Association for Public Policy Analysis & Management

Panel: Determinants of Quality in Healthcare

(Health Policy)

This session includes three papers that study the effects of various changes in the U.S. healthcare system on quality of care. Recent trends in healthcare delivery and health insurance have included large increases in publicly provided insurance, increased emphasis on cost containment by insurers, and increased emphasis on competition between providers coupled with changes in technology for patient engagement. None of these trends are directly focused on the quality of care received by patients when they use the healthcare system, and they may negatively impact quality if increases in insurance coverage strain the delivery system, if cost containment incentives hinder quality of care, and if providers invest in wasteful competition that diverts patients from high quality facilities. This session tackles these questions using a variety of unique data sources and methods. 

The first paper asks whether insurance expansions caused by the Affordable Care Act strained nurse labor markets and in turn harmed quality of care. Using variation in state decisions to implement the Medicaid expansion in 2014, the paper estimates the impact of expansion on nursing labor market outcomes and quality of care. Results suggest that nurses worked more hours and employment of licensed practical nurses increased. This reallocation of nursing labor did not have negative effects on quality of care as measured by patient ratings of nursing care and hospital-acquired infection rates. 

The second paper studies whether cost containment incentives in Medicaid Managed Care (MMC) plans reduce quality for children with chronic illnesses. In this case study of Georgia’s MMC plan, the authors are fielding a survey of physicians and nurse practitioners that deliver care through federally qualified health centers. This survey will provide information on whether these providers perceive difficulties in delivering appropriate care due to constraints in the MMC plans. The authors will supplement the quantitative analysis based on the survey responses with qualitative interviews with clinicians. 

The third paper explores how hospital engagement in social media and investment in advertising impact patients’ choices of high quality hospitals. This paper combines a unique dataset of hospital-initiated online social media posts and consumer responses to these comments with data on hospital advertising expenditures, patient hospital choices, and hospital quality measures. The authors first estimate whether patient hospital choice responds to a hospital’s social media activity and advertising investments. They then test whether these changes in patient flows lead patients to seek care at higher or lower quality hospitals along both clinical quality dimensions and patient satisfaction.