Person:

Botta, Michael David

Objective: To discern how the public in four countries, each with unique health systems and cultures, feels about efforts to restrain healthcare costs by limiting the use of high-cost prescription drugs and medical/surgical treatments. Design: Cross-sectional survey. Setting: Adult populations in Germany, Italy, the UK and the USA. Participants: 2517 adults in the four countries. A questionnaire survey conducted by telephone (landline and cell) with randomly selected adults in each of the four countries. Main outcome measures: Support for different rationales for not providing/paying for high-cost prescription drugs/medical or surgical treatments, measured in the aggregate and using four case examples derived from actual decisions. Measures of public attitudes about specific policies involving comparative effectiveness and cost-benefit decision making. Results: The survey finds support among publics in four countries for decisions that limit the use of high-cost prescription drugs/treatments when some other drug/treatment is available that works equally well but costs less. The survey finds little public support, either in individual case examples or when asked in the aggregate, for decisions in which prescription drugs/treatments are denied on the basis of cost or various definitions of benefits. The main results are based on majorities of the public in each country supporting or opposing each measure. Conclusions: The survey findings indicate that the public distinguishes in practice between the concepts of comparative effectiveness and cost-effectiveness analysis. This suggests that public authorities engaged in decision-making activities will find much more public support if they are dealing with the first type of decision than with the second.

This dissertation consists of three papers, two quantitative and one mixed-methods. Paper 1 uses cross-sectional and logistic regression analyses of survey data to assess Americans' opinion on the use of cost effectiveness research (CER) in government health coverage decisions, and to examine the factors predicting approval or disapproval of specific decisions. I use vignettes drawn from real international decisions to assess opinions. I find that opposition to a CER agency is widespread, with partisan affiliations playing a significant role. In general, Republicans are more likely to oppose a government agency playing a role in cost effectiveness determinations. With regards to specific examples, Americans hold even greater opposition, with no significant differences by political affiliations.

Background: In 2011, federal incentive payments for meaningful use of electronic health records (EHRs) began. This study evaluates the impact of the program on hospitals and EHR vendors, identifying how it affects EHR planning and development. Specifically, it assesses whether vendors and Chief Information Officers (CIOs) are viewing the meaningful use requirements as a floor – the minimally acceptable level of implementation, upon which development continues – or as a ceiling – the upper-bound on EHR development and implementation. Methods: The study combines interviews with EHR vendors and hospital CIOs with EHR adoption data from American Hospital Association surveys. Results from interviews with 17 hospital and system CIOs (representing 144 individual acute-care hospitals) and 8 EHR development executives (representing twothirds of installations) are detailed. Furthermore, it compares adoption of two key EHR functions, BCMA and CPOE, which are treated differently under stage 1 of the incentive program. Results: Three key findings emerge from the study. First, meaningful use requirements can serve as either a floor or a ceiling, depending on the abilities of institutions implementing EHRs. Second, the increasing focus on achieving meaningful use across both hospitals and vendors risks missing the forest of health care system change through the trees of meeting discrete requirements. Third, while the meaningful use incentive program has accelerated the development and implementation of some key functions, it has also slowed development of others. Conclusions: Policy makers should craft subsequent stages of the incentive program to ensure smaller facilities and additional features necessary for health care system change are not left behind.