Graduation Year

2021

Document Type

Dissertation

Degree

Ph.D.

Degree Name

Doctor of Philosophy (Ph.D.)

Degree Granting Department

Industrial and Management Systems Engineering

Major Professor

José Zayas-Castro, Ph.D.

Committee Member

Hadi Charkhgard, Ph.D.

Committee Member

Robert Frisina, Ph.D.

Committee Member

Mingyang Li, Ph.D.

Committee Member

Jay Wolfson, Dr.P.H.

Keywords

house-call, Nash bargaining solution, proactive care, social determinants of health, value-based payments

Abstract

The quadruple aim is an approach to optimize the performance of the health system in the United States and consists of four dimensions. The main objective is to improve the population's health, followed by reducing cost, improving patients' experience, and increasing providers' satisfaction. In the present doctoral dissertation, I explore three strategies that help accomplish the quadruple aim at the primary care level. The analysis combines data science and operation research principles to address health system engineering questions.

Each strategy proposed in this document emphasizes one objective more than another; however, all of them in conjunction serve to attain the four goals of the quadruple aim directly or indirectly. The first strategy involves restoring house call services as a setting to deliver primary care services. The second strategy examines efficiency and fairness in care access to home-based primary care practices, considering two divergent approaches, proactive and reactive care. The analysis involves medical and non-medical conditions (i.e., social determinants of health) as part of the selection criteria to admit patients. The third strategy relates to financial implications for primary care practices of using a reimbursement model that pays for performance and considers a factor that primary care practices can control. Under this strategy, I evaluate the two most recent Medicare alternative payment models, the 'comprehensive primary care plus' and the 'primary care first,' regarding profit, revenue, and patient selection.

The main findings indicate that the house call setting better achieves, on average, the objectives measured in this study for solo, small, and medium primary care practices. Similarly, small home-based primary care practices that provide proactive care seemingly more efficient and equitable than those that are more reactive. Regarding the value-based payments models, the comprehensive primary care plus resembles a more stable reimbursement model for a primary care practice; however, the primary care first reimbursement model further emphasizes the performance component. The disadvantage of the primary care first payment model is its high variability in all output variables and an inclination to select less severe patients. In contrast, the comprehensive primary care plus holds a high percentage of fee-for-service (i.e., a volume-based payment).

It is expected that the research findings will influence public policy development to enrich the primary care level, and thus, improve the overall population health. I also anticipate that the correct implementation of these strategies will impact everyone who uses the health system, contribute to increasing the satisfaction among primary care providers, and reduce costs in the system.

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