision-making processes by which ethical, clinical and economic considerations maybe taken into account. To date, limited work has been conducted regarding the use and funding of HCMs in public hospitals. There are no published data on perceptions, concerns and attitudes, among health care decision-makers or among the community-at-large about access to HCMs in public hospitals. The research reported in this thesis describes the decision-making process and criteria used by health care decision-makers to allocate resources to HCMs in public hospitals. The investigation triangulated quantitative and qualitative methods used to collect and analyse data. Four studies were conducted to describe the decision-making process and explore the perceptions, concerns and attitudes of health care decision-makers and the perceptions of members of the general public regarding access to HCMs in public hospitals. The first study, reported in Chapter Three, was a review of individual patient use (IPU) requests for non-formulary HCMs. This study showed that these requests had a significant impact on the capped expenditure of a public hospital. Subsequent to this review, a new policy and procedure for managing requests for HCMs for IPU was established. A high-cost drugs subcommittee (HCD-SC) operating under the auspices of the Drug and Therapeutics Committee (DTC) was created. The second study, reported in Chapter Four, described the operations of the newly formed HCD-SC. This study also evaluated the decision-making process using the ethical framework “accountability for reasonableness”. (3) Different factors were involved in decisions about access to HCMs and decisions were not solely based on effectiveness and cost. HCD-SC members considered it was important to have consistency in the way decisions were being made. The evaluation of this process allowed identification of good practices and gaps which were considered as opportunities for improvement. The third study, reported in Chapter Five, found that health care decision-makers in an Area Health Service echoed the concerns and agreed about the problems associated with access to HCMs expressed by the HCD-SC members. These studies concluded that the majority of decision-makers wanted an explicit, systematic process to allocate resources to HCMs. These studies also identified tensions between funding systems and hospital decision-making. According to participants there were no mechanisms in place to systematically capture, analyse and share the lessons learned between the macro level (ie. Federal, Pharmaceutical Benefits Scheme - PBS) and the meso level (ie. Institution, public hospital) regarding funding for HCMs. Furthermore, decision-makers considered there are strong incentives for cost-shifting between the Commonwealth and the States. Health care decision-makers also acknowledged the importance of public participation in decision-making regarding allocation of resources to HCMs in public hospitals. However the results of these studies showed that those decisions were not generally made in consultation with the community. Decision-makers perceived that the general public does not have good general knowledge about access to HCMs in public hospitals. A survey of members of the general public, reported in Chapter Six, was then conducted. The survey aimed to gather information about the knowledge and views of members of the general public about access to HCMs in public hospitals. Results of this fourth study showed that respondents had good general knowledge but were poorly informed about the specifics of funding of hospitals and HCMs in private and public hospitals. The results also offered support for the development of a process to involve community members in discussion on policy on the provision of treatment and services within health care institutions and specifically, to seek the views of members of the public on the provision of HCMs and expensive services within public hospitals. In summary, the research reported in this thesis has addressed the gaps in the literature as to how decisions are made, and in particular, the decision-making process and criteria used by health care decision-makers to allocate resources to HCMs in public hospitals. In a move towards more explicitness in decision-making regarding the allocation of scarce health care resources, the findings from these studies provide an evidence base for developing strategies to improve decision-making processes regarding access to HCMs the public sector.

Doctor of Philosophy(PhD) / In the public hospital sector in Australia there is no dedicated scheme to offset costs associated with high cost medications (HCMs) to the institution or the public. (1) Concerns exist as to the equity of access and appropriate mechanisms to manage access to HCMs in public hospitals. (2) There are gaps in the literature as to how decisions are made, and in particular, decision-making processes by which ethical, clinical and economic considerations maybe taken into account. To date, limited work has been conducted regarding the use and funding of HCMs in public hospitals. There are no published data on perceptions, concerns and attitudes, among health care decision-makers or among the community-at-large about access to HCMs in public hospitals. The research reported in this thesis describes the decision-making process and criteria used by health care decision-makers to allocate resources to HCMs in public hospitals. The investigation triangulated quantitative and qualitative methods used to collect and analyse data. Four studies were conducted to describe the decision-making process and explore the perceptions, concerns and attitudes of health care decision-makers and the perceptions of members of the general public regarding access to HCMs in public hospitals. The first study, reported in Chapter Three, was a review of individual patient use (IPU) requests for non-formulary HCMs. This study showed that these requests had a significant impact on the capped expenditure of a public hospital. Subsequent to this review, a new policy and procedure for managing requests for HCMs for IPU was established. A high-cost drugs subcommittee (HCD-SC) operating under the auspices of the Drug and Therapeutics Committee (DTC) was created. The second study, reported in Chapter Four, described the operations of the newly formed HCD-SC. This study also evaluated the decision-making process using the ethical framework “accountability for reasonableness”. (3) Different factors were involved in decisions about access to HCMs and decisions were not solely based on effectiveness and cost. HCD-SC members considered it was important to have consistency in the way decisions were being made. The evaluation of this process allowed identification of good practices and gaps which were considered as opportunities for improvement. The third study, reported in Chapter Five, found that health care decision-makers in an Area Health Service echoed the concerns and agreed about the problems associated with access to HCMs expressed by the HCD-SC members. These studies concluded that the majority of decision-makers wanted an explicit, systematic process to allocate resources to HCMs. These studies also identified tensions between funding systems and hospital decision-making. According to participants there were no mechanisms in place to systematically capture, analyse and share the lessons learned between the macro level (ie. Federal, Pharmaceutical Benefits Scheme - PBS) and the meso level (ie. Institution, public hospital) regarding funding for HCMs. Furthermore, decision-makers considered there are strong incentives for cost-shifting between the Commonwealth and the States. Health care decision-makers also acknowledged the importance of public participation in decision-making regarding allocation of resources to HCMs in public hospitals. However the results of these studies showed that those decisions were not generally made in consultation with the community. Decision-makers perceived that the general public does not have good general knowledge about access to HCMs in public hospitals. A survey of members of the general public, reported in Chapter Six, was then conducted. The survey aimed to gather information about the knowledge and views of members of the general public about access to HCMs in public hospitals. Results of this fourth study showed that respondents had good general knowledge but were poorly informed about the specifics of funding of hospitals and HCMs in private and public hospitals. The results also offered support for the development of a process to involve community members in discussion on policy on the provision of treatment and services within health care institutions and specifically, to seek the views of members of the public on the provision of HCMs and expensive services within public hospitals. In summary, the research reported in this thesis has addressed the gaps in the literature as to how decisions are made, and in particular, the decision-making process and criteria used by health care decision-makers to allocate resources to HCMs in public hospitals. In a move towards more explicitness in decision-making regarding the allocation of scarce health care resources, the findings from these studies provide an evidence base for developing strategies to improve decision-making processes regarding access to HCMs the public sector.

Master of Science

Introdução: O medicamento, imprescindível no tratamento e recuperação da saúde, cresce em importância, tanto para os profissionais de saúde como para a população. Objetivo: Incluir a experiência da população de baixa renda, na pesquisa em saúde pública, sobre necessidade de tomar medicamentos; apresentar dificuldades vivenciadas, em busca destes; relatar as estratégias adotadas, diante da impossibilidade de consegui-los gratuitamente; estudar a compreensão do valor monetário deste produto; identificar a possibilidade de aquisição de medicamentos de médio e alto custo. Método: Metodologia qualitativa, usando a técnica de grupo focal, com a construção de 3 grupos, com a participação de 31 sujeitos, no período de dezembro de 2008 a março de 2009. Os sujeitos são moradores da região do Butantã, SP/SP, com 40 anos ou mais, com renda mensal até 3 salários mínimos e usuários do SUS, fazendo uso de pelo menos um medicamento. Os três grupos foram formados por usuários de medicamentos de uso contínuo; usuários de medicamentos de médio e alto custo e por moradores de uma favela. As discussões foram conduzidas por 2 profissionais e, foram baseadas em 5 perguntas referentes aos objetivos. Para a análise das discussões, optou-se pelo método do DSC (Discurso do Sujeito Coletivo), com utilização do software Qualiquantisoft®. Resultados: As discussões geraram 23 respostas categorizadas, destacando: a necessidade do medicamento, a dificuldade para consegui-lo gratuitamente; a má divulgação e a falta de informação sobre os programas de distribuição gratuita; a dependência de terceiros para aquisição; a necessidade de procura do medicamento em vários postos de saúde; a necessidade de compra. Medicamentos com preço até 50 reais foram considerados caros para a maioria. Os de alto custo são adquiridos, com algumas dificuldades, destacando-se tempo de espera, e falhas na dispensação. Conclusão: O acesso aos medicamentos mostrou-se parcial, apesar do avanço das políticas públicas na área, fazendo-se necessário um amplo conjunto de medidas, que priorize a manutenção de estoques regulares, a humanização do atendimento, a disponibilidade de profissionais competentes e que tenham compromisso social, para que a população de baixa renda alcance gratuitamente o sucesso terapêutico desejado, de forma regular e sistemática. / Introduction: Prescription drugs are indispensable to medical treatment for both health professionals and the general population. Objective: the goals of this study were to include in public health research the experience of the poor population who needs prescription drugs; to describe practical difficulties of the poor population to obtain prescription drugs from public health units; to report the main actions taken by this population when it is not possible to obtain free drugs in public health units; to evaluate the comprehension of the financial value of these drugs within this demographic segment of the population; to identify the strategies to obtain prescription drugs of medium and high cost. Method: The focal group qualitative method was selected for this research, with three groups comprising 31 subjects, studied in the period from December 2008 to March 2009. Subjects had to be residents of Butantã District, São Paulo-SP; besides being over 40 years old, in use of at least one prescription drug; to have a monthly income of up to three minimum salaries; to be a regular user of the public health system and units. All subjects lived in slums and were under treatment with medium-high cost drugs of continuous use. Two professionals conducted discussions on the five questions concerning the objectives. The collective subject method (CSM) was used for the analysis, which was performed with the Qualiquantisoft® computer program. Results: the five questions generated 23 answers, which were characterized as follows: necessity of the drug; difficulty to obtain the drug from public health units; deficiency in the advertisement programs and lack of information on free distribution programs; reliance on other people to obtain the drugs; necessity to reach many public health units to obtain the drugs; necessity to buy the drug. Drugs with prices up to R$ 50,00 were considered expensive. High cost drugs are purchased with some difficulty, such as slot time and dismissing flaws. Conclusion: Despite the advances in public health policies, the access to prescription drugs was biased, revealing a demand for a set of actions to prioritize storage and regular maintenance of these drugs, well prepared professionals to speed up and humanize the advising and assistance strategies in public health units, in order to promote a better distribution of these drugs and the effective achievement of therapeutic success for this population in a regular and systematic way.

As the lending practices of the alternative financial services (AFS) industry harm many consumers and consumers' access and use of traditional credit are restricted, the use of AFS is a growing concern. The financial education of consumers determines their financial behavior, which may be inadequate to make effective financial decisions regarding high-cost borrowings. The purpose of this quantitative study was to examine if and to what extent the sources of financial education is related to the use and frequency of use of AFSs among U.S. consumers. The theory of planned behavior and the transtheoretical model of change shaped the theoretical framework for this study. An explanatory correlational design was used to analyze archival data collected by the FINRA Investor Education Foundation for their 2015 National Financial Capability Study. Binary logistic and negative binomial regression analyses indicated that exposure to formal financial education did not contribute to reduced use and lower frequency of use of AFSs but, instead, contributed to the exact opposite. Only parental financial education was found to contribute to reduced use and lower frequency of use of AFSs. One-way ANOVA analyses indicated that all forms of financial education contributed to increased perceived financial knowledge. This study may lead to positive social change by informing policymakers about the necessary steps to remedy the problem of continuous AFS usage and serving as a foundation for future studies that should consider other factors beyond formal financial education that could influence the use and frequency of use of AFSs.

Purpose – The purpose of this thesis is to identify the critical competitive priorities and capabilities that enables competitive manufacturing in the high cost environment of Sweden and how these can be improved to increase manufacturing performance. Method – The purpose of this thesis was achieved through two main research methods. First a systematic literature review was conducted in order to condensate the existing literature on competitive priorities and capabilities. Secondly a case study was conducted in order to examine the identified competitive priorities and capabilities in the context of a high cost environment. Findings – Initially, a set of articles were identified and included in the literature review. Through an analysis of the included articles, a framework was created including competitive priorities and competitive capabilities. A comparison between the framework and the empirical data collected at the case company identified a number of priorities and capabilities considered critical for competitive manufacturing in a high cost environment. The literature review revealed a set of improvement actions and methods that could be used to improve the identified critical competitive priorities and capabilities in order to increase manufacturing performance. Implications – The thesis makes a theoretical contribution by condensing the existing literature on competitive priorities and capabilities in a high cost environment, and creates a starting point for future research. Further it makes a practical contribution by providing awareness for practitioners regarding priorities and capabilities, what may be important in the future, and how these could be improved. Limitations – This study identifies how critical priorities and capabilities can be improved, however, it does not specify how they can or should be applied and used. Additionally, the inclusion criteria in the systematic literature review did not include improvement actions and thus other suggestions for improvements may not be included. The case study was limited to one company, making the result difficult to generalize.

Operations capabilities provide the fundamental basis of competitive advantage for manufacturing firms. Thus, it is crucial for managers as well as researchers to understand the importance of operations capabilities within the respective market environment. This thesis evaluates the most important operations capability dimensions as well as operations capabilities for competitive manufacturing in a high-cost environment and how they differ based on manufacturing firm characteristics. Therefore, a quantitative survey was conducted within the high-cost environments Sweden and Germany. Empirical findings show that quality is the order-winning criterion in high-cost environments, followed by delivery, cost and flexibility. However, the importance highly differs across the various manufacturing firm characteristics. Managers of manufacturing firms in high-cost environments can use these findings to validate and adjust their operations strategy to achieve a competitive advantage.

This thesis examines the regulation and development of the moneylending and pawnbroking markets in Britain since the 1870s. The six regulatory episodes examined illustrate how the role of state intervention in these markets has been debated, and how it has evolved. The thesis asks: what were the motivations for reform, which market features were regulators most concerned with, and what were their proposed solutions? It demonstrates how majority and minority viewpoints have informed regulation and documents the often-conflicting expectations of how regulation was meant to influence lending decisions, borrower outcomes and poverty. By identifying the primary motivating factors behind regulation, the study answers why and how some policymakers sought to restrict low-income borrowers from gaining access to credit. It finds that policymakers have shifted their focus from market competition and freedom of consumer choice towards financial inclusion and poverty reduction. The result is a better understanding of the regulation and development of two credit products that were, and remain, vital to the working class. This research shows that the motivations for reform have varied over time. In 1872, 1900, 1927, 2006 and after the Great Recession, policymakers sought to restrict ‘illegitimate, evil and predatory’ small loan lenders, who were accused of exacerbating the conditions of the poor. In 1974, policymakers sought enhanced regulation such as information disclosure to increase market competition and decrease the cost of borrowing. In 2014, the FCA believed that the payday loan market still lacked price competition and implemented price controls as a corrective measure. Less varied were the issues of concern and proposed solutions. This research identifies five main areas of regulatory concern: the high cost of loans, advertising, the use of an annual percentage rate (APR), the legitimacy of moneylenders and pawnbrokers in the financial system and regulatory enforcement. It identifies three main policy responses: price controls, information disclosure and licensing. By analysing the motivations, debated issues and proposed solutions, this research examines wider questions concerning freedom of contract, borrower rationality, bargaining inequity, market segmentation and credit rationing. It contributes to the scholarly and policy dialogue on price controls, information disclosure and the development of non-bank lending. This research also provides new perspectives on the Victorian poverty debate and the modern financial inclusion agenda as they relate to the interaction between regulation, high-cost credit and poverty.