Dissertation Title:  "Essays on Payment Reform, Physician Compensation and the Clinical Workforce"Chapter 1 studies the impact of the Medicaid Expansion on states' clinical workforce. Expansion states experienced health care and economic improvements including access to care, management of chronic conditions, mortality, and hospital finance. The increased demand for care from the newly-eligible lead to questions on how providers kept up with demand, including increases in the clinical workforce. Using county-level counts on a range of clinicians, this study applies a triple-difference approach to measure the impact of the Medicaid expansion on the clinical workforce, taking into account the pre-expansion county-level uninsured rate as a measure of the intensity of expansion. This analysis shows that expansion states had higher concentrations of clinicians relative to non-expansion states at baseline, but we find no evidence that the Medicaid Expansion is associated with changes in the clinical workforce. States that expanded Medicaid might have been better prepared to handle increases in healthcare demand due to their larger stocks of clinical workforce. The documented increases in healthcare access and utilization associated with the Medicaid Expansion does not seem to be due to increases in the numbers of clinicians in expansion states.

Chapter 2 analyses whether different physician compensation models affect certain patters on care delivery. This study uses 2012-2015 cross-sectional data on ambulatory physician visits from the National Ambulatory Health Care Survey. First, the modern compensation landscape is remarkably similar to over a decade ago. From the sample of 3,826 PCPs, 15.4% of PCPs report salary-based, 4.5% productivity-based and 12.9% “mixed” compensation, while 61.4% were practice owners. Delivery of out-of-visit/office care, which improves patient experience, but is relatively under-compensated, is more common for practice owners and “mixed” compensation PCPs. There is little association between compensation type and rates of high- or low-value care delivery. Despite early health reform efforts, the overall landscape of physician compensation remains strongly tethered to fee-for-service. The lack of consistent association between compensation and care delivery raises questions about the potential impact of payment reform on individual physicians’ behavior

Chapter 3 uses a new data source to explore the resource and information technology constraints faced by Safety-Net Providers (SNPs) in delivering care. SNPs play a critical role in the health system, as they are central providers of care for vulnerable populations, including those with economic constraints, higher rates of chronic conditions and co-morbidities, and lower attachment to the health care system. However, as value-based contracting broadens in scope, SNPs risk financial penalties if they are unable to meet program benchmarks. This makes SNPs ability to collect, analyze and act on clinical performance data to improve their internal processes a first-order priority. Using the National Survey on Healthcare Organizations and Systems, this chapter explores whether SNPs differ in their information and data usage capacities from other practices. The analysis also focuses on other differences between SNPs and other practices, such as payer shares, system attachment, and other practice characteristics, and whether these are associated with barriers in the use of clinical performance data.