The Medicare Annual Wellness Visit (AWV) has been available to Medicare beneficiaries since 2005; however, most eligible individuals have not taken advantage of this benefit. The literature supports that patients are willing to schedule and complete an AWV if urged to do so by their primary care provider; however, providers are reluctant to advise patients to pursue the AWV due to the lack of perceived value and overall health benefit. The integrative theory of health behavior change was used as the theoretical framework for the project. By increasing patient self-management skills through education, engagement, and support, the project was designed to create a positive impact on the overall health of individuals eligible for the AWV, as demonstrated by evidence of a long-term decrease in chronic conditions and related complications. A retrospective chart review was conducted to evaluate the number of preventive care measures completed in 2 patient populations: -¬those with a completed AWV in 2017, and those without a completed AWV in 2017. The number of completed preventive screenings for colon cancer, breast cancer, fall risk, and depression was as much as 41.6% higher among patients that had completed an AWV. The project's findings will be used to educate providers and patients about the usefulness of Medicare AWVs. Finally, the project findings support positive social change through enhanced patient activation in preventive health strategies.

Previous studies have shown that Medicare Part D beneficiaries tend not to switch plans even though they are encouraged to reevaluate their current plans and switch plans if needed every year. Little is known about why this "plan stickiness" occurs, so there is a critical need to better understand this non-switching behavior. This dissertation project aimed to describe how Part D beneficiaries processed information and how they perceived the plan switching process. It also aimed to describe how switchers and non-switchers were different and to test a model of Part D plan information processing that adapted from Motivation, Opportunity, and Ability (MOA) model. To achieve these objectives, this study had a cross-sectional descriptive design and used a mixed- methods approach consisting of focus groups, interviews, and mailed survey. The qualitative study sample was recruited from two cities in Iowa and transcripts of audio-recorded discussions were analyzed. The population studied in the quantitative phase was voter registered Iowa Part D beneficiaries who were older than 65 and did not receive Low Income Subsidies (LIS). Stratified random sampling was used to identify survey subjects. An eight page survey assessing factors related to Part D plan decisions was developed and mailed to 2,250 subjects, with reminder postcards as well as phone calls used to increase response rate. Finally, confirmatory factor analysis and structural equation modeling (SEM) were used to test a model of Part D plan information processing. A total of 16 participants from three focus groups and three interviews were included in the qualitative analysis. The results indicated that Part D beneficiaries processed different amounts of information even though they made the same decision (i.e. non-switching); whether to receive help from others in reviewing coverage options emerged as an important theme in the plan switching decision. A usable response rate of 22.5 percent was obtained. Of this sample, 264 respondents were non-LIS Part D beneficiaries and were used for further analysis. About one fifth of the sample switched plan between 2012 and 2013, supporting existing literature that has reported a low plan switching rate. Switchers and non-switchers had few demographic differences, but twice as many switchers as non-switchers received help from others in reviewing coverage options. The results from the SEM analysis indicated that those who had lower risk perception about plan switching, higher motivation, and higher self-efficacy were likely to read larger amounts of plan information. They also indicted that higher perceived risk, involvement, and self-efficacy were positively associated with motivation to process plan information. The findings of this dissertation suggest that plan stickiness has two types - active (i.e. informed choice) and passive (i.e. inertia) - depending on the amount of information processed, which was determined by beneficiaries' levels of perceived risk, motivation, self-efficacy, and needs. Furthermore, findings suggest that whether to receive help in understanding plan information may play a large role in leading informed beneficiaries to act on their knowledge and switch plans. The present study is the first to integrate the concept of information processing to understand Part D beneficiaries' plan switching decisions and the first to examine psychological factors affecting beneficiaries' information processing as well as their plan switching decisions. Study findings will help policy makers developing efficient communication strategies with beneficiaries to help them to make informed choices.

Continuity of patient care is an essential element of primary care because it should result in better quality care and disease management, especially for older adults who often have multiple chronic illnesses. Even though continuity of care has been studied for decades, it remains difficult to define and quantify and, there is no consensus about best practices for assessing whether or not a patient experiences it or a practitioner provides it. Moreover, no theoretically-driven measures for the assessment of continuity of care exist, and there have been few rigorous evaluations of its association with subsequent health and health service utilization outcomes. The principal purpose of this dissertation research was to better understand continuity of care for older adults by identifying the components of the patient-provider relationship that are important from the patient perspective, understanding how commonly used provider-proxy continuity measures relate to the patient experience, and evaluating whether the patient experience or provider-proxy assessments are associated with improved health and health services utilization. I used survey data from the 2,997 Medicare beneficiaries who participated in the 2004 National Health and Health Services Use Questionnaire (NHHSUQ) linked to their Medicare claims for 2002-2009. The NHHSUQ contained patient-reported data on usual primary provider, usual place of care, and the quality and duration of the relationship with their provider. By linking this information to their Medicare claims, I was able to evaluate both patient-reported and provider-proxy (claims-based) measures of continuity of care from two years prior to the survey, and evaluate the impact of continuity on health and health service utilization for five years after the survey. Study results indicate that the older adult patient experience of continuity is reflective of both relationship duration and patient-provider interaction during the care visit, and that most provider-proxy continuity assessments did not relate to patient perceptions. And, the patient and provider-proxy experiences of continuity had different relationships with important health outcomes. These results enhance our understanding of continuity of care for older adults and inform policymakers and researchers about aspects of continuity that are important for the health of older adults and the appropriate use of health care resources.

This work evaluates Medicare Hospice Benefit (MHB) eligibility standards that are referenced throughout this work as either "Medicare prognostic criteria," or "Local Medical Review Policies." Following the Chapter 1 overview of prognosis in end-stage disease, association between the Medicare clinical predictors and survival outcomes in dementing, cardiovascular and cerebrovascular illnesses are described in Chapter 2. Chapter 3 examines the prognostic belief systems of multidisciplinary hospice personnel. Chapter 4 seeks to improve the predictive performance of the Medicare prognostic criteria for dementia. The fifth and final chapter critiques the Medicare prognostic criteria from conceptual, methodological, and applied perspectives and suggests related research and policy directions. The Chapter 2 sample comprised 453 medical records of terminally ill persons; Chapter 4 sample, 187 medical records. Thirty-seven hospice personnel comprised the respondent sample in the Chapter 3 study. Chapter 2 assesses the scientific validity of federally sanctioned Medicare "severe illness/end-stage illness" demarcations in three non-cancer disease catregories. Calculation of measures of predictive validity revealed striking and consistent imbalances of false negative and false positive errors across the three diagnostic categories studied, suggesting inequitable distribution of the costs and benefits of regulatory reform among public health payers, consumers and providers. Chapter 3 qualitatively examines the belief systems of experienced hospice personnel regarding physical and non-physical time-to-death influences in end-stage disease. Non-physical survival influences were believed by these expert informants to have more survival impact in non-cancer as opposed to cancer end-stage diseases, and at remote as compared to imminent death proximities. Chapter 3 highlights the enormous complexity of time-to-death influences as well as the importance of non-physical influences on duration of survival in end-stage disease. Chapter 4 demonstrates that dropping one of the three prognostic criteria for dementia (the medical complications criteria) may improve predictive validity. This finding demonstrates that, in dementing illnesses at least, functional debility may better identify 6-month survival prognosis and thus hospice eligibility, than the composite Medicare prognostic criteria. The merit of parsimony in objective definitions of terminality is implied. Chapter 5 critiques the Medicare prognostic criteria, and suggests policy alternatives that are both prognostically- and non-prognostically-based. Peripheral findings of this work and suggestions for future end-of-life research conclude the dissertation.

The medicare system within the Taiwanese government has been cutting public hospitals' purchasing budget on antibiotic drugs year after year, making antibiotic suppliers less profitable. This essay takes a close look at how the medicare is minimizing aitibiotic supplier's profit, and the right sales strategies needed for suppliers to survive in this hostile environment.

Since January 2006 Medicare beneficiaries have the option to purchase prescription drug benefits from Medicare under the Part D program. The addition of outpatient drugs to the Medicare programs reflects Congress’ recognition of the fundamental change in recent years in how medical care is delivered in the U.S. It recognizes the vital role of prescription drugs in the health care delivery system and the need to modernize Medicare to assure their availability to Medicare beneficiaries. The Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA) created the Medicare drug benefit and specified a standard plan. The law also enables plans to offer alternative benefit packages that are either actuarially equivalent or provide enhanced benefits above the basic benefits. A majority of these alternative plans offer multitiered formulary where different medications have different patient copayments. Different from traditional Medicare, Part D benefits are provided by private sector plans through a competitive bidding process. Firms submit a bid to the Center for Medicare and Medicaid Services (CMS) which represents the expected cost to the firm for providing basic benefits to an individual of average health. The competition between plans was expected to drive premiums down toward marginal cost, ensuring that the beneficiaries receive maximum benefits for a given public expenditure (Biles et al. 2004). This dissertation examines the stand-alone Medicare Prescription Drug Plans (PDPs) bid and premium from the following perspectives using the 2006-2008 PDP data. First, we examine the use of multiple-tier copayment structures. In particular, we tend to discover the relationship between enrollee cost sharing at each tier and prescription drug plan (PDP) bids. Bids are equivalent to the total premiums charged by an insurer. This includes the premium paid by the consumer and the portion paid by the federal government. Further, we decompose plan bid and premium changes between 2006 and 2008 into two components, the proportion due to changes in plan characteristics and the proportion due to changes in marginal price. By doing so, we estimate whether the actuarial methods used to price those characteristics play a role in explaining the plan bid and premium difference across years.  Finally, we measure the Medicare beneficiaries’ sensitivity to price in the PDP market, specifically the elasticity and semi-elasticity of enrollment with respect to PDP premium.

Anecdotal descriptions and small studies have reported decreasing reimbursements from Medicare Part D sponsors and commercial third-party payers, resulting in decreased gross margins for independent pharmacies; however, reports are inconclusive regarding which payer more greatly affects independent pharmacies’ financial viability. Using 2006-2009 prescription claims data collected by a pharmacy switching company, the purpose of this study was to calculate and describe estimated reimbursement formulas and mean gross margins to assess the relative impact of these two payer groups. The study evaluated a total of 2,929,696 prescription claims paid for by Medicare Part D sponsors (n = 1,830,896) and commercial third-party payers (n = 1,098,800). The prescriptions were dispensed by 418 Texas independent pharmacies to 192,968 patients aged 65 to 94. Between 2008 and 2009, the median ingredient reimbursement ranged from AWP-17% to AWP-15% for Part D sponsors and from AWP-17.44% to AWP-15% for commercial third-party payers. The median dispensing fee ranged from $1.50 to $2.00 for Part D sponsors and from $1.10 to $2.00 for commercial third-party payers. For all payers, the median dispensing fee and median ingredient reimbursement decreased or was stagnant. Similarly, aggregate percent gross margin (calculated using the payers’ estimates of acquisition cost) decreased for both payer types between 2007 and 2009, with the mean gross margin of 4.0 percent earned for Part D prescriptions being higher than the 3.7 percent earned for commercial third-party prescriptions. In the same timeframe, the mean aggregate percent gross margin ranged from 2.8 percent to 6.0 percent among the five most popular Part D sponsors in the sample, and from 2.4 percent to 5.1 percent among the five most popular commercial third-party payers. The generic dispensing ratio explained a portion of the variance between and among payers. This study shows that significant variation exists in reimbursement formulas and percent gross margin between and among several of the most popular Part D sponsors and commercial third-party payers and supports pharmacy assertions that reimbursements from both payer types are decreasing. Pharmacies can respond to these pressures by being more conscientious of their business’ margins when reviewing contracts and increasing the proportion of generic drugs dispensed. / text

Chapter 1 investigates whether physicians' financial incentives influence health care supply, technology diffusion, and resulting patient outcomes. In 1997, Medicare consolidated the geographic regions across which it adjusts payments for physician services, generating area-specific price shocks that are plausibly exogenous with respect to health care demand. Areas with higher payment shocks experience significant increases in health care supply. On average, a 2 percent increase in payment rates leads to a 5 percent increase in care provision per patient. Elective procedures such as cataract surgery respond twice as strongly as less discretionary services like dialysis. Higher reimbursements also increase the pace of technology diffusion, as non-radiologists acquire magnetic resonance imaging scanners more readily when prices increase. The magnitudes of our empirical findings imply that changing provider incentives explain up to one third of recent growth in spending on physician services. The incremental care has no significant impacts on mortality, hospitalizations, or heart attacks. In chapter 2, we analyze bargaining between health care providers and private insurers in the shadow of large public insurance programs. Using several distinct sources of variation in Medicares payment rates, we find robust evidence that private insurers adapt to Medicare pricing. The relationship between private and public prices is both significantly positive and significantly less than one-for-one. The results reject both the strong view that private insurers mimic Medicare and views that emphasize cost-shifting as the predominant feature of these markets. Private responses to Medicare payments are larger in states with more competitive insurance markets. The evidence is consistent with models in which Medicares payment rates serve as a basis for negotiations between insurers and provider networks. Chapter 3 revisits the standard user cost model of housing prices and concludes that the predicted impact of interest rates on prices is much lower once the model is generalized to include mean-reverting interest rates, mobility, prepayment, elastic housing supply, and credit-constrained home buyers. The modest predicted impact of interest rates on prices is in line with empirical estimates, and suggests that lower real rates can explain only one-fifth of the rise in prices from 1996 to 2006. / Economics

The objective of this dissertation is to evaluate whether two different types of policy interventions in the United States are associated with health service utilization and economic outcomes. Paper 1: The number of government lawsuits accusing pharmaceutical companies of off-label marketing has risen in recent years. We use Medicare and Medicaid claims data to evaluate how an off-label marketing lawsuit and its accompanying media coverage affected utilization and spending on gabapentin as well as other anticonvulsant medications. In this interrupted time series analysis of dual eligible patients with bipolar disorder, we found that the lawsuit and accompanying media coverage corresponded with a decrease in market share of gabapentin, a substitution of newer and expensive anticonvulsants, and a substantial increase in overall spending on anticonvulsants. Paper 2: Medicare Part D was a major expansion of Medicare benefits to cover pharmaceuticals. There were initial concerns about how the dually eligible population who previously had drug coverage through Medicaid would fare after transitioning to Part D plans. Using a nationally representative longitudinal panel survey of Medicare Beneficiaries that are dually eligible for Medicaid, we investigated whether differences in generosity of Medicaid drug benefits were associated with differential changes in drug utilization and out-of-pocket spending for duals after they transitioned to Part D. Our finding suggest that those who previously encountered a monthly drug cap prior to Part D implementation experienced a differentially higher increase in annual prescription drug fills compared with those who did not face a cap.

Thesis (Ph. D.)--University of North Texas, May, 2007. / Title from title page display. Includes bibliographical references.