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Medicaid provides coverage to approximately 60 million individuals and is the largest single payer of healthcare for children. Given this scope of the program and the concentration of low-income and minority recipients, improvements to the quality of care delivered to Medicaid members represents a significant opportunity to reduce health care disparities and improve the overall delivery and quality of healthcare within the U.S. The current study sought to evaluate the various approaches that state Medicaid agencies are taking to assess and improve the quality of care to their managed care enrollees and the degree to which they have implemented recommendations of various policy experts. A survey was distributed to the Medicaid Directors of all 50 states. A total of 23 states with risk based managed care programs responded, representing 62% of the states that have managed care programs. The results indicated that nearly all states are utilizing standard performance measures as one method to assess quality, with virtually all relying on HEDIS measures for this purpose. Additional strategies that are being used include public reporting of quality data and the use of pay-for-performance incentives; few states are currently focusing on health information technology. Recommendations are made for steps that the Medicaid program could take at both the state and federal level to further develop quality improvement programs.

Chief Executive Officers (CEO) remuneration has been a hot topic the last couple of years and has brought a great amount of attention in the media, when some companies have increased the CEO’s compensation even though the firm have been reporting lower earnings. Bonus systems have recently become more frequent to increase CEOs incentives, but have also been a disputed subject since the financial crisis in 2008. The aim of this thesis is to study the relation between CEO compensation and companies’ size as well as performance. The study extends over a four-year period, from 2007 to 2010, comprising the companies within the finance and real estate industry listed under large-, mid and small cap on NASDAQ OMX Stockholm. A four-year period from 2000 to 2003 and a  three-year period after the financial crisis from 2011 to 2013 is analyzed and taken into account in the study to get a deeper understanding of how the compensation has varied over time. The study takes a quantitative approach using secondary data from the companies’ annual reports. A pooled regression analysis is used as the statistical method where we are able to take multiple companies into account over several periods. The empirical results find that there is no significant relation between CEO compensation and firm performance. The study does however show a strong positive relation with market capitalization, suggesting that the companies’ size have a great effect on the CEO compensation.

Syftet med denna studie var att bidra med empiriskt material om hur relationen mellan individers framgång i ett monetärt belöningssystem och motivation påverkas av individers stewardship-grad. En stor del av tidigare forskning på motivation och monetära belöningssystem har fokuserat på det traditionella sambandet mellan motivation och prestation; att monetära belöningssystem är motivationsskapande. Vi valde istället att fokusera på det faktiska utfallet av ett monetärt belöningssystem, genom att analysera utbetald rörlig ersättning och dess relation till motivation med hänsyn till stewardship-teori. Vi utvidgade befintlig forskning och teori genom att separera effekten på motivation från en individs framgång i ett monetärt belöningssystem, och studerade effekten i samverkan med stewardship-grad. Det empiriska materialet inhämtades från två separata företag inom samma Skandinaviska koncern. I överensstämmelse med vår hypotes är ett monetärt belöningssystems utfall på motivation i allra högsta grad beroende av stewardship-graden. Vårt resultat indikerar att individer med en låg stewardship-grad blir mer motiverade när framgången i ett monetärt belöningssystem är högre. Vidare tyder vårt resultat att individer med en hög stewardship-grad blir demotiverade när framgång i ett monetärt belöningssystem ökar. Vårt resultat bidrar till befintlig forskning om monetära belöningssystem och motivationshämmande effekter. / The aim of this study was to contribute to empirical studies about how the relationship between an individual's prosperity in a monetary reward system and motivation is influenced by an individual's stewardship-rate. Most previous research regarding motivation and monetary reward systems had studied the traditional relationship between motivation and performance. Suggesting that motivation was created by offering pay for performance to employees. We on the other hand, focused on the aftermath of a reward system by analyzing actual outcome from a monetary reward system and its effects on motivation, with respect to stewardship-theory. We therefore extended previous research and theorizing by separating the effects on motivation from an individual's prosperity in a reward system, by testing the interaction effect between prosperity and stew-ardship-rate. The empirical data were collected through two separate companies within a Scandinavian corporate group. In conformity with our prediction, a monetary reward system and its outcome on motivation, is highly related to an individual's stewardship-rate. Our result indicated that individuals with a low stewardship-rate gets more motivated when prosperity in a monetary reward system is higher. Furthermore our results indicated that individual's with a high stewardship-rate gets demotivated when prosperity in a monetary reward system is higher. These results contribute to the existing research on monetary reward systems and motivational crowding-out.

Le paiement à la performance (P4P) appliqué aux soins ambulatoires a vu le jour dans les années 2000 dans les pays anglo-saxons et a connu un fort développement ces dix dernières années. Il a été introduit en France sous forme optionnelle au travers des Contrats d’Amélioration des Pratiques Individuelles (CAPI) en 2009, puis généralisé en 2012 avec la Rémunération sur Objectifs de Santé Publique (ROSP). Son principe consiste à allouer un surcroît de rémunération aux médecins en échange d’une meilleure qualité de leur pratique, celle-ci étant mesurée à partir d’une batterie d’indicateurs. Les principes de justice et de bienfaisance qui pourraient se voir renforcés dans ce cadre, semblent mis en tension avec le principe d’autonomie, le P4P pouvant être considéré comme un outil supplémentaire visant à normaliser les pratiques médicales tout en renforçant l’exclusion de toute singularité. Nous avons d’abord interrogé les médecins généralistes sur la notion de norme médicale. Ils ont semblé s'accommoder du concept sans exprimer le besoin de le préciser. Ils avaient le sentiment qu'une normalisation stricte de leur pratique était impossible. Les considérations éthiques, élevées en pare-feu, ont structuré leurs déclarations. Nous avons ensuite analysé la nature des freins à la signature du CAPI auprès d’un panel de plus de 1 000 médecins généralistes. Nous avons identifié deux profils de médecins : ceux percevant les risques éthiques comme étant globalement faibles et acceptant de signer (31,7%) et ceux les percevant forts, refusant de signer (68,3%). L’absence d’information des patients concernant l’adhésion de leur médecin au CAPI était le principal risque perçu par les non-signataires. Puis, nous avons étudié l’impact du P4P sur une variable associée à la qualité des soins : la durée de consultation. Notre principal résultat était que le CAPI n’a pas eu un impact significatif sur la durée de consultation. Enfin, nous avons interrogé directement des patients. Leur avis était très partagé, d’aucuns considérant que l’attribution d’une prime pourrait améliorer certaines pratiques comme la prévention et le dépistage, d’autres étant fondamentalement hostiles à ce principe qu’ils estimaient aller à l’encontre des valeurs du soin. / Pay for performance (P4P) applied to outpatient care has emerged in the 2000s and has experienced strong growth over the past decade. It was introduced in France under optional form through the Improvement of Individual Contracts Practice (CAPI) in 2009 and was generalized in 2012 with the Compensation on Public Health Objectives (ROSP). Its principle is to allocate additional compensation to doctors in exchange for a better quality of their practice, the latter being measured from a set of indicators. The principles of justice and beneficence that could be strengthened in this context seem in tension with the principle of autonomy. P4P can be regarded as an additional tool to standardize medical practices while reinforcing the exclusion of any singularity. We first asked general practitioners on the notion of medical standard. They appeared to live with the concept without expressing the need to clarify it. They felt that a strict standardization of their practice was impossible. The ethical considerations have structured their statements. We then analyzed the nature of the obstacles to the signature of CAPI from a panel of over 1,000 general practitioners. We identified two profiles of doctors: those feeling ethical risks as generally low and agreeing to sign (31.7%) and those perceiving them strong, refusing to sign (68.3%). The lack of patient information concerning the adherence of their doctor to a P4P contract was the main risk perceived by the non-signatories. Then, we investigated the impact of P4P on a variable associated with the quality of care: the consultation length. Our main result was that the CAPI has not had a significant impact on the consultation length. Finally, we interviewed patients directly. Their opinion was very divided, some thought the allocation of a bonus could improve certain practices such as prevention and screening, others being fundamentally hostile to this principle they considered going against the values care.

Le programme ‘rémunération à la performance’ (P4P) a, au cours des dernières années, devenu populaire pour les fournisseurs de soins de santé. Contrairement aux régimes de paiement traditionnels de soins de santé mesurés par le volume, il récompense les fournisseurs (individus ou institutions) qui répondent à certaines attentes en matière de la performance en ce qui a trait aux soins de santé de qualité ou de l'efficacité. Son développement à l’étranger a bien connu des avancées, au cours de la dernière décennie, même si les preuves empiriques sont mitigées. En septembre 2012, le gouvernement français a lancé son premier programme national de P4P pour les hôpitaux - Incitations Financières à l'Amélioration de la Qualité (IFAQ). Compaqh-MOS-EHESP a élaboré les principes de cette expérimentation.L’objectif de cette thèse est d’examiner et d'analyser les controverses autour du P4P, par l’analyse de la conception, de la mise en œuvre et de l'évaluation de l’impact d’IFAQ. Inspirés de programmes étrangers, IFAQ est conçu dans le contexte des soins de santé en France. Le processus de mise en œuvre d’IFAQ inclut la sélection de critères de jugement, la construction de score composite, et la décision des modes de valorisation financiers. L'évaluation de l'impact d’IFAQ est effectuée en comparant un groupe intervention et un groupe de contrôle, tout en tenant compte de l'évolution de la tendance des indicateurs de qualité et de l'effet d'une série de caractéristiques des hôpitaux.Un cadre d'analyse d’évaluation médico-économique des programmes P4P a également été construit. Enfin, la capacité de transfert du modèle IFAQ a été appréhendée par l’étude de son application potentielle dans un autre contexte, à savoir la Chine. / Pay-for-Performance (P4P) has, in recent years, become a popular remuneration method for health care providers. Unlike traditional health care payment schemes that focus on volume, It rewards providers (individuals or institutions) who meet certain performance expectations with respect to health care quality or efficiency. Internationally, P4P has experienced wide development over the last decade, though empirical evidences are mixed. In September 2012, the French government launched its first national P4P program for hospitals, named Financial Incentives for Quality Improvement (IFAQ). COMPAQH-MOS has developed the principles of this experiment.The aim of this thesis is to test and to analyse the existing P4P controversies, through the design, implementation and evaluation of IFAQ. Based on previous international programs, a new P4P initiative is designed under the actual French health care context. The implementation process of IFAQ involves selection of quality judgement criteria, construction of scoring method, and decision of financial incentive structures. The impact evaluation of IFAQ is conducted by comparing the treatment and control hospitals’ quality results, while taking into account time trend evolution of quality indicators and the effect from a group of hospital characteristics.A framework of cost-effectiveness analysis on P4P programs has also been constructed, and the feasibility of transferring P4P into another context, namely China, has been studied by conducting a case study of P4P in the Chinese health care market.

BACKGROUND: There is continued attention towards using patient demographic and clinical characteristics available in health administrative data when case mix adjusting the measurement of length of stay (LOS) for hospitalized children. However, little is known about what proportion of children’s LOS is explained by these characteristics. OBJECTIVES: The objectives of the study were to quantify the amount of variation in LOS within and across hospitals that is explained by demographic and clinical factors of hospitalized pediatric patients. METHODS: A retrospective cohort analysis was completed of 818,848 hospitalizations for any reason occurring from 1/1/2014 to 12/31/2014 in one of 44 freestanding children’s hospitals in the Pediatric Health Information Systems (PHIS) dataset. A generalized linear model was derived to simultaneously regress demographic factors [age, race/ethnicity, payer, rural residence, health professional shortage area (HPSA) residence, income, and distance traveled], and clinical factors (severity of illness, type and number of chronic conditions) on LOS. The percentage of LOS attributable to each characteristic within each hospital was quantified using the covariance test of the hospital random effect. RESULTS: The factors with the greatest impact on LOS were severity of illness and chronic condition type and number, with a median (interquartile range) of 16.8% (IQR 15.0%-19.4%) and 4.0% (IQR 2.9%-4.5%) of LOS, respectively, explained by these characteristics across hospitals. LOS varied significantly (p<0.05) with both severity of illness and chronic condition type and number for all 44 hospitals in the cohort. All patient demographic factors, (age, race/ethnicity, payer, rural residence, HSPA residence, income, and distance traveled) had minimal impact on LOS, with <0.1% of LOS explained by each characteristic. Across hospitals, 78.3% (IQR 75.8-80.2%)] of LOS remained unexplained by the patient characteristics under study. CONCLUSIONS: Patients’ clinical characteristics ascertained from administrative data account for approximately one-fifth of LOS whereas their demographic characteristics account for a negligible amount. Efforts to optimize the efficiency of inpatient care for hospitalized children might benefit from uncovering how much of the vast amount of unexplained LOS is due to modifiable aspects of care quality. / 2018-06-16T00:00:00Z

<p>This thesis focuses on two important areas of health economics: health dynamics during pre-adulthood, and physician behaviour. The first two essays seek to explore the important factors that determine the health production process during the period of pre-adulthood. The third chapter then turns the focus to physician labour and service provision behaviours.</p> <p>The first chapter examines the impact of family social economic status (SES) and neighbourhood environment on the dynamics of child <em>physical</em> health development. It examines the distribution of health outcomes and health transitions and explores the determinants of these distributions by estimating the contributions of family SES, neighbourhood status, unobserved heterogeneity and pure state dependence.</p> <p>The second chapter extends the research on health development in pre-adulthood by examining the roles of family SES, early childhood life-events, unobserved heterogeneity and pure state dependence in explaining the distribution of depression among adolescents and young adults. It also explicitly models the depression dynamics and quantifies both the mobility and persistence of this type of <em>mental</em> health problem from adolescence to early adulthood.</p> <p>The third chapter examines whether and how pay-for-performance (P4P) payments can motivate physician service provision to improve the quality of health care. It exploits a natural experiment in the province of Ontario, Canada to identify empirically the impact of P4P incentives on the provision of targeted primary care services, and whether physicians’ responses differ by age, practice size and baseline compliance level.</p> / Doctor of Philosophy (PhD)

During the past decades, CEO and board compensation has increased substantially. Top management compensation and firm performance has been an extensively researched subject, and a large amount of previous studies have examined the relation of top management pay and firm performance. However, the findings and discussions have been contradictory and inconsistent. The purpose of this thesis is to examine if there is a relationship between the top management variable compensation and firm performance. We aim to explore this subject in further depth by focusing on the Swedish context and by studying if contextual issues, in terms of different industries, have an impact on this relation. In order to examine this relation multiple regression analysis were performed. The empirical evidence displays that on a general level, incentive systems of the top management have no significant effect on firm performance. We also conclude that the relation of variable pay and performance is contingent on industry. We therefore argue that the context in which the firm operates has an impact on the investigated relation in this thesis. Furthermore, the Swedish context and the Swedish governance model can be considered as one of the main explanations of the attained result.

This study investigates the effects of insider entrenchment on Chief Executive Officer (CEO) compensation in firms conducting an initial public offering (IPO). The sample comprises 220 US firms that went public between 1996 and 2002. Corporate governance choices regarding entrenchment are captured by six provisions in the corporate charter and bylaws, as well as five anti-takeover statutes, which may or may not be in effect in the state of incorporation. Firm-level items are supermajority requirements for charter amendments, bylaws amendments, and merger approvals, along with the presence or absence of a staggered board of directors, poison pills, and golden parachute agreements. The anti-takeover laws examined are Business Combination, Control Share Acquisition, Fair Price, Poison Pill Endorsement, and Constituencies Statutes. A factor analysis reveals three distinct components of entrenchment: firm- and state-level external entrenchment and firm-level internal entrenchment. External entrenchment is related to market control over management by means of corporate takeovers; internal entrenchment relates to shareholder control over management by means of their voting power. Evidence is found for a positive association between entrenchment at IPO and subsequent CEO cash and total compensation. These relationships are driven by firm-level external entrenchment. Firm-level external entrenchment is also significantly and positively associated with CEO stock-based compensation. The positive effects of entrenchment at IPO on CEO compensation appear not to be transitory and remain constant for at least five years post-IPO. Furthermore, entrenchment at IPO is shown to affect CEO pay-for-performance sensitivity. On balance, entrenchment reduces the sensitivity of CEO compensation to stock returns and returns on assets. The results of this study underscore the crucial importance of insiders' governance decisions made at the time of the IPO. Little support is found for a re-balancing of components of the CEO's compensation contract in response to entrenchment as predicted under the optimal contracting theory of compensation contracts. The findings of this study are almost entirely consistent with the managerial power theory, according to which entrenchment at IPO causes a permanent shift in bargaining power, which enables CEOs to influence compensation contracts in their favor.