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OBJECTIVE: High-quality primary care is envisaged as the centerpiece of the emerging health care delivery system under the Affordable Care Act. Reengineering the US health care system into a primary care-driven model will require widespread, rapid changes in the management and organization of primary care physicians (PCPs). Financial incentives to influence physician behavior have been attempted with various approaches, without empirical evidence of their effectiveness in improving care quality. This study examines the above research question adjusting for the patient-centeredness of the practice climate, a major contextual factor affecting PCPs' ability to provide high-quality care. METHODS: Secondary data on a sample of salaried PCPs (n = 1733) from the nation-wide Community Tracking Study Physician Survey 2004-2005 were subject to generalized multinomial logit modeling to examine associations between financial incentives and PCPs' self-reported ability to provide quality care. RESULTS: After adjusting for patient-centered medical home (PCMH)-consistent practice environment, financial incentive aligned with care quality/care content is positively associated with PCPs' ability to provide high-quality care. An encouraging finding was that financial incentives aligned with clinic productivity/profitability do not to impede high-quality care in a PCMH practice environment. CONCLUSION: Financial incentives targeted to care quality or content indicators may facilitate rapid transformation of the health system to a primary care-driven system. The study provides empirical evidence of the utility of practically deployable financial incentives to facilitate high-quality primary care.

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OBJECTIVE: To test the performance tilting hypothesis using information asymmetry (IA) within the community oriented activities of prospective payment system (PPS) hospitals. DATA SOURCES: American Hospital Association (AHA) Annual Survey Database and Medicare Cost Report from the Centers for Medicare and Medicaid Services both in fiscal year 2000; Health maintenance organization (HMO) penetration from the Area Resource File. STUDY DESIGN: A cross-sectional analysis was performed, using a national sample of 3162 PPS hospitals merged from the AHA data set and Medicare profit data. The individual hospital serves as the unit of empirical analysis. General linear model, multiple and logistic regressions are utilized to examine the association between IA and hospital performance indicators. PRINCIPAL FINDINGS: A positive relationship between IA and Medicare profit margins was found. Higher IA was associated with decreased likelihood that the hospital would report having a long-term plan for the health of its host community, and with increased likelihood of performance tilting. CONCLUSION: Information asymmetry offers hospitals an advantageous position in achieving profit maximization. The study also documented the presence of performance tilting by health-care management. Whether increased information demands from a society accustomed to significant disclosure will reduce this agency problem is not yet clear.

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OBJECTIVE: Identify factors associated with HIV care utilization in South Carolina. DESIGN: Cross-sectional analysis of South Carolina nonpregnant HIV-infected individuals (N = 13,042) for the period 1 January 2004 to 31 December 2006. METHODS: Reporting of HIV laboratory markers is legally mandated in South Carolina. Individuals with reported viral load tests or CD4 cell counts during a calendar year were defined as 'in HIV-medical care' that year. Care utilization categories were in care, care all 3 years; not-in-care (NIC), no care received; and transitional care, during some but not all years. Multinomial logistic regression using generalized logits was used to estimate relationships between care utilization and predictor variables. RESULTS: Five thousand, two hundred and seventeen (40.0%) of South Carolina HIV-infected adults were NIC and 3300 (25.3%) were in transitional care during 2004-2006. Although a larger number of black than white HIV-infected adults were NIC, adjusted odds for NIC status were lower among blacks than whites [adjusted odds ratio (AOR), 0.82; 95% confidence interval 0.74, 0.92)]. Women had lower odds of being NIC than men (AOR, 0.66; 95% confidence interval 0.58, 0.74). Compared with individuals 55 years or older, individuals who were 25-34 years old were most likely to demonstrate both the NIC (AOR, 1.85; 95% confidence interval 1.29, 2.65) and transitional (AOR, 1.85; 95% confidence interval 1.31, 2.62) care patterns. CONCLUSION: Large proportions of the South Carolina HIV-infected adult population are not consistently accessing HIV-medical care. Targeted programs are needed to improve engagement for HIV-infected adults most likely to transition or not be in care.

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There is a demand for non-traditional doctoral education in healthcare management and policy among many countries in support of their health system reform efforts. Healthcare professionals need retooling to provide stewardship to complex new health financing systems. Most health service leaders are mid career professionals and cannot transplant themselves to study on American university campuses. They demand high quality programs, designed to enable most coursework to be completed overseas. Aided by recent distance education technology, the University of South Carolina's Department of Health Services Policy and Management developed and provides doctoral programs for working professionals in Taiwan and South Korea with a minimal and convenient campus attendance requirement. This paper presents the experience of setting up the programs, management, quality control, and benefits for both students overseas and for our Department's mission and on-campus programs. Our experience is that there are many challenges, but it is also rewarding from academic, scholarly, and financial perspectives.

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Accreditation of academic programs is one of the most significant developments in the evolution of professional education in the United States. Efforts in several fields to extend programmatic accreditation to institutions outside the United States have had mixed results. This report describes such an accreditation experience in health services administration, its pitfalls, and the lessons that the site visit team (the authors) learned. The authors hope that others undertaking such tasks can benefit from this experience.

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The authors study the association between physician leadership styles and leadership effectiveness. Executive directors of community health centers were surveyed (269 respondents; response rate = 40.9 percent) for their perceptions of the medical director's leadership behaviors and effectiveness, using an adapted Multifactor Leadership Questionnaire (43 items on a 0-4 point Likert-type scale), with additional questions on demographics and the center's clinical goals and achievements. The authors hypothesize that transformational leadership would be more positively associated with executive directors' ratings of effectiveness, satisfaction with the leader, and subordinate extra effort, as well as the center's clinical goal achievement, than transactional or laissez-faire leadership. Separate ordinary least squares regressions were used to model each of the effectiveness measures, and general linear model regression was used to model clinical goal achievement. Results support the hypothesis and suggest that physician leadership development using the transformational leadership model may result in improved health care quality and cost control.

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The impact of states' small group market reforms on uninsurance rates was examined. Reform status was quantified on five reform dimensions: Access Improvement, Premium Reduction, Premium Differential Reduction, Continuity of Coverage, and Enhancing Valued Plan Features. These reform indices were calculated based on actuarial judgment of the market impact potential of each regulation. Regression analysis showed no association between uninsurance rates and the depth of reforms on any dimension, while controlling for income, foreign-born population, black population, and employment in the smallest businesses. Possible reasons for the lack of impact are discussed.

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The objective of the study described in this article was to identify a model that best predicts state uninsurance rates and quantifies the contribution of socio-economic factors to enable targeted state programs to reduce uninsurance. Linear regression analysis was carried out using state uninsurance rate as the dependent variable and state-level data on demographic, employment, income, and health care environment data (independent variables). For 2000 data, the model R is 0.77, indicating that 77% of the variation in uninsurance rates is explained by the percentage of immigrant population, the workforce in very small businesses, the Black population, the state's median income, and the Medicare-aged population (model R = 0.77 for 1999 and 0.68 for 1998 data). A 1% increase in immigrant population is associated with 0.18% increase in uninsurance rate. A 1% increase in workforce employed in very small businesses associates with 0.79% increase in uninsurance. The findings indicate substantial potential for reducing uninsurance through targeted state policies. Policy recommendations are made to alleviate the insurance hurdles faced by immigrant and small business employee populations.

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A clinical and functional integration strategy has a positive influence on increasing hospital revenue, and a solely functional integration strategy has a negative influence on increasing hospital expenses. Functional integration and clinical/functional integration strategies have a positive influence on hospital profit and the overall operations of the hospital. The mechanism of influence differs, however, based on the strategy used. Clinical/functional strategy has an impact on increasing hospital revenue, while functional integration strategy has an impact on reducing hospital expenses. Overall, the study shows that a functional integration strategy is more profitable than a clinical/functional integration strategy.

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Small group health insurance statutes of 48 states and the District of Columbia, as of 1999, were reviewed. Reform provisions judged to have some relevance for the market are catalogued and total 74 distinct regulations. Judgment of market relevance was based on actuarial experience at a leading health insurance company. The regulations are categorized under: (1) Access improvement; (2) Pricing and Rating Reforms; (3) Improving stability of coverage; and (4) Improving valued features of plans. The nuances and variety of these regulations, adopted in various combinations by the states, are discussed. The complexity of the reform scenario suggests the need for impact studies that take into account the totality of reform. Past studies have evaluated the impact of selected major reforms in isolation, and, thus, have been inadequate to provide definitive conclusions on the reforms' impact.

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States are ranked based on the potential of their small group health insurance reforms to enhance health insurance uptake. Reforms were quantified based on their market impact potential. Five dimensions of reforms were identified, Access Improvement, Premium Reduction, Premium Differential Reduction, Continuity of Coverage, and Enhancing Valued Plan Features. The reform indices representing these dimensions were developed based on document review of state statutes, combined with actuarial judgment to identify and assign scores to market-relevant regulations in line with their impact potential. The distribution of the states' reform scores and rankings show wide variation in the depth and focus of their reforms. Only seven of the top ten states on the Total Reform index had consistently higher scores on two or more reform dimensions. The conceptual linkages between specific regulations and the documented small group market problems lead to normative expectations of an association between the depth of state reforms and the prevalence of uninsurance.

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This paper presents a qualitative analysis of states' small group health insurance reforms that impact small group premiums, mostly enacted by the states during 1996-99, following the federal Health Insurance Portability and Accountability Act in 1996. It draws from an intensive review of statutes of 48 states and the District of Columbia as of 1999. It analyses regulations related to insurer pricing and rating practices concerning rating criteria and rating bands, pricing incentives, premium stability from year to year, minimum loss rations, reinsurance and carve-out coverage for the medically uninsurable. It also covers regulations targeting employer purchasing and coverage practices such as pooled purchasing and adverse selection. This is the second of a two-part series analyzing states' small group market reforms, the first being devoted to state reforms to promote access and improving the value of health plans offered in this market (Xirasagar et al. 2004). The variety in pricing and rating reforms illustrate the differences in the depth of reforms across states, and represent a far wider range of potential actuarial combinations than the sample of reforms documented in past literature.

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The purpose of the study is to identify factors affecting hospital profitability and to find the optimal hospital bed size that assures maximum profit. This is a cross-sectional study using survey data obtained from acute care hospitals in South Carolina in 1997. The relationship of hospital profitability and hospital bed size revealed that when bed size increases, hospital profitability increases, decreases, and then increases again. For the patient profit proportion, the turning points in bed size are 238.22 and 560.08. For the total profit proportion, the turning points in bed size are 223.31 and 503.86. The results on the relationship between bed size and hospital profitability indicate that medium-size hospitals have less profitability.

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