Significant out-of-pocket spending to afford medications to control blood glucose in elderly people with diabetes is one of the chief challenges to medication adherence. In an effort to reduce the financial burden of prescription drugs on the elderly, Medicare Part D was created and went into effect in 2006. However, one in four Medicare Part D beneficiaries experiences a coverage gap where they must pay 100% of total prescription drug costs. Approximately a quarter of those individuals discontinued their drugs when they reached the coverage gap. Currently, with the Patient Protection and Affordable Care Act of 2010, the coverage gap will be eliminated by 2020. This dissertation examines which factors affect medication adherence in adults with diabetes (Aim 1) and whether the recent policy effort of Medicare Part D effectively decreases the financial burden of prescription drugs on the elderly with diabetes (Aim 2). Chapter One provides the significance of out-of-pocket costs for medication adherence in elderly individuals with diabetes as well as background information on Medicare Part D and its coverage gap. Chapter Two reviews the literature to synthesize current knowledge that has informed the methodology for this dissertation. This chapter also identifies gaps in this body of work. These include comparing advantages and disadvantages of medication adherence as measured by patient self-report, pharmacy refills, and electronic lids on medication containers. Two systematic reviews are conducted in order to determine the most commonly used measurements and definitions of medication adherence measured by pharmacy claims data, and to identify barriers to and facilitators of medication adherence among adult diabetes patients. Lastly, previous studies that focused on the impact of Medicare Part D and its coverage gap on out-of-pocket pharmacy costs and medication adherence are reviewed. Chapter Three describes the methodologies to address Aims 1 and 2 including the study design, information on the data source, sample descriptions, a conceptual framework, study variables and analytic plans. Chapter Four presents key findings of this study, and Chapter Five concludes with summaries and interpretations of the findings, implications for practice and policy, and recommendations for future research.

The objectives of this study were to assess patient activation levels, to assess association between sociodemographic characteristics and patient activation, to assess association between health status characteristics and patient activation, and to assess association between patient activation and medication adherence among Medicare beneficiaries with type 2 diabetes. A retrospective cohort study was conducted using data from the 2009 through 2013 Medicare Current Beneficiary Survey (MCBS). Patient activation was measured with the Patient Activation Supplement in the MCBS and was categorized as low, moderate, and high levels based on activation scores. Medication adherence was assessed with proportion of days covered (PDC) using Medicare Part D administrative records from the MCBS within a period of six months after measurement of patient activation. The sample included Medicare beneficiaries who completed the MCBS Patient Activation questionnaire, who were diagnosed with type 2 diabetes, and who were 18 or older. Beneficiaries were excluded if they responded “Not ascertained,” “Not Applicable,” “Don’t know” or “Refused” to more than 50 percent of the Patient Activation questions, did not have continuous Medicare Part A and Part D coverage throughout the assessment period, had less than two Medicare Part D claims for an antidiabetic medication throughout the assessment period, used insulin during the assessment period, resided in long-term care facilities, or had Alzheimer’s disease, dementia, mental retardation or mental disorder. All analyses were conducted in SAS 9.4 for Unix environment. An <i>a priori</i> alpha level of 0.05 was used to determine significance. Bivariate and multivariable weighted ordinal logistic regression were applied for assessing associations. A total of 571 individuals met sample selection criteria. The mean age was 72.4 years. Of the 571 persons in the sample, 27.5 percent were at low activation level, 38.7 percent were at moderate activation level, and 33.7 percent were at high activation level. Approximately three-fourths of the sample persons were adherent to antidiabetic medications. Low activation was more likely to be found in males, less educated patients, and patients without arrhythmia. Ex-smokers as compared to non-smokers and overweight patients as compared to those with healthy weight were less likely to report low activation. In multivariable logistic analysis adjusting for race, gender, osteoporosis, Charlson Comorbidity Index score, and number of prescribed medications, patient activation level was not significantly associated with medication adherence. Non-Whites and patients with a Charlson Comorbidity Index score of 1 as compared to those with a score of 0 were more likely to be non-adherent. A lower number of prescribed medications was associated with higher odds of non-adherence.

With the passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Congress made changes to several important federal health programs. First, MACRA reformed the Sustainable Growth Rate, a mechanism created under the Balanced Budget Act of 1997. Second, MACRA instituted the framework for the QPP which solidifies efforts to shift payments to value-based arrangements and streamline several existing programs under a single policy. This thesis aims to better understand how providers are responding to this new policy in four parts. First, I explain how MACRA passed in Congress with nearly unanimous bipartisan support. Second, I review the QPP and the two tracks offered under the program. Third, I review the literature on value-based payment arrangements, including the response of providers and health systems to these arrangements. Finally, I present original research on how major health systems and provider groups in the state of Iowa are preparing for MACRA implementation. I find several characteristics among health systems and provider groups that are associated with efforts to align payments to value-based measures. Across the tracks laid out under the QPP, there is consistency in the types of investments and operational changes being made. Work on these changes has been occurring for several years, and continued investment and reforms are likely.

The Annual Wellness Visit (AWV) is a benefit available to Medicare beneficiaries. This benefit has the potential to address many areas of prevention in one focused visit to the primary care clinic, yet it is currently being provided to only 19% of Medicare beneficiaries. This research attempted to examine the extent to which certified health education specialists (CHES) have provided and perceive themselves to be prepared to provide the preventive health services (PHS) within the AWV, along with seven additional preventive counseling services (PCS). A web-based survey assessed the perceived preparedness of health educators, specifically CHES (N=998), to deliver these PHS. The results of these surveys include the development of a single factor internally consistent scale to measure perceived preparedness for the PHS within the AWV. They reveal health educators were least prepared to assist with end-of-life-planning and conduct a basic hearing test. No association was found for education level and perceived preparedness; however, prior experience did account for a significant amount of the variance in perceived preparedness to provide AWV services. Lastly, when compared to historical data regarding physician’s perceived preparedness to provide PCS, health educators were more prepared to counsel on diet and exercise and less prepared to counsel on six other PCS. These results may aid in the understanding of whether CHES perceive they are prepared to provide (PHS) and demonstrate the experience CHES have with each of these PHS.

In 2009, the Government Accountability Office reported that 15% of federal nursing home (NH) recertification surveys nationwide and 25% of surveys in nine states underscored serious deficiencies in nursing care provided to 1.5 million residents residing in NHs. The state nursing home survey agencies' surveyors attributed the Centers for Medicare and Medicaid Services (CMS) administrative rules and the documents in the surveyor guidance manual as too complex and ambiguous to correctly assign deficiency severity scores. In review of nursing literature, it was noted that standardized nursing language can increase the clarity of complex systems. The premise of this exploratory study was to determine if the standardized language of the Nursing Outcomes Classification (NOC) could provide a cross-linkage of the CMS rules, indicators of substandard nursing care, and the full guidance manual used to assign deficiency severity scores. The study attempted to achieve this goal by aligning select NOC outcomes and indicators with nursing outcomes indicators in the CMS administrative rules, select documents in the surveyor guidance manual and select documents in the Quality Indicator Survey. The data analysis suggested the relationship of the origin of the CMS rule and documents to the degree of alignment with the select NOC outcomes and indicators. It was also found that the intent of the CMS rule and select documents shared common themes. In addition, the data analysis revealed that the CMS rule and select documents aligned in various degrees with all of the selected NOC outcomes and respective indicators. The data analysis confirmed that there is sufficient evidence of a degree of alignment of select NOCs with the CMS rule and documents in the guidance manual for activities of daily living and functional status. Furthermore, the data analysis confirmed that this body of work can be a baseline for future research to develop an NOC specific to NHs as a viable cross-link to the CMS rules and guidance manual.

Multiple research studies have demonstrated racial, socioeconomic status (SES), and neighborhood disparities in first-line treatment of colorectal cancer patients, including those with metastatic colorectal cancer. However, disparities in adjunct monoclonal antibody treatment disparities have not been explored. The purpose of this study was to assess racial, SES, and neighborhood disparities in adjunct monoclonal antibody treatment of elderly metastatic colorectal cancer patients. The research was rooted in 3 theories: the fundamental cause theory, the diffusion of innovations theory, and theory of health disparities and medical technology. Data from the SEER-Medicare database and logistic regression were used to assess the relationship between the variables of interest and adjunct monoclonal antibody therapy. In this study, race (p = 0.070), SES (p = 0.881), and neighborhood characteristics (p = 0.309) did not significantly predict who would receive monoclonal antibody therapy. The results demonstrated a potential improvement in historically documented colorectal cancer treatment disparities. Specifically, historical treatment disparities may not be relevant to newer therapies prescribed to patients with severe disease. The difference could be related to improved access to care or a change in treatment paradigm due to the severity of metastatic colorectal cancer. Future studies aimed at understanding the causes of this social change (i.e., reduced treatment disparities) are warranted. Understanding the root cause of the reduced treatment disparities observed in this study could be used to reduce treatment disparities in other cancer populations.

In the fiscal year 2014, approximately 1,337 health care providers lost their provider license to Medicare/Medicaid fraud. Out of the 1,318 criminal convictions reported by the U.S. Medicaid Fraud Control Units (MFCU), 395 (30%) were home health care aides who claimed to have rendered services not provided. The purpose of this multiple case study was to explore licensed and certified home health care business managers' strategies to mitigate Medicare/Medicaid fraud risk. A purposive sampling of 9 business managers and chief executive officers from 3 licensed and certified home health care businesses in Franklin County, Ohio participated in semistructured face-to-face interviews. Data from the interviews were transcribed, coded, and analyzed to identify themes regarding Medicare/Medicaid fraud risk management strategies. Drawing from the Committee of Sponsoring Organization's internal control framework and fraud management lifecycle theory, 5 themes emerged: the control environment, risk assessment, control activities, information and communication, and monitoring activities. Findings from this study included maintenance of integrity and culture, training and educating both staff and clients about fraud reporting processes and the consequences of fraud, rotating staff on a regular basis, performing fraud risk assessments, implementing remote timekeeping and monitoring system, and compensating shift leaders to coordinate activities in the clients' residences. The implication for positive social change includes reducing healthcare cost for all taxpayers through Medicare/Medicaid fraud reduction.

Using the Health and Retirement Study Panel core files from 1996 to 2014, I analyze how Medicare Part D impacted access to prescription drug coverage by various demographic factors such as race, gender, and income. In Chapter 1, I find the highest take-up rates for those who were white, female, and with higher incomes. However, increases in coverage were high across the board, such that Medicare Part D also improved drug insurance coverage for those who were black, male, and with lower income. Thus, although Medicare Part D did increase prescription drug insurance coverage for seniors across the board, I also find potential for improvement in enrollment for difficult-to-reach groups. Next, Chapter 2 examines the impact of Medicare Part D on mortality. Although I do not find an impact on the life expectancy of respondents as a whole, I do find a significant positive effect for black respondents, indicating that Medicare Part D may have mattered more for disadvantaged groups. The largest impact is for black men, who have an additional 9 percentage point chance of living to age 73 for an additional 8 years of coverage (significant at the 5% level). When looking only at cardiovascular mortality, which is more likely to be influenced by drug coverage, I find improvements in life expectancy for the total population, with stronger effects for minorities and men. Overall, my findings suggest that Medicare Part D did move the needle on its goal: to improve the health of those who, without government intervention, had the most difficulty paying for prescription drugs. Chapter 3 looks at the impact of Medicare Part D prescription drug coverage on cost-related medication adherence, food insecurity, and finances among seniors. It would be reasonable to assume that Medicare Part D, which led to near-universal drug coverage among senior citizens, could allow seniors to shift money previously spent on drug expenditures to other areas. The strongest effect of Medicare Part D is on cost-related medication nonadherence, leading to a 21% decrease for an additional 8 years of Medicare Part D coverage. The impact is even stronger for the black male population (30%). I fail to reject the null hypothesis that Medicare Part D did not reduce food insecurity or household debt. Overall, Medicare Part D appears to have improved the financial stability of seniors.

The value-based purchase requirement of the Patient Protection and Affordable Care Act puts pressure on hospital leaders to control cost while improving quality of care. The resource dependency theory was the theoretical framework for this correlational study. Archival data from the Centers for Medicare and Medicaid Services collected from 166 acute care urban hospitals for the Fiscal Year 2016. Multiple linear regression analysis was used to determine the relationship between nursing salaries per patient day, cost of uncompensated care as a percentage of net patient revenue, percentage of net income from patient services, and overall patient satisfaction for quality of care received. The multiple regression analysis results indicated the model as a whole to significantly predict overall patient satisfaction for quality of care for the Fiscal Year 2016, F (3,162) = 13.788, p = .000, and R2 = .203. In the final model, all 3 independent variables significantly predicted overall patient satisfaction for quality of care. Nursing salaries per patient day and percentage of net income from patient services were significant positive predictors of overall patient satisfaction for quality of care. Nursing salaries per patient day (� = .366, t = 5.120, p = .000) accounted for a higher contribution to the model than percentage of net income from patient services (� = .169, t = 2.374, p = .019). The cost of uncompensated care as a percentage of net patient revenue displayed a significant negative relationship with overall patient satisfaction for quality of care (� = .176, t = €2.458, p = .015). The implications of this study for positive social change include the potential to enhance the quality of care for patients while maintaining local hospitals' financial viability.

Healthcare centers face increasing revenue risk under the Medicare Access and Children's Health Insurance Program Reauthorization Act (MACRA). The purpose of this multiple case study was to explore strategies that successful leaders of healthcare centers use to mitigate the risk of reimbursement penalties under MACRA. The conceptual framework of this study was Generation 3 cultural-historical activity theory (CHAT-III), and the analysis process used was Yin's recursive and iterative phases. Participants of this study were 6 leaders of healthcare centers in the United States identified as having high quality and low cost via the Centers for Medicare and Medicaid public use files. Semistructured interviews were used to explore the identification of strategic opportunity, strategy formation, implementation, and control. Themes for organizational culture that emerged from data analysis included a foundation core with flexibility and iterative process-improvement practice. Themes in the strategy formation process included total employee involvement and a quality-first, cost-benefit strategy structure. Themes in the implementation process included multiple departmental and organizational collaboration, task-based implementation, and data transparency. Localized cadence meetings were a theme in the control process. Improvements to the organization as a result of this study include a series of standards for organizational culture, a toolbox including CHAT-III as a tool for the identification of strategic opportunity and a methodology for strategy formation and implementation, and control to help ensure financial sustainability. Implications for positive social change include the increased probability of continued ready access to healthcare, improved population health, and lower mortality rates for the communities served.