Dissertation Title: "Technological Innovation and Policy Responses in Health Care”
This dissertation consists of three papers, two quantitative and one mixed-methods. My first paper uses cross-sectional and logistic regression analyses of survey data to assess Americans’ opinion on the use of cost effectiveness research (CER) in US government health care coverage decisions, and to examine the factors predicting approval or disapproval of specific cost effectiveness decisions. I use vignettes drawn from real-world coverage decisions in international markets to assess opinions on the types of decisions likely to be made by a CER agency in the US. 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. Opposition to a government role in cost effectiveness has a clear partisan dimension, but opposition to real-world coverage decisions spans all political boundaries, making action on CER difficult for policy makers.
My second paper evaluates the hospital- and state-level factors influencing hospital adoption of electronic health records (EHRs), attempting to identify levers subject to influence by policy makers in the ongoing effort to drive increased adoption. This project employs multi-level poisson regression to examine cross-state variation in the relationship between hospital EHR function adoption and hospital and state level characteristics. Data is drawn from American Hospital Association IT adoption surveys, Medicare cost reports, and state legislation records compiled by the National Conference of State Legislatures. I find that a multitude of factors influence hospital EHR adoption, with several subject to influence by policy makers. In particular, prospective financial incentives at the state level to hospitals struggling to break even financially have a noted effect in increasing adoption rates. New efforts on the parts of policy makers to incentivize for-profit hospitals to increase adoption are also needed, as current incentives have not proven as effective in motivating their participation in comprehensive EHR adoption.
My third paper uses a mixed-methods approach to answer the question of whether hospitals view the requirements of the EHR meaningful use incentive program as a floor, above which further development continues, or as a ceiling, marking the limit of their EHR development and adoption efforts. I incorporate data from AHA IT adoption surveys with interviews with EHR vendors and hospital CIOs to assess their development efforts in the face of the billions of dollars introduced to the industry via the program. I draw three key findings from this research: first, the meaningful use requirements serve as either a floor or a ceiling, depending on the abilities of the facility implementing EHRs. Second, the increasing focus on meeting the requirements across both hospitals and vendors in the industry risks missing the forest of health care system change through the trees of meeting discrete requirements. Without further development on the technology needed for population health care and management of shared-savings models, the American health care system lacks the infrastructure for successful health reform. Third, while the meaningful use incentive program has accelerated the development and implementation of some functions, it has also slowed development of other important functions.